Prevention
- Avoid d4T and ZDV or pre-emptively switch away from them
Management
- Modification of ART
- Switch d4T or ZDV to ABC or TDF:
- Only ART modification proven to partially restore subcutaneous fat; increase in total limb fat ~400-500g/year
- Risk of toxicity from new drug (see p. 36).
- Switch to regimen not including NRTIs
- Increase in total limb fat ~400-500g/year
- May increase risk of dyslipidaemia
- Less data on virological safety
- Surgical intervention
- Offered for relief of facial lipoatrophy only i
- Pharmacological interventions to treat lipoatrophy have not been proven to be effective and may introduce new complications
- Pioglitazone - possibly beneficial in patients not taking d4T
- Rosiglitazone and Pioglitazone - improvement in insulin sensitivity
- Rosiglitazone: increases in blood lipids and possible IHD.
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Prevention
- No proven strategy
- Weight gain expected with effective ART and reflect “healthy” response
- Weight reduction or avoidance of weight gain may decrease visceral adiposity
- Avoid inhaled fluticasone with some PI
Management ii
- Diet and exercise may reduce visceral adiposity;
- Limited data, but possibly reduction of visceral adipose tissue and improvement in insulin sensitivity and blood lipids, especially in obesity associated with lipohyperthrophy
- No prospective trials in HIV-infected patients to definitely indicate degree of diet and/or exercise needed to maintain reduction in visceral fat.
- May worsen subcutaneous lipoatrophy
- Pharmacological interventions to treat lipohypertrophy have not been proven to provide long-term effects and may introduce new complications
- Growth hormone ii
- Decreases visceral adipose tissue
- May worsen subcutaneous lipoatrophy, may worsen insulin resistance
- Metformin
- Decreases visceral adipose tissue in insulin resistant persons
- May worsen subcutaneous lipoatrophy.
- Surgical therapy can be considered for localised lipomas/buffalo humps
- Duration of effect variable
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