Because we still don't have a widely accepted case definition of lipodystrophy and we're still figuring out the causes of lipohypertrophy, we don't have universally effective treatments for 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, first for lipoatrophy and next for lipohypertrophy:
Lipoatrophy Treatments:
Switching or avoiding certain ARV therapies : As discussed earlier, two NRTIs have been strongly linked to lipoatrophy: Zerit and Retrovir. It was primarily for this reason that the Department of Health and Human Services (DHHS) recommends, in the HIV treatment guidelines they publish, against the drugs' use whenever possible in people with HIV. For people who have developed lipoatrophy, switching either of the two offending drugs for either tenofovir (found in Viread, Truvada and Atripla) or abacavir (found in Ziagen, Epzicom and Trizivir) is recommended. Studies have shown that the progression of lipoatrophy not only halts after switching, but may actually reverse somewhat. People who have not yet developed lipoatrophy should avoid taking Zerit or Retrovir to prevent the condition.
Plastic surgery: Surgery to restore facial fullness and buttocks fullness has become very popular. There are two non-permanent injectable fillers approved to treat facial lipoatrophy in the United States. No fillers have been specifically approved to fill out the buttocks due to lipoatrophy, though gortex implants are an approved treatment in the U.S. for other conditions to restore fullness to larger areas of the body that have been hollowed out.
Fat, fat substitutes, and skin thickeners, injected directly into the face, are being used by a number of dermatologists and plastic surgeons. Many people go to other countries where more permanent fillers are available, though people should do extensive research about the proposed treatment and the provider and clinic they are considering. For a comprehensive lesson on facial lipoatrophy, including possible treatments, check outChanges 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.
Drugs for body-shape changes: 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, though other small studies have shown at least some benefit [check out Changes to Your Face (Facial Lipoatrophy) for more information].
Lipohypertrophy Treatment:
Plastic surgery: 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.
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.
Drugs for body-shape changes: Two drugs—one a synthetic human growth hormone (Serostim), and the other a synthetic growth hormone releasing factor (tesamorelin)—have demonstrated the ability to reduce accumulated fat at least somewhat. The company that makes Serostim failed to provide enough data for the drug to achieve approval for HIV-related lipohypertrophy, though the drug is approved to combat AIDS wasting. The company that makes tesamorelin—which causes a relatively similar reduction in gut fat accumulation as Serostim, with less risk for problems with blood sugar— has also filed for Food and Drug Administration (FDA) approval. A decision about tesamorelin's approval is expected by 2010.
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.
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: Though no ARV drugs have demonstrated the ability to reverse lipohypertrophy, there are certainly drugs available that have much less of an impact on cholesterol and triglycerides. These include the NNRTIs Viramune (nevirapine) and Intelence (etravirine), the integrase inhibitor Isentress (raltegravir) and the entry inhibitor Selzentry (maraviroc). Two protease inhibitors, Reyataz and Prezista (darunavir), are also less likely to increase cholesterol and triglycerides, but both require that their blood levels be boosted with low-dose Norvir (ritonavir). Norvir does increase cholesterol and triglycerides. Thus, any potential benefits of these drugs may be blunted somewhat by the Norvir.
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