Because we really don't know what lipodystrophy is or what causes it, we don't know how best to treat it. Developing effective treatments for lipodystrophy depends on this information.
There are a number of treatment approaches being looked at by researchers, none of which have yet been proven to be effective. But early results from clinical trials, and word-of-mouth reports by patients and doctors, paint a promising picture. Here's a look at what's being tried and developed:
Plastic surgery: Surgery to correct changes in body fat caused by lipodystrophy has become very popular in recent years. There are two types of plastic surgery being talked about: 1) liposuction, a surgical produce in which fat is sucked out of a specific area of the body, and 2) implants, a procedure in which fat or fat substitutes are either injected or surgically implanted into the face to help "fill out" sunken cheeks and other troubled spots (e.g., the temples and around the eyes or mouth).
Although there have been no clinical trials of liposuction for the treatment of lipodystrophy, numerous HIV-positive people report that it can help reduce fat buildup in the breasts and at the back of the neck. Generally speaking, liposuction cannot be used to remove visceral fat—fat deep within the body—by liposuction; there is a significant risk of internal organs being punctured or damaged during the procedure. It is also important to note that liposuction to reduce fat in the breasts or at the back of the neck may not be permanent—some people see the fat buildup return, usually several months after the procedure. Liposuction can also be painful and is generally not covered by health insurance plans, although some people have had some success getting reimbursed for this expensive procedure.
Fat, fat substitutes, and skin thickeners, injected directly into the face, are being used by a number of dermatologists and plastic surgeons. For a comprehensive lesson on facial lipoatrophy, including possible treatments, check out Changes to Your Face (Facial Lipoatrophy).
If you are considering plastic surgery to correct changes in your body fat, it is very important that you consult with a plastic surgeon (or dermatologist) who has experience performing plastic surgery in HIV-positive people with these types of problems. Some private insurance companies have paid for these types of plastic surgery. The health-care provider conducting the procedure should contact your insurance company to confirm that the procedure is necessary for quality-of-life and medical purposes.
Lipid-lowering drugs: High levels of triglycerides and cholesterol in the blood greatly increase the risk of experiencing heart disease, a heart attack, or a stroke. These drugs are reviewed in our lesson, Risks to Your Heart (Hyperlipidemia).
Drugs for body-shape changes: Some researchers think that anabolic drugs, such as human growth hormone (Serostim), might help control some of the body-shape changes seen in some people with lipodystrophy. In studies of Serostim for the treatment of AIDS-related wasting syndrome, it was demonstrated that the drug helps reduce fat buildup and promotes muscle growth. In HIV-positive people with lipodystrophy, a few studies have shown that Serostim might help reduce fat buildup around the waist, breasts, and back of the neck. The drug might also help increase muscle size in the legs and arms, ultimately covering up the loss of fat. Serostim does come with side effects, including increased glucose levels (which can be a big problem for people who are already experiencing this problem) and muscle aches, so researchers are currently experimenting with low-dose Serostim to see if it is still effective and causes fewer problems. The dose currently being tested in clinical trials is 4mg every day for 12 weeks, followed by a lower dose every day or every other day (for wasting syndrome, the dose is 6mg every day continuously).
The manufacturer is currently negotiating with the U.S. Food and Drug Administration to determine if it should be approved for the management of HIV-related body-shape changes.
Synthetic testosterone—manufactured versions of the sex hormone found in both men and women—has also been studied as a potential treatment for lipodystrophy. Like Serostim, testosterone is an anabolic agent that may help burn excess fat. In one study (ACTG 5079), researchers compared AndroGel (a gel containing testosterone that is rubbed onto the skin) to placebo in 88 HIV-positive people with lipodystrophy. Unfortunately, AndroGel did not perform better than placebo in terms of decreasing visceral fat. In fact, visceral fat increased in both groups of patients. Patients taking testosterone also saw a reduction in the amount of fat in their limps (e.g., legs and arms), a potential problem for people with lipoatrophy.
Glitazones, such as pioglitazone (Actos) and rosiglitazone (Avandia), belong to a class of drugs called the thiazolidinediones. They are best known for their ability to make cells more sensitive to insulin, hence they are approved for the treatment of diabetes. Interestingly, they have also been shown to help correct the function of fat cells. As a result, they have been studied as potential treatments for lipodystrophy, particularly lipoatrophy. There have been a handful of studies evaluating Actos and Avandia for the correction of lipoatrophy, including an Australian study completed in 2004 that failed to find any benefit in patients with lipoatrophy, as well as more recent studies suggesting that there may be some benefit after all [check out Changes to Your Face (Facial Lipoatrophy) for more information].
Diet and exercise: A handful of research reports have found that some patients who increased their exercise or started low-fat diets saw a reduction in their lipid levels and body-shape changes. Generally speaking, lowering the amount of saturated fats, such as those found in animal products, may help reduce cholesterol levels. To reduce triglyceride levels, reducing the amount of fats and carbohydrates might be effective. Considering that everyone can benefit from more exercise and a healthy diet, all HIV-positive people—whether they have lipodystrophy or not—are encouraged to speak with a nutritionist or dietician about the steps they can take to improve their nutritional status and activity levels.
Switching therapies: Because anti-HIV drugs are believed to be the most likely cause of lipodystrophy, the usual first step—before other therapies, such as those discussed above, are considered—is to switch the possible offending drug for one that might not cause the same problems. Protease inhibitors have been said to be a likely cause of lipodystrophy. In turn, several research teams have experimented with drug switches to help control the problem. For example, some patients receiving a protease inhibitor in combination with two nucleoside reverse transcriptase inhibitors (NRTIs) might be able to switch the protease inhibitor for a non-nucleoside reverse transcriptase inhibitor (NNRTI). Some studies have shown this to be beneficial—lipid levels in the blood and body-shape changes decreased in some patients who switched their therapies. Other studies, however, have not produced much promising information, suggesting protease inhibitors are not the root cause of the problem or that the body-shape changes, once they occur, can be difficult to reverse simply by switching drugs.
Some of the nucleoside reverse transcriptase inhibitors (NRTIs), particularly Zerit (d4T), are believed to play a role in in the development of lipoatrophy (loss of fat in the face and limbs). In turn, if lipoatrophy begins to develop in someone taking Zerit, a first approach is to switch the Zerit for another NRTI believed to be less likely to cause this problem, such as Viread (tenofovir), Ziagen (abacavir), or even Retrovir (AZT).
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