Guidelines issued for metabolic complications related to HIV & antirectrovirals

By Jeff Sheehy on November 04, 2002

The first comprehensive recommendations for assessing, monitoring and treating metabolic complications such as insulin resistance and abnormal body fat distribution that are occurring in association with HIV infection and antiretroviral therapy have been issued by an International AIDS Society-USA (IAS-USA) volunteer panel.

“These recommendations are important for clinicians because significant metabolic complications are affecting as many as half of all HIV-infected patients on antiretroviral regimens.  Concerns about complications are causing some patients to delay initiating therapy and others to reconsider their use of these life-saving medications,” said the panel’s chair, Morris Schambelan, MD, UCSF professor of medicine and director of the General Clinical Research Center at San Francisco General Hospital Medical Center.

The recommendations, published in the November 4 issue of the Journal of Acquired Immune Deficiency Syndromes, identify five major areas of concern: insulin resistance with alterations in glucose metabolism, abnormalities in lipid metabolism, lactic acid disorders, bone disease, and abnormal body fat distribution. These metabolic complications are troubling-high cholesterol and blood glucose levels may increase the risk of heart disease and stroke.  Lactic acidosis is a potentially fatal disorder.

In the article, the IAS-USA panel makes recommendations to clinicians regarding tests to identify and monitor metabolic complications in HIV-infected patients on antiretroviral therapy in each of the five areas. 

Approaches such as switching antiretroviral therapy, treatment of the complication with medication and behavior change such as diet and exercise are evaluated and recommended for each complication.

“Like the first guidelines for antiretroviral use issued by the IAS-USA in 1996 and updated thereafter, these recommendations are a work in progress and may change as new data become available.  They represent what is reasonable to do in a clinical practice based on the currently available evidence,” said Schambelan.

Estimated percentages of patients experiencing each complication and possible causes are also discussed in the article. “We are not completely sure about what role HIV-infection plays and what role the antiretrovirals play in each instance.  For example, AIDS-related wasting was the first metabolic problem seen in HIV-infected patients and that was clearly associated with HIV infection itself. For the current metabolic complications, antiretroviral medications as well as host factors appear to also play a role,” said Schambelan.
To develop the recommendations, IAS-USA selected a twelve-member international panel of experts in HIV clinical care, antiretroviral therapy, and endocrine and metabolic disorders in 2000. 

The panel reviewed results of clinical, epidemiological, and basic science studies and data, including studies of similar abnormalities in non-HIV infected persons. For each metabolic complication, the panel reviewed all available evidence. The recommendations of the panel were determined by full group consensus.

## Panel members and co-authors are:

* Co-chair Constance A. Benson, MD, professor of medicine, Division of Infectious Diseases, the University of Colorado Health Sciences Center;
* Andrew Carr, MD, associate professor of medicine, HIV, Immunology, and Infectious Diseases Clinical Service Unit, St. Vincent’s Hospital, Sydney, Australia;
* Judith S. Currier, MD, UCLA associate professor of medicine, associate chief, Division of Infectious Diseases, UCLA Medical Center;
* Michael P. Dubé, MD, associate professor of medicine, Indiana University School of Medicine;
* John G. Gerber, MD, professor of medicine and pharmacology, University of Colorado Health Sciences Center;
* Steven K. Grinspoon, MD, associate professor of medicine, Harvard Medical School;
* Carl Grunfeld, MD, PhD, UCSF professor of medicine, chief of the metabolism and endocrine sections at the San Francisco Veterans Affairs Medical Center;
* Donald P. Kotler, MD, professor of medicine, St. Luke’s-Roosevelt Hospital, Columbia University;
* Kathleen Mulligan, PhD, UCSF associate professor of medicine at San Francisco General Hospital Medical Center;
* William G. Powderly, MD, FRCPI, professor of medicine, chief, Division of Infectious Diseases, Washington University School of Medicine; and
* Michael S. Saag, MD, professor of medicine, The University of Alabama at Birmingham.

The International AIDS Society -USA funded this work and provided administrative and editorial management. The IAS-USA is a not-for-profit organization based in San Francisco that provides information and education for physicians involved in HIV/AIDS care.