Gang
I am very happy about having been selected to be a community member to this respected panel. This is my second try in the past 4 years and I finally made it through. This is one of the most important (if not the most important) medical guidelines panel in HIV treatment. I will be lucky to be working with great researchers and clinicians, and will make sure that the concerns from the patients in the field are brought to their attention. Jules Levin has already reminded not to forget bone density issues, aging related issues, some women-specific issues and toxicities as areas to bring up as data and signals in the field become available. I am glad I have good mentors like Jules, Bob Munk. Marty Delaney and Lynda Dee that have been there before me !
Wish me luck!
Nelson
Issue No. 52 | December 12, 2008
AIDSinfo.nih.gov is pleased to provide you with a weekly update of highlights about what has happened in the world of HIV/AIDS treatment, prevention, and research. We hope you find this encapsulated view of HIV/AIDS news useful.
Adult and Adolescent Guidelines Panel Announces New Members
The Department of Health and Human Services (DHHS) Panel on Antiretroviral Guidelines for Adults and Adolescents (a working group of the Office of AIDS Research Council) is pleased to welcome the following new members to the Panel. The new members will begin a 4-year term beginning February 2009.
New Scientific Members:
Robert Dodge, Ph.D., R.N., A.N.P. (University of North Carolina)
Christopher Gordon, Ph.D. (National Institute of Mental Health, NIH)
Michael Hughes, Ph.D. (Harvard University)
William Kapogiannis, M.D. (National Institute of Child Health & Human Development, NIH)
Daniel Kuritzkes, M.D. (Harvard University)
Mark Sulkowski, M.D. (Johns Hopkins University)
New Community Member:
Nelson Vergel (Houston, Texas)
The following members will be concluding their services to the Panel in February 2009. The Panel thanks them for their contributions over the years.
A. Cornelius Baker (National Black Gay Men's Advocacy Coalition)
Charles Carpenter, M.D. (Brown Medical School)
Suzanne Willard, Ph.D., C.R.N.P. (Elizabeth Glaser Pediatric AIDS Foundation)
-
The untold Side of the movie "Dallas Buyers Club"
The movie Dallas Buyers Club brings attention to a little-recognized part of the AIDS activist movement: ....
-
Exhorbitant Price New Hepatitis C Drug
Fair Pricing Coalition Condemns Gilead Sciences on the High Price of New Hepatitis C Drug Sovaldi™...
-
Six Promising HIV Drugs in the Pipeline (2013-2014)
What new HIV medications do we have to look forward to over the next few years? How will these newer drugs improve upon the older ones? To shed some light on these questions....
-
What Can We Look Forward to in HIV Cure Research
TheBodyPRO.com's Nelson Vergel sat down with leading HIV cure research activist Richard Jefferys for an update on current important aspects, and controversies, in HIV cure research....
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What Supplements Can I take with HIV medications?
Is it ok to supplement with Creatine (Cell-Tech), and Protein (Nitro-Tech) along with Glutamine...
Saturday, December 13, 2008
Tuesday, December 02, 2008
Should I take Vitamin D if I am taking Viread or Truvada?
Vitamin D and Viread. Should I be concerned?
Dec 1, 2008
Dear Nelson:
Thanks for what you do for us
I just read an email that said that a study showed that people on Viread had low vitamin D and may have problems with bone. Should I take Vitamin D with Viread?
I do not want to have broken bones as I age
Tony
Response from Mr. Vergel
Dear Tony
Researchers at Mount Sinai School of Medicine recently presented a very interesting paper at the ICAAC 2008 conference on this issue. As you well know, Tenofovir (Viread) is probably the best nucleoside analog out there with the least problems with lipoatrophy and other side effects. However, it has been associated with kidney issues in some treatment experienced patients and also with loss of bone density in some studies. It seems that the bone effects are greater in those taking tenofovir with boosted protease inhibitors. Unfortunately, most of us do not know we have low bone density until we get a fracture.
Vitamin D is needed by our bodies to metabolize calcium to build up bone. Most of it is made when our skin in exposed to sunlight. Many people do not get enough sun in winter months.
In this study, most patients on tenofovir had low Vitamin D levels in their blood (measured as 25(OH)D). 39% of those with low Vitamin D levels also had high parathyroid hormone levels (PTH)
PTH is produced in the parathyroid glands which are four pea-sized glands located on the thyroid gland in the neck. Though their names are similar, the thyroid and parathyroid glands are entirely different glands, each producing distinct hormones with specific functions. The parathyroid glands secrete PTH, a substance that helps maintain the correct balance of calcium and phosphorus in the body. PTH regulates the level of calcium in the blood, release of calcium from bone, absorption of calcium in the intestine, and excretion of calcium in the urine.
When the level of calcium in the blood falls too low, the parathyroid glands secrete just enough PTH to restore the blood calcium level. High PTH usually means that there may be some bone loss problems. Low Vitamin D is known to cause hyperparathyrodism (high PTH).
