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The What, the Why, and the How of Lipoatrophy in HIV CEU Information Accreditation Statement(s): ANCC Medical Education Collaborative (MEC) is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. RNs, LPNs, LVNs and NPs can receive up to .7 contact hours for participation in this program. This program is cosponsored with Medical Education Collaborative, Inc. (MEC) and Visionary Health Concepts. Provider approved by the California Board of Registered Nursing, Provider Number CEP 12990, for .8 contact hour(s). Joint Sponsor This activity is joint sponsored by Visionary Health Concepts and Medical Education Collaborative (MEC). MEC is a non-profit organization that has been certifying quality educational activities since 1988. Commercial Support This activity was made possible by an educational grant from Abbott Laboratories.
Learning Objectives Upon completion of this educational activity, participants should be able to:
Recognize the physical symptoms of HIV-associated lipoatrophy
Assist patients in understanding the way lipoatrophy is diagnosed and treated
Discuss recent studies related to ART and lipoatrophy
This program is intended for all healthcare providers, including nurses, treating HIV-positive patients, especially those who are seeking current and comprehensive information on lipoatrophy.
The What, the Why, and the How of Lipoatrophy in HIV CEU Information
The purpose of this program is to increase and improve patient/provider communication on the topic of lipoatrophy by providing both a simple, yet comprehensive, overview of the topic and an update of recent data related to the topic.
Release date: October 5, 2007; Expiration date: October 5, 2008
Instructions for Credit
There are no fees for participating in or receiving credit for this educational activity. This activity was developed to be completed within the time designated on the title page; providers should claim only those credits that reflect the time actually spent in the activity. For questions regarding the accreditation of this activity, please contact Medical Education Collaborative at 303-420-3252.
Follow these steps to earn CEU:
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To receive a certificate, participants must score at least a 70% on the post test and
submit it along with the credit application and evaluation form to the address/fax
number indicated. Statements of credit will be mailed within 6-8 weeks following the program.
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The What, the Why, and the How of Lipoatrophy in HIV CEU Information
Faculty Disclosures The planning committee and faculty members have the following disclosures: CEU Chairperson Andrew Carr, MBBS, MD, FRACP, FRCPA St. Vincent's Hospital; Professor of Medicine, University of New South Wales, Sydney, Australia Dr. Andrew Carr has the following relationships to disclose: grants for paid research, speaker’s bureau and advisory boards from Abbott Laboratories. Editor Maggie Sosa, APRN, BC, AACRN, ACHPNNP Nurse Practitioner, Broadway House for Continuing Care, Newark, NJ, USA Maggie Sosa has no relationships to disclose. The What, the Why, and the How of Lipoatrophy in HIV CEU Information
Faculty Disclosures continued Writers Lillian Thiemann President, Visionary Health Concepts, Gardiner, NY, USA Lillian Thiemann has no relationships to disclose. Deneen Robinson Savant Consultants, Dallas TX, USA Deneen Robinson has the following relationships to disclose: stock ownership: Abbott Laboratories; advisory committee: Bristol-Myers Squibb; speaker’s bureau: Gilead Sciences. Accredited Provider The employees of Medical Education Collaborative, the accredited provider for this activity, have no significant relationships to disclose. The What, the Why, and the How of Lipoatrophy in HIV CEU Information
In The What, The Why, and The How of Lipoatrophy in HIV slide set, we’ll:
Describe what lipoatrophy is, and what it’s not
Discuss current studies about lipoatrophy in HIV
Provide information on surgical and non-surgical treatment of lipoatrophy
Provide tips for better communication with patients
Point out the differences between lipoatrophy and AIDS wasting
Review types of body fat changes (lipodystrophy)
Antiretroviral therapy extends life Percentage of persons surviving through June 2005, by years after acquired immunodeficiency syndrome (AIDS) diagnosis cohorts during 1981-2003 and by year of diagnosis--United States [Centers for Disease Control and Prevention 2005]
Lipo means fat and atrophy means shrinkage lipoatrophy = “fat loss”
Is often seen in people living with HIV who take anti-HIV drugs
Also can occur in those with HIV who have never taken anti-HIV drugs, and in other diseases such as diabetes or in rare genetic diseases
AIDS wasting is not lipoatrophy Fat loss Weight loss & diarrhea CD4 Count HIV under control? Associated with risk of death? Affects looks? AIDS Wasting yes yes Less than 50 No yes yes Lipoatrophy (fat loss) yes no Over 200 yes no yes
The estimates are affected by how long people have been on HIV treatment and what type of HIV medication
Reported less often in women—10% to 35%, and may be low due to underreporting.
[Bernasconi E et al. JAIDS 2002;31:50.] [Young J et al. Antiviral Therapy 2005;10:73.] [Miller J et al. HIV Med 2003;4:293.] [Lichtenstein KA et al. 13 th CROI 2006; Denver. Abstract #769.] [Chen D et al. J Clin Enocrinol Metabol 2002;87:4845.]
