Expert Consensus Statement on an Updated Definition of Unintended Weight Loss Among Persons With Human Immunodeficiency Virus in the Modern Treatment Era.

The era of modern antiretroviral therapy (ART) has markedly improved health and survival among persons with human immunodeficiency virus (HIV) (PWH). In the pre-ART era, wasting was associated with HIV disease progression to acquired immunodeficiency syndrome and death. Effective ART has reduced the prevalence and incidence of this pre-ART form of HIV-associated wasting. However, a subgroup of ART-treated virally suppressed PWH continue to lose weight, often accompanied by aging-related comorbidities and/or functional deficits. For this subgroup of patients, the older definition of HIV-associated wasting (HIVAW) cannot and should not be applied. An expert panel comprising the authors of this white paper convened to review the existing definition of HIVAW and to create an updated definition that they termed HIV-associated weight loss, based on clinically defined parameters among contemporary PWH receiving ART. Here, clinical features and laboratory biomarkers associated with HIV-associated weight loss are reviewed and approaches to screening and treatment are considered. Available management approaches, including the use of current US Food and Drug Administration-approved medications for HIVAW and other available therapies are discussed. The expert panel also identified knowledge gaps and provided recommendations for clinicians, payers, and researchers.

Are cannabinoids effective for HIV wasting syndrome? / ¿Es efectivo el uso de cannabinoides en el síndrome de emaciación (wasting) en VIH/SIDA?

INTRODUCTION: Wasting syndrome is a common problem in HIV. It leads to substantive morbidity and mortality. The use of cannabinoids has been suggested as a treatment for weight, but it is not clear whether they are really safe and effective. METHODS: To answer this question we used Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies and generated a summary of findings table using the GRADE approach. RESULTS AND CONCLUSIONS: We identified eight systematic reviews including ten studies overall, of which six were randomized trials. We concluded it is not clear whether cannabinoids increase appetite or weight in HIV wasting syndrome because the certainty of the evidence is very low, and they probably lead to frequent adverse effects.

INTRODUCCIÓN: El síndrome de emaciación (wasting) en VIH/SIDA aún permanece como un problema común, constituyéndose como un factor de mortalidad en esta población. Se ha postulado el uso de cannabinoides como tratamiento de la baja de peso secundaria a la infección por VIH, lo que aún es controvertido. MÉTODOS: Para responder esta pregunta utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios y preparamos tablas de resumen de los resultados utilizando el método GRADE. RESULTADOS Y CONCLUSIONES: Identificamos ocho revisiones sistemáticas que en conjunto incluyen 10 estudios primarios, de los cuales, seis son ensayos aleatorizados. Concluimos que no está claro si los cannabinoides aumentan el apetito o incrementan el peso en el síndrome de wasting en pacientes con VIH, y probablemente los efectos adversos son frecuentes.

[Wasting syndrome in HIV-infected patients].

The review of literature analyzes scientific data on wasting syndrome in HIV-infected patients. It considers its etiology, diagnosis,and therapeutic approaches.

Pharmacologic management of human immunodeficiency virus wasting syndrome.

Pharmacologic interventions for human immunodeficiency virus (HIV) wasting have been studied since the 1990s, but the results of these interventions have been difficult to compare because the studies used different HIV wasting definitions and assessed various patient outcomes. Thus, we performed a systematic review of the current literature to identify studies that evaluated pharmacologic management of HIV wasting and to compare and contrast treatment options. Further, we provide a comprehensive review of these treatment options and describe the definition of HIV wasting used in each study, the outcomes assessed, and whether antiretroviral therapy was used during the HIV wasting treatment. Literature searches of the PubMed/Medline (1946-2014) and Google Scholar databases were performed, and a review of the bibliographies of retrieved articles was performed to identify additional references. Only English-language articles pertaining to humans and HIV-infected individuals were evaluated. Thirty-six studies were identified that assessed pharmacologic interventions to treat HIV wasting. Appetite stimulants, such as megestrol acetate, have been shown to increase total body weight (TBW) and body mass index in HIV-infected patients with wasting. Studies evaluating dronabinol showed conflicting data on TBW increases, but the drug may have minimal benefit on body composition compared with other appetite stimulants. Testosterone has been shown to be effective in HIV wasting for those who suffer from hypogonadism. Recombinant human growth hormone has been evaluated for HIV wasting and has shown promising results for TBW and lean body mass increases. Thalidomide has been studied; however, its use is limited due to its toxicities. Although megestrol acetate and dronabinol are approved by the U.S. Food and Drug Administration (FDA) for the treatment of HIV wasting, it is important to recognize other comorbidities such as depression or hypogonadism that may contribute to the patient's appetite and weight loss. If a patient is diagnosed with hypogonadism and HIV wasting, testosterone would be a good therapeutic option. Although mirtazapine is not FDA approved for the management of HIV wasting, it has been shown to promote weight gain while treating depression symptoms. Mirtazapine may be a promising pharmacologic option in the management of HIV wasting and depression, but further research is needed.

