Lipodystrophy and discontinuation of Therapy
Posted: Jan 18, 2005
QUESTION:
Dear Dr. G. Pierone,
My patient is HIV positive in 1997 August. HAART therapy started in July, 1998 with Stavudine-40 + Lamividine-150 + Nelfinavir-2500 till December 2002 with strict adherence. VL less than 20 and CD4=654 (Dec,2002). Abruptly stopped in Dec. 2002 because of lipoatrophy symptoms.Then the readings are as follows and pt. has no symptoms: April, 2003 - VL is 945 & CD4 is 624; July, 2003 -- VL is 2552 & CD4 is 571; April, 2004 -- vl is 11320 & CD4 is 249. Now the question is -- Shall I defer the therapy for some more time keeping the patient under monitoring? Shall I restart the theray immediately? If so, what is the ideal combination to avoid lipoatrophy and Peripheral Neuritis? Please advise?
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RESPONSE FROM: 
This scenario occurs quite commonly a patient has a gratifying virologic and immunologic response to therapy, but then develops significant medication-related side effects and says "thanks, but no thanks", and stops HAART.
So does this patient need immediate treatment? On the basis of the one CD4 count reading of 249 from April 2004, probably not. But a second reading below a count of 350 would convince more clinicians that it is time to start. For a detailed discussion on the data regarding initiation of antiretroviral therapy see the DHHS guidelines.
What regimen when this patient does restart? Since non-adherence was not an issue, drug resistant virus is unlikely. Stavudine (Zerit) is the agent most likely responsible for lipoatrophy and should be avoided. Other nucleosides that may cause lipoatrophy and peripheral neuritis include ddI (Videx) and AZT (zidovudine, Retrovir). A better choice nucleoside choice would be tenofovir (Viread) based on it lower rate of mitochondrial toxicity as compared with Zerit. Viread can be paired with either Epivir or Emtriva to complete the nucleoside backbone. The third agent is up for grabs. If this patient tolerated Viracept well, it now comes in a more palatable 625 mg tablet that translates into a reduction from 10 pills per day to 4 pills per day. For a simpler regimen, a NNRTI like Sustiva or Viramune is also available for this patient.
Thanks for posting.
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