Marina, thank you for your question.
The treatment of the lipodystrophy syndromes has been quite frustrating, with only limited successes.
Because of initial speculation of an etiologic role of protease inhibitors, many studies that switched patients from PIs to NNRTIs were conducted-- in general, without demonstrable benefit.
Recent therapeutic trials have acknowledged the differences between lipoaccumulation and lipoatrophy-- though there is considerable epidemiologic overlap.
One intriguing study using high-dose niacin for lipoaccumulation was presented recently by Fessler and colleagues from the Northern California Kaiser group-- showing significant reduction (~25%) in intraabdominal fat as measured by CT, among persons who took 3 grams daily. This is a huge dose, and likely not universally well tolerated; and has the potential for adverse reactions. In our hands we've not been able to say that we've had dramatic results with this intervention. Additionally, with regard to your patient, this study did not address dorsocervical adenopathy, so expectations about reduction of fat in this site needs to be tempered.
By contrast, a select number of patients with dorsocervical fat accumulation underwent surgical resection-- I wouldn't call it liposuction, since the tissue is more fibroadenomatous, and less amenable to liposuction; some of these patients have had relatively durable improvement in their fat accumulation and symptoms. Others have noted (and some patients in our practice) a reaccumulation of fat after reduction surgery, so I wouldn't say that the results have been uniformly good.
There are also case reports of retrogression of lipoaccumulation for some patients who were concomitantly switched off of protease inhibitors-- it suggests that for a subset of patients, this drug class might have a pathogenetic role. Since you mention that your patient is on ARVs, this could be a potential intervention (with the above caveat).
Good luck, BY