Growth hormone: the expansion of available products and indications.

Growth hormone is a widely used hormone. This article describes its historical use, current indications and studies for possible future uses.

Growth hormone and HIV infection: contribution to disease manifestations and clinical implications.

In untreated HIV patients growth hormone deficiency contributes to loss of lean and fat mass. Pharmacologic doses of growth hormone successfully reverse this wasting process. In patients responding to antiretroviral therapies several non AIDS-related complications usually common among older, uninfected persons now occur more frequently in younger HIV patients. Among these conditions are cardiovascular disease and metabolic disorders. Although their etiology is multifactorial, changes in growth hormone biology reflecting relative growth hormone deficiency occur and may be involved. In these patients truncal obesity, and associated dyslipidemia and glucose homeostasis changes contribute to impaired quality of life and increased cardiovascular risk. Treatment with growth hormone and growth hormone releasing factor leads to short-term improvement of some of these abnormalities. This paper will review abnormalities of growth hormone biology and the use of growth hormone and growth hormone releasing factor as therapeutic agents in HIV patients.

Decreased limb muscle and increased central adiposity are associated with 5-year all-cause mortality in HIV infection.

BACKGROUND: Unintentional loss of weight and muscle due to aging and disease has been associated with increased mortality. Wasting and weight loss occur in HIV infection even in the modern era of effective antiretroviral therapy. METHODS: We determined the association of MRI-measured regional and total skeletal muscle and adipose tissue with 5-year, all-cause mortality in 922 HIV-infected persons in the study of Fat Redistribution and Metabolic Change in HIV Infection (FRAM). RESULTS: After 5 years of follow-up, HIV-infected participants with arm skeletal muscle in the lowest tertile had a mortality rate of 23%, compared with 11 and 8% for those in the middle and highest tertiles. After multivariable adjustment for demographics, cardiovascular risk factors, HIV-related factors, inflammatory markers, and renal disease, we found that lower arm skeletal muscle, lower leg skeletal muscle and higher visceral adipose tissue (VAT) were each independently associated with increased mortality. Those in the lowest tertile of arm or leg skeletal muscle had higher odds of death [arm: odds ratio (OR) = 2.0, 95% confidence interval (CI) 0.96-4.0; leg: OR = 2.4, 95% CI 1.2-4.8] compared with the highest respective tertiles. Those in the highest tertile of VAT had 2.1-fold higher odds of death (95% CI 1.1-4.0) compared with the lowest VAT tertile. CONCLUSION: Lower muscle mass and central adiposity appear to be important risk factors for mortality in HIV-infected individuals. A substantial proportion of this risk may be unrecognized because of the current reliance on body mass index in clinical practice.

Therapeutic effects of nandrolone and testosterone in adult male HIV patients with AIDS wasting syndrome (AWS): a randomized, double-blind, placebo-controlled trial.

PURPOSE: We aimed to compare therapeutic effects of intramuscular (IM) nandrolone decanoate and IM testosterone enanthate in male HIV patients with AIDS wasting syndrome (AWS) with placebo control. METHODS: In this randomized, double-blind, placebo-controlled, 12-week trial, 104 patients with AWS who satisfied our inclusion criteria were randomly allotted in a 2:2:1 ratio to the 3 intervention groups: nandrolone, testosterone, and placebo. We administered 150 mg nandrolone and 250 mg testosterone (both IM, biweekly). The primary outcome measure was a comparison of absolute change in weight at 12 weeks between the nandrolone decanoate, testosterone, and placebo groups. RESULTS: Intent-to-treat analysis was done. The nandrolone group recorded maximum mean increase in weight (3.20 kg; post hoc P < .01 compared to placebo). Body mass index (BMI) of subjects in the nandrolone group had a significantly greater increase (mean = 1.28) compared to both testosterone (post hoc P < .05) and placebo (post hoc P < .01). Waist circumference and triceps skinfold thickness of patients on nandrolone showed similar results. Nandrolone also ensured a better quality of life. Patients with low testosterone level (<3 ng/mL) benefited immensely from nandrolone therapy, which increased their weight and BMI significantly compared to placebo (P < .05). CONCLUSION: Our trial demonstrates the superior therapeutic effects of nandrolone in male AWS patients, including the androgen deficient.

Bone loss in patients with HIV infection.

