II. Pathophysiology

  1. Occurs in some patients never exposed to Antiretroviral
  2. Common adverse effect of Anti-Retroviral Therapy
    1. Occurs in 64% of patients on Protease Inhibitors
    2. Also occurs with nRTI therapy

III. Signs

  1. Peripheral Fat Wasting
    1. Loss of facial fat (e.g. cheeks with deep dimples)
    2. Loss of subcutaneous fat in the legs
  2. Redistribution of fat centrally
    1. Increased abdominal fat (Protease Paunch)
    2. Gynecomastia
    3. Neck fat pad hypertrophy (Buffalo hump)
      1. Seen also in Cushing's Syndrome
  3. Hyperlipidemia
  4. Insulin Resistance

IV. Complications

  1. Pancreatitis
  2. Metabolic Syndrome equivalent
  3. Pro-thrombotic state with potential increased risks
    1. Cerebrovascular Accident (stroke)
    2. Increased risk of cardiovascular disease
    3. Mortality may be increased

V. Management

  1. Low Fat Diet
  2. HMG CoA Reductase Inhibitors (Statins)
  3. Fibric Acid Derivatives (Gemfibrozil)
  4. Recombinant Growth Hormone
    1. May offer short term benefit in lipohypertrophy
  5. Liposuction with redistribution to areas of fat loss
  6. Polylactic acid and Calcium hydroxylapatite injections
    1. May offer short-term benefit with facial Lipoatrophy
  7. Consider adjusting Antiretroviral regimen
    1. Change Protease Inhibitor (Indinavir to Nelfinavir)
    2. Switch Protease Inhibitor to another Antiretroviral
      1. Nevirapine (Viramune)
      2. Efavirenz (Sustiva)
  8. Hyperinsulinemia
    1. Metformin
    2. Thiazolidinediones (e.g. Rosiglitazone)
      1. Efficacy and safety in Lipodystrophy is unclear

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