The study investigators hypothesize that Viread's effect on bone may be related to this low Vit D/high PTH effect. More studies are needed with a larger number of patients
You may want to ask your doctor to measure 25 (OH) D levels. I am also an activist who is trying to get DEXA bone scans to be part of standard of care for people with HIV. It would be great to get a DEXA bone scan before someone starts HAART and then repeated it every two to three years to see how your bones are doing on therapy.
By the way, HIV infection by itself has also been associated with loss of bone density. But some medications may also add to this problem.
Bone density research in HIV is progressing. I tell people to work out with weights and machines, to get at least 30 minutes of sun a day, and to make sure their thyroid hormones and testosterone are in normal range to prevent bone loss. Some people would also benefit from taking Calcium/Vitamin D supplements and/or precription drugs approved to increase bone density.
Talk to your doctor since this is very new data.
Nelson
Dec 1, 2008
Dear Nelson:
Thanks for what you do for us
I just read an email that said that a study showed that people on Viread had low vitamin D and may have problems with bone. Should I take Vitamin D with Viread?
I do not want to have broken bones as I age
Tony
Response from Mr. Vergel
Dear Tony
Researchers at Mount Sinai School of Medicine recently presented a very interesting paper at the ICAAC 2008 conference on this issue. As you well know, Tenofovir (Viread) is probably the best nucleoside analog out there with the least problems with lipoatrophy and other side effects. However, it has been associated with kidney issues in some treatment experienced patients and also with loss of bone density in some studies. It seems that the bone effects are greater in those taking tenofovir with boosted protease inhibitors. Unfortunately, most of us do not know we have low bone density until we get a fracture.
Vitamin D is needed by our bodies to metabolize calcium to build up bone. Most of it is made when our skin in exposed to sunlight. Many people do not get enough sun in winter months.
In this study, most patients on tenofovir had low Vitamin D levels in their blood (measured as 25(OH)D). 39% of those with low Vitamin D levels also had high parathyroid hormone levels (PTH)
PTH is produced in the parathyroid glands which are four pea-sized glands located on the thyroid gland in the neck. Though their names are similar, the thyroid and parathyroid glands are entirely different glands, each producing distinct hormones with specific functions. The parathyroid glands secrete PTH, a substance that helps maintain the correct balance of calcium and phosphorus in the body. PTH regulates the level of calcium in the blood, release of calcium from bone, absorption of calcium in the intestine, and excretion of calcium in the urine.
When the level of calcium in the blood falls too low, the parathyroid glands secrete just enough PTH to restore the blood calcium level. High PTH usually means that there may be some bone loss problems. Low Vitamin D is known to cause hyperparathyrodism (high PTH).
The study investigators hypothesize that Viread's effect on bone may be related to this low Vit D/high PTH effect. More studies are needed with a larger number of patients
You may want to ask your doctor to measure 25 (OH) D levels. I am also an activist who is trying to get DEXA bone scans to be part of standard of care for people with HIV. It would be great to get a DEXA bone scan before someone starts HAART and then repeated it every two to three years to see how your bones are doing on therapy.
By the way, HIV infection by itself has also been associated with loss of bone density. But some medications may also add to this problem.
Bone density research in HIV is progressing. I tell people to work out with weights and machines, to get at least 30 minutes of sun a day, and to make sure their thyroid hormones and testosterone are in normal range to prevent bone loss. Some people would also benefit from taking Calcium/Vitamin D supplements and/or precription drugs approved to increase bone density.
Talk to your doctor since this is very new data.
Nelson
World AIDS Day: Adverse Impact of Steroid Law and Steroid Hearings on Anabolic Therapies
World AIDS Day: Adverse Impact of Steroid Law and Steroid Hearings on Anabolic Therapies
Posted on 15:42 December 1st, 2008 by Millard Baker
http://www.mesomorphosis.com/blog/2008/12/01/world-aids-day-adverse-impact-of-steroid-law-for-hiv/
In recognition of World AIDS Day, we urge Congressional leaders in the United States to carefully consider the significant harm that morally-guided U.S. steroid policy has had for the life-saving therapeutic applications offered by anabolic-androgenic steroids. The criminalization of anabolic steroids and steroid hysteria perpetuated by Congressional steroid hearings has had an adverse impact on medical research and medical therapies involving anabolic steroids, particularly in the prevention and treatment of HIV+ associated wasting disease.
Anabolic steroids are one of the safest and most effective treatments for HIV associated wasting and have been invaluable in helping HIV+ patients retain, preserve and restore lean body weight and stay alive. Given that wasting is one of the most common symptoms of HIV and that HIV+ patients with wasting symptoms have significantly higher mortality rates, anabolic steroids have been an invaluable medical treatment.
Michael Mooney, of Medibolics, and Nelson Vergel, of the Program for Wellness Restoration, have spearheaded educational efforts and have extensively documented the benefits of anabolic steroid therapy for AID/HIV wasting in “Built to Survive“. Mooney and Vergel have discussed the negative consequences arising from the demonization of steroids by the Anabolic Steroid Control Act of 1990 (”Anabolic Steroid Legality and the Physician,” January 28).