The prognosis of HIV infection has been considerably improved by the introduction of antiretroviral drugs. However, the longer survival times are associated with the emergence of new complications including decreased bone mineral density (BMD) values and/or bone insufficiency fractures. A meta-analysis of studies published between 1966 and 2005 showed bone absorptiometry results indicating osteoporosis in 15% of HIV patients and osteopenia in 52%. Longitudinal studies found no evidence that antiretroviral drug therapy contributed to the occurrence of bone loss. Available data indicate uncoupling with increases in bone resorption markers and decreases in bone formation markers. In addition to conventional risk factors for osteoporotic fractures, factors in HIV-infected patients may include malnutrition (wasting syndrome), hypogonadism, disorders in calcium and phosphate metabolism, and HIV infection per se. In patients with established bone insufficiency, bisphosphonate therapy should be considered. Alendronate in combination with vitamin D and calcium supplementation has been found effective in improving BMD values.

Medical marijuana in HIV-positive patients: what do we know?

On November 4, 2008, our state passed the Michigan Medical Marijuana Act (MMMA), which allows the medical use of marijuana for certain conditions and/or constellation of symptoms. This article will (1) review the current evidence that medical marijuana is useful for certain chronic conditions, particularly pain and wasting syndromes experienced by HIV-positive people; (2) discuss the adverse effects of marijuana; (3) summarize the new Michigan law and the challenges it poses for physicians, and (4) review the experience in California where medical marijuana has been legal since 1996.

Beneficial effects of nandrolone decanoate in wasting associated with HIV.

Recent studies have demonstrated the role of nandrolone decanoate (ND) in reversal of wasting associated with HIV infection. However, such studies in Indian scenario are lacking. Hence, the present study was planned with an objective to assess the effect of ND in patients of HIV-associated wasting in Indian subjects. The study was a prospective, randomised, multicentric, open labelled and comparative one in male HIV-infected subjects, aged between 18 and 65 years with involuntary weight loss of 10% over 12 months or 7.5% over 6 months or 5% over 3 months. The subjects were on stable antiretroviral therapy including at least 2 agents with CD, count > or =50 cells/microl. In the treatment group, ND (150 mg) intramuscularly every 2 weeks for 12 weeks was administered according to randomisation. Fat-free mass (FFM), body weight, CD4 count, and patient perception of treatment were the main outcomes measures. Of the 73 enrolled subjects, 69 completed study duration of 12 weeks. Compared to baseline, ND treated group demonstrated significant increase in FFM (0.49 +/- 1.26 kg; p < 0.01) and body weight (1.31 +/- 1.87 kg; p < 0.01) and control group demonstrated significant increase in body weight (0.99 +/- 1.48 kg; p < 0.01) at the end of treatment period. Compared to control group, patient perception of benefit and subjective recovery of symptoms was significantly (p < .0001) greater in the ND group. None of the patients had any clinically significant deterioration of biochemical as well as laboratory safety parameters. Nandrolone was well tolerated with few reported adverse events of mild and non-serious in nature. Nandrolone improved patient perception of benefit and subjective recovery of symptoms in wasting associated HIV. Nandrolone therapy may prove to be effective and safe in reversing wasting associated with Indian HIV patients on antiretroviral therapy (ART) and nutritional replacement.

Nutritional status of Malawian adults on antiretroviral therapy 1 year after supplementary feeding in the first 3 months of therapy.

OBJECTIVE: To test the hypothesis that individuals on antiretroviral therapy (ART) for 3 months with a greater body mass index (BMI) as a result of supplementary feeding with ready-to-use fortified spread would maintain a higher BMI 9 months after the feeding ended. METHODS: Two cohorts of wasted adults with AIDS, after 12 months of ART and 3 months of supplementary feeding with either ready-to-use fortified spread, an energy dense lipid paste; or corn/soy blended flour, were assessed for clinical and anthropometric status, quality of life, and ART adherence after 3 and 9 months. RESULTS: 336 ART patients participated: 162 who had received ready-to-use fortified spread and 174 who had received corn/soy blended flour. 9 months after stopping food supplements, both groups had a similar BMI, fat-free body mass, hospitalization rate and mortality. Binary logistic regression modelling showed that lower BMI, lower CD4 count, and older age at baseline were associated with a higher risk of death (odds ratio for BMI = 0.63, 95% CI 0.47-0.79). Adherence to the ART regimen and quality of life were similar in both cohorts. CONCLUSION: While supplementary feeding with ready-to-use fortified spread can ameliorate the BMI, an established risk factor for mortality, this effect is sustained only during the time of the intervention. Supplementary feeding of wasted patients for longer than 3 months should be investigated.

