Fat accumulation

Abdominal fat accumulation
Treatments for fat accumulation
Switching studies

More about lipodystrophy:

Associated drugs: nukes, NNRTIs and protease inhibitors.

Abdominal fat accumulation

Abdominal fat accumulation associated with lipodystrophy is generally visceral rather than subcutaneous. Visceral fat is around the organs inside the abdomen rather than fat just under your skin (‘love handles’).

With visceral fat your stomach walls are pushed out from the inside, so your stomach muscles can sometimes be quite defined, but your stomach will still be very extended.

In severe cases, your internal organs can become compressed so that normal functions like breathing and eating can be affected.

In these cases there is a greater medical urgency to reverse the fat accumulation. This may help you access treatments like growth hormone releasing factor (GHRF, Tesamorelin), growth hormone (rHGH) or switch drugs like T-20 or raltegravir.

Fat can also accumulate across the back of your neck and shoulders. This is sometimes called buffalo hump. Breast size can increase in both men and women. A fatty deposit in the breasts of men is called gynaecomastia.

Small bumps or collections of fat, called lipomas, can occur under the skin in other parts of the body including the pubis.

Treatments for fat accumulation

Many of the approaches used to lower cholesterol and triglycerides are being studied to treat fat accumulation. These include diet, exercise, and investigational drugs (see switching studies below).

Steroid treatment for lipodystrophy, particularly for fat accumulation, is also being studied. Although steroids have the potential to reduce fat accumulation, they should be used with caution as they may also worsen fat loss.

Recombinant Human Growth Hormone (rHGH) showed the potential to reduce visceral abdominal fat and fat pads from the back of the neck and shoulders in several small studies, but the side effects profile limits use of rHGH, even at lower doses. Dosing at 2, 3 or 4 mg daily rather than the 6mg in early studies reduces side effects. Fat accumulation appears to return if rHGH is stopped.

More recently, a Growth Hormone Releasing Factor called Tesamorelin (formerly TH-9507) produced similar results (approximately 20% reduction in visceral fat) with a much safer side effect profile than rHGH.

The benefits from GHRF are also only short-term and fat is likely to return unless treatment is continued, The maintenance dose of Tesamorelin has not been established,

Neither Tesamorelin nor rHGH are approved in Europe as treatments for lipodystrophy.

Removing fat pads using liposuction or surgically has worked well for some people. The fat returned, after several months, in 25-50% of people, but the results were more sustained in about half these reports.

There may be a higher likelihood of a permanent result if HIV treatment is modified at the same time.

Unless the underlying metabolic mechanism is altered, as with Tesamorelin or rHGH, fat accumulation is likely to return after several months.

Liposuction cannot be used for visceral fat accumulation in the abdomen.

Anecdotally, testosterone cream massaged onto the fat pads has reduced fat pads on the shoulders. A much lower dose would be used for women than for men.

Dihydrotestosterone gel (Andractim) has been used to treat breast enlargement (gynaecomastia) in men.

Women with lipodystrophy may have higher levels of testosterone than either HIV-positive women without lipodystrophy or HIV-negative women. It is not clear whether this is due to high insulin levels associated with lipodystrophy, although a link between the length of time on PI-therapy (but not other drugs) and a greater chance of higher testosterone was found in one study.

Switching studies

Studies switching individual drugs have been less helpful with fat accumulation than with fat loss.

If you change your combination, you have to change it to one that is just as effective against HIV.

Studies switching a PI to an NNRTI have been too poorly designed to show any change clearly. Often background nucleosides were not changed, when we now think that this would have helped too. There are often reports of better adherence, easier regimens, fewer pills, and most importantly no viral load rebound, but effect on fat is less clear.

There have been anecdotal reports and case studies of people whose shoulder and/or abdominal fat decreased after switching to atazanavir.

Atazanavir does not cause the elevated blood lipid levels associated with other protease inhibitors, but long-term impact on risk of other symptoms of lipodystrophy is still being studied. Raltegravir, a new integrase inhibitor, does not affect blood lipids, but the impact on lipodystrophy is unclear

In theory, if one particular drug is linked to these body changes then it is very reasonable to at least try another one, in case this works for you.

Diagram showing effect of visceral fat accumulation

An MRI scan through your stomach shows that fat is inside the abdomen and around the organs rather than being directly under your skin.

Visceral fat accumulation compresses organs