Mitochondria are the cell’s ‘energy factories’ where sugar and fat are burned to turn it into energy
If mitochondria are damaged, fat cells start to shrink and then die
Switching anti-HIV drugs Change from baseline (kg) Week Switching NRTIs d4T/AZT did help reverse the fat loss. However, there was no return to “normal”. [Carr et al, AIDS 2001] [Martin et al, AIDS 2004] [McComsey et al, Clin Infect Dis 2004] [Milinkovic et al, CROI 2005] [Carr et al, JAMA 2002] [ Moyle et al, CROI 2005] [Murphy et al, CROI 2005]
Families of HIV drugs: Non nucleoside reverse transcriptase inhibitors (NRTIS) Brand name Generic name Image Atripla™ (Sustiva* + Viread + Emtriva) efavirienz + tenofovir + emtricitabine Rescriptor ® delavirdine, DLV Sustiva ® efavirenz, EFV Viramune ® nevirapine, NVP
Uses x-rays to look at slices of the body. Expensive, more commonly used to measure fat gain, exposes patient to radiation, 1 per year allowed.
Lower jaw (mandible) measure - left [Carey D et al. CROI 2007; Los Angeles. Abs #40.] CAT scan
Baseline mandible - left
Baselines drawn between points of bone
Maximum distance to skin line measured
Tools to measure fat loss (3) Skin-fold test A metal tool is used to “pinch” body tissue in several places. The measurements are compared to standards. Requires a skilled technician. MRI (Magnetic Resonance Imaging) uses a magnetic field to create an image of the body showing the location and amount of fat; very expensive [Levine J et al. J Appl Physiol 2000;88:452.] [Kamel E. et al Obes Res 2000;8:36.] [Mitsiopouools J Appl Physiol 1998;85:115.]
Can’t we just take another pill? [Slam L, et al. 13th CROI 151LB.] [Cavalcanti RB, et al. and Grinspoon S et al. J Infect Dis .--both Published online , ahead of print (May 2, 2007).] [Mallon PWG et al. Antiviral Therapy 10: L5, 2005.] [Macallan, DC, et al.. 46th ICAAC. Abs H-1897.] ] Agents studied to try to increase fat Results Rosiglitazone Minimal effect and may hurt heart by raising cholesterol and triglycerides Pioglitazone In one study pioglitazone raised limb fat but only in those NOT taking Zerit (stavudine, d4T) Pravastatin Fat gains shown but the study was small, and of short (12W) duration Uridine NucleoMaxx® is EXPENSIVE! Fat gains shown but the study was small, and of short (12W) duration Human Growth Hormone Makes fat loss worse
There are currently several treatments to restore the appearance of the face
These products are facial fillers that correct the symptoms of lipoatrophy
They do not correct the cause of the problem: fat cell destruction
Commonly-used options for HIV-related facial lipoatrophy Table provided by PoWeR (Program for Wellness Restoration) and www.facialwasting.org. Source: Comparison of Poly-L-lactic Acid and Calcium Hydroxylapatite for Treating Human Immunodeficiency Virus-Associated Facial Lipoatrophy; Cosmetic Dermatology, May 2007, Vol 20 No. 5 PRODUCT TYPE/SESSIONS FDA APPROVED? COST Sculptra (Poly-L-lactic acid) Non-permanent/ several sessions needed Yes Patient assistance for product only (under $40,000/yr income: www.needymeds.com/papforms/ sculpt1039.pdf ). Labor cost avg. $400 per session. Full price: $1100 per session for product. Radiesse (Calcium hydroxylapatite ) Non-permanent/ several sessions needed Yes Patient assistance for product only (under $80,000 a year w/sliding scale). Labor avg. $400 Full price: $1200 per session. Silikon 1000 (Purified polydimethyls-iloxane ) Permanent/ several sessions needed Off label use: FDA approved for intraocular injections to treat CMV- related retinal detachment No patient assistance available. Full price: $800 per session.
Commonly used options for HIV-related facial lipoatrophy (2) Table provided by PoWeR (Program for Wellness Restoration) and www.facialwasting.org. Source: Comparison of Poly-L-lactic Acid and Calcium Hydroxylapatite for Treating Human Immunodeficiency Virus-Associated Facial Lipoatrophy; Cosmetic Dermatology, May 2007, Vol 20 No. 5 PRODUCT TYPE/SESSIONS APPROVED? COST PMMA-polymethylmethacrylate Permanent/ 1-2 sessions needed Not FDA approved: Mexico, Brazil $1200 avg total cost Autologous fat transfer: fat pulled from one spot in the body and injected into the face Non-permanent/ several sessions needed FDA approved $3,000 avg total cost Hyaluronic Acid (Restylane, Perlane, Hylaform) Permanent/ several sessions needed Only Restylane is FDA approved Approximately $1,500 per visit Polyalkylimide ( Bioalcamid) Permanent/ several sessions needed Not FDA approved: Europe, Canada, Mexico, others $4,500 avg total
It is better to avoid fat loss in the first place with careful anti-HIV drug selection than to try to fix it after it’s gone: The NRTI, Zerit (stavudine, d4T)—and to a lesser extent, Retrovir (zidovudine, AZT)—are to be avoided, if possible.
Some anti-HIV drugs are more fat-loss friendly than others: Viread (tenofovir), Ziagen (abacavir), Kaletra (lopinavir/ritonavir) have all shown little—or significantly less—fat loss than the drugs they were compared to in recent studies
Switching Zerit or Retrovir to fat-loss friendly NRTIs can help restore some fat, but a return to “normal” isn’t happening
Use DEXA scan to assess for fat loss (or fat gain) early on and later in therapy. It’s good to have results from different time periods to compare
There are patient assistance programs available to help with cost of two facial filler treatments