[The use of growth hormone to treat endocrine-metabolic disturbances in acquired immunodeficiency syndrome (AIDS) patients]. / O papel do hormônio de crescimento no tratamento dos distúrbios endócrino-metabólicos do paciente com a síndrome da imunodeficiência adquirida (Aids).

Acquired Immunodeficiency Syndrome (Aids) was initially related to HIV-associated wasting syndrome, and its metabolic disturbances to altered body composition. After Highly Active Antiretroviral Therapy (HAART) was started, malnutrition has declined and HIV-associated lipodystrophy syndrome has emerged as an important metabolic disorder. Aids is also characterized by hormonal disturbances, principally in growth hormone/insulin-like growth factor 1 (GH/IGF-1) axis. The use of recombinant human GH (hrGH) was formerly indicated to treat wasting syndrome, in order to increase lean body mass. Even though the use of hrGH in lipodystrophy syndrome has been considered, the decrease in insulin sensitivity is a limitation for its use, which has not been officially approved yet. Diversity in therapeutic regimen is another limitation to its use in Aids patients. The present study has reviewed the main HIV-related endocrine-metabolic disorders as well as the use of hrGH in such conditions.

O papel do hormônio de crescimento no tratamento dos distúrbios endócrino-metabólicos do paciente com a síndrome da imunodeficiência adquirida (Aids): [revisão] / The use of growth hormone to treat endocrine-metabolic disturbances in acquired immunodeficiency syndrome (Aids) patients: [review]

As primeiras descrições da síndrome da imunodeficiência adquirida (Aids) associavam-se à síndrome de emaciamento, e os distúrbios metabólicos às alterações na composição corporal. Após a introdução da terapia anti-retroviral altamente ativa (HAART), houve declínio na desnutrição, e surge a lipodistrofia como importante distúrbio metabólico. A Aids também se caracteriza por distúrbios hormonais, principalmente no eixo hormônio de crescimento/fator de crescimento insulina-like tipo 1 (GH/IGF-1). O uso do GH recombinante humano (hrGH) foi inicialmente indicado na síndrome de emaciamento, a fim de aumentar a massa muscular. Embora também não existam dúvidas quanto aos efeitos do hrGH na lipodistrofia, a diminuição na sensibilidade à insulina limita o seu uso, o qual ainda não está oficialmente aprovado. A diversidade nos esquemas de tratamento é outro limitante do uso dessa medicação em pacientes com Aids. Esta revisão apresenta os principais distúrbios endócrino-metabólicos associados à Aids e ao uso do hrGH nessas condições.

Acquired Immunodeficiency Syndrome (Aids) was initially related to HIV-associated wasting syndrome, and its metabolic disturbances to altered body composition. After Highly Active Antiretroviral Therapy (HAART) was started, malnutrition has declined and HIV-associated lipodystrophy syndrome has emerged as an important metabolic disorder. Aids is also characterized by hormonal disturbances, principally in growth hormone/insulin-like growth factor 1 (GH/IGF-1) axis. The use of recombinant human GH (hrGH) was formerly indicated to treat wasting syndrome, in order to increase lean body mass. Even though the use of hrGH in lipodystrophy syndrome has been considered, the decrease in insulin sensitivity is a limitation for its use, which has not been officially approved yet. Diversity in therapeutic regimen is another limitation to its use in Aids patients. The present study has reviewed the main HIV-related endocrine-metabolic disorders as well as the use of hrGH in such conditions.

Mecasermin.

Mecasermin (recombinant human insulin-like growth factor-I [IGF-I]) is approved in the US for the long-term treatment of growth failure in children with severe primary IGF-I deficiency or with growth hormone (GH) gene deletion who have developed neutralizing antibodies to GH, and in the EU for the long-term treatment of growth failure in children and adolescents with severe primary IGF-I deficiency. Subcutaneous mecasermin 0.12 mg/kg twice daily stimulated linear growth in children with growth failure and severe IGF-I deficiency associated with GH insensitivity, according to the results of a noncomparative, multicenter trial (n = 76) [mean duration of therapy 4.4 years; range 0.04-12.5 years]. During the first year of treatment, height velocity significantly increased from a mean 2.8 cm/year at baseline to a mean 8.0 cm/year; mean growth velocities remained above baseline for up to 8 years. Mecasermin also promoted statural growth in a small noncomparative trial in children with growth failure and GH insensitivity syndrome (n = 8). After 6.5-7.5 years of mecasermin therapy, the mean increase in the height standard deviation score was +1.4. Mecasermin was also shown to have beneficial effects in various other conditions including diabetes mellitus and anorexia nervosa. Subcutaneous mecasermin was generally well tolerated in children with severe IGF-I deficiency associated with GH insensitivity.