Algorithm for the evaluation and treatment of weight loss in patients with HIV disease. Intensive antiretroviral therapy should be instituted in patients who are not already receiving it, and antiretroviral therapy should be augmented in those who continue to have detectable viral loads. Quantitative plasma HIV RNA should be assessed, since active viral replication is associated with increased resting energy expenditure and may increase the amount of weight loss.
Symptoms of HIV
Consistent with current guidelines, changes in antiretroviral therapy should involve, if possible, the introduction of at least two agents not previously used by the patient without waiting to achieve control of opportunistic disease. Recent reports have implicated protease inhibitors in the development of glucose intolerance, hypertriglyceridemia, hypercholesterolemia and abnormal central fat accumulations that occur in association with peripheral wasting. However, unless patient safety or preference dictates otherwise, there currently is no reason to discontinue protease inhibitor therapy, especially in patients otherwise benefiting from this type of agent.
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However, HMG-CoA reductase inhibitors should be avoided in patients with hypercholesterolemia until concerns about possible interactions with protease inhibitors are clarified. Fibrates, such as gemfibrozil Lopid , and niacin are probably safe in patients receiving protease inhibitors.
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Alternatively, use of combination antiretroviral regimens that do not contain protease inhibitors may be considered. Opportunistic diseases should be aggressively treated as soon as they are diagnosed. Measures to stimulate the patient's appetite, institution of enteral or even parenteral feeding in the case of a severe malabsorptive state and control of fever should accompany treatment of opportunistic pathology as required.
Table 4 summarizes the different types of drugs used in the treatment of HIV-related wasting syndrome. The use of appetite stimulants and antiemetics in conjunction with caloric supplementation has long been considered a mainstay of therapy. In planning the treatment approach, it is important to differentiate between nausea and anorexia.
In addition, underlying causes of gastrointestinal symptoms, such as drug toxicity, should be sought and resolved whenever possible. Appetite Stimulants. Megestrol Megace , a progestin used in the treatment of breast cancer, has been shown in anorectic patients to improve appetite, quality of life and total body weight. Anabolic Agents. Androgens—particularly oxandrolone Oxandrin , nandrolone Deca-Durabolin , oxymetholone Anadrol and testosterone—are used to increase body cell mass in patients with wasting syndrome, although there are no accepted standards for indications, dosages and duration of therapy.
Small studies of HIV-positive men have shown that body cell mass increases in response to supraphysiologic doses of testosterone, 16 , 17 consistent with the results of studies in uninfected men. Until these issues are clarified, administration of androgens to help control HIV-related wasting should be reserved for use in men with hypogonadism and in patients who fail to respond to other therapies. Recombinant human growth hormone rhGH; Humatrope is labeled by the U. A week study revealed that rhGH, in a dosage of 0. The safety and efficacy of long-term rhGH therapy and its impact on survival are unclear.
Also unknown is the question of whether similar outcomes can be achieved with other, less expensive interventions.
5.14 Wasting and weight loss
It seems advisable, therefore, to reserve the use of rhGH for patients who are undergoing unexplained significant weight loss, who have not responded to other therapies and who require short-term treatment to maintain body cell mass during acute infection. However, because toxicity from this drug can be significant, its utility may be limited to only those situations in which other therapies have failed.
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- Evaluation and Treatment of Weight Loss in Adults with HIV Disease.
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Male and female patients must be counseled about its teratogenic potential. Treatment of painful or obstructive dental disease may significantly improve nutritional intake. Periodontitis and gingivitis may be prevented with regular use of a topical antiseptic and should be aggressively treated when present. All patients with HIV disease should be referred for regular preventive dental care. The best strategy to prevent wasting is to incorporate the patient's food preferences into the goal of an adequate intake of calories and protein to meet metabolic needs Table 5.
To preserve small bowel function, solid food is recommended whenever possible. For example, if oral inflammation is present, it may be helpful to avoid hard foods. Micronutrients in the form of multivitamin preparations should be routinely prescribed. Patients should be counseled about safe food procurement, storage and preparation to reduce the risk of exposure to intestinal pathogens.
For females: intake of 2, to 3, kcal per day, with 1.
For males: intake of 3, to 3, kcal per day, with 1. Daily micronutrient supplement should include vitamins A, B 6 , B 12 and selenium. Nutritional recommendations for problems related to wasting syndrome. Avoid temperature extremes, highly seasoned foods and hard foods e. Consume mild flavors, foods at a moderate temperature and appetizing foods. Lipisorb and Peptamen may be useful in patients requiring tube feeding.
Identifying Contributing Factors
Consume lactose-free, low-fiber, low-osmolality diet. Consume low-fat diet; supplements should contain medium-chain triglycerides. Caloric and protein supplements may be useful if they do not supplant more nutritionally diverse foods and are provided in a palatable form that can be easily ingested. Nutritional supplements are not useful in the prevention of weight loss and should be reserved for use in patients in whom normal dietary intake is clearly inadequate for sustaining weight. In patients whose oral intake remains below 25 percent of the calculated caloric goal for more than three days, nocturnal nasogastric or percutaneous endoscopic gastronomy tube feedings may be required.
Exercise that provides a workout of skeletal muscle should be encouraged in patients able to tolerate it Table 3 and accompanying patient information handout.
Evaluation and Treatment of Weight Loss in Adults with HIV Disease - American Family Physician
Data demonstrating synergy between resistance exercise and anabolic steroids in enhancing body cell mass and strength suggest that exercise may be an important adjunctive therapy. Treatment of HIV-related wasting syndrome requires vigilance in looking for the early signs of its onset. Regular evaluation of patients with HIV infection must include a review of nutritional intake and physical activity, a review of symptoms to elicit any symptoms of occult opportunistic disease and virologic monitoring.
Aggressive antiretroviral therapy should be used to minimize the HIV load. Another important part of follow-up includes ongoing patient education to enhance adherence to medication regimens, nutritional intake and exercise.
In addition, collaboration among the primary care clinician, dietitian, subspecialists, exercise physiologist or physical therapist, dentist, pharmacist, household caregivers and patient is important to ensure that a multifaceted approach to the condition is adequately coordinated. Pharmacologic intervention should, in general, be reserved for use in patients failing other therapies.
With early identification and aggressive treatment, wasting syndrome in HIV disease is a manageable condition and need not inevitably result in disability or death. Aggressive treatment often results in complete restoration of the patient's baseline weight and health. Already a member or subscriber?
Log in. Her research interests include the effects of recombinant human growth hormone on HIV wasting syndrome, use of magnetic resonance imaging spectroscopy in elucidating mitochondrial and metabolic dysfunction in HIV wasting syndrome, and age-related sarcopenia. Her research interests include body composition, anthropometrics and nutritional habits of patients with chronic disease, including HIV infection and hantavirus pulmonary syndrome.
Address correspondence to Bruce Williams, M. Reprints are not available from the authors. Magnitude of body-cell-mass depletion and the timing of death from wasting in AIDS. Am J Clin Nutr. Weight loss as a predictor of survival and disease progression in HIV infection. Visceral abdominal-fat accumulation associated with use of indinavir. Sharpstone D, Gazzard B. Gastrointestinal manifestations of HIV infection. Gastrointestinal viral infections in homosexual men who were symptomatic and seropositive for human immunodeficiency virus.
J Infect Dis.