The Anabolic Steroid Act of 1990 created grave misunderstandings about the legal status of “steroids as medicines” to the public and to the physicians trying to help their patients. This law states only that anabolic steroids can not be prescribed for cosmetic or athletic purposes, but the impression it created was that steroids were off limits to everyone, and that they are basically illegal for any use. This is not the case. To compound this climate of fear, it seems that when this law was passed in 1990 several of the more conservative regional governing medical organizations made doctors uneasy, giving them impression that they would become the object of scrutiny if they prescribed steroids at all.
The scheduling of anabolic steroids as controlled substances was a medical catastrophe that pandered to anti-doping crusaders in sports while ignoring the medicinal value of androgens and the life-saving therapeutic potential this category of pharmaceutical drugs offered for HIV+ patients. The regulatory agencies in charge of scheduling of drugs strongly protested the inclusion of anabolic steroids in the Controlled Substances List. Legislators ignored the scientific advisors and experts from the American Medical Association (AMA), the Food and Drug Administration (FDA), the Department of Health and Human Services (DHHS) and the Drug Enforcement Enforcement (DEA) to pass the Anti-Drug Abuse Act of 1988 and the Anabolic Steroid Control Act of 1990.
The legislators were guided by the moral condemnation of athletes that use anabolic steroids and performance enhancing drugs rather than a rational empirical analysis of steroid use and abuse and the effects of such legislation on leigitmate medical research and anabolic therapy.
Unfortunately, the steroid hysteria has continued with the Congressional steroids and baseball hearings initiated by Henry Waxman (and former chief of staff Phil Schiliro) and the passage of more draconian steroid laws in recent years. California resident Mark A. Meier outlined the impact the steroid hearings in a letter to the Nancy Pelosi, Speaker of the House (”Representative Henry Waxman’s Hearings on Steroids in Sports and the Impact on Treatments for HIV and other Medical Conditions,” March 12).
The result, then, of Representative Waxman’s hearings has been an attack on an important, powerful, beneficial and legal therapy solely because professional athletes use it improperly. Patients with legitimate medical needs should not be made to suffer because of the improper actions of a few.
Nelson Vergel of the HIV Blog explains how political pressure and steroid hysteria have restricted the availability of anabolic steroids for HIV+ patients. The moral and political pressure resulted in the discontinuation of Deca Durabolin by Watson Pharmaceutical and the discontinuation of nandrolone decanoate by compounding pharmacies like Applied Pharmacy (”Important information about nandrolone in the U.S.” March 17).
Watson stopped making [nandrolone decanoate] because… Congress and the DEA are treating anabolics like the treat crack-cocaine and are closely watching every prescriber’s and manufacturer’s move. No HIV doc has ever got in trouble since many studies have shown nandrolone’s benefit and can justify its medical use. However, inexperienced HIV doctors who have not been around long enough to know its history shy away from prescribing due to the bad publicity and misconceptions around these medicines. [...]
Applied Pharmacy stopped all production due to DEA pressure. Some compounders are making doctors sign a waiver to say they will not prescribe nandrolone for non medical uses. Some doctors feel this represents extra liability.
The effects of anabolic steroids in treating HIV+ associated wasting syndrome by preserving and increasing lean body weight has been well documented by multiple studies. Unfortunately, Congressional leaders in the United States have based steroid policy on emotional testimony and moral objections to cheating in sports rather than scientifically-guided legislative policy; this has been to the detriment of individuals with AIDS/HIV+ associated wasting syndrome. The morally-guided steroid policy has effectively limited the availability of anabolic steroids for those individuals who use steroids as a matter of medical necessity. We urge Congress to reconsider and re-evaluate the Anabolic Steroid Control Act to address the address the adverse effects of current steroid policy on the advancement of anabolic therapies in medicine.
Posted on 15:42 December 1st, 2008 by Millard Baker
http://www.mesomorphosis.com/blog/2008/12/01/world-aids-day-adverse-impact-of-steroid-law-for-hiv/
In recognition of World AIDS Day, we urge Congressional leaders in the United States to carefully consider the significant harm that morally-guided U.S. steroid policy has had for the life-saving therapeutic applications offered by anabolic-androgenic steroids. The criminalization of anabolic steroids and steroid hysteria perpetuated by Congressional steroid hearings has had an adverse impact on medical research and medical therapies involving anabolic steroids, particularly in the prevention and treatment of HIV+ associated wasting disease.
Anabolic steroids are one of the safest and most effective treatments for HIV associated wasting and have been invaluable in helping HIV+ patients retain, preserve and restore lean body weight and stay alive. Given that wasting is one of the most common symptoms of HIV and that HIV+ patients with wasting symptoms have significantly higher mortality rates, anabolic steroids have been an invaluable medical treatment.
Michael Mooney, of Medibolics, and Nelson Vergel, of the Program for Wellness Restoration, have spearheaded educational efforts and have extensively documented the benefits of anabolic steroid therapy for AID/HIV wasting in “Built to Survive“. Mooney and Vergel have discussed the negative consequences arising from the demonization of steroids by the Anabolic Steroid Control Act of 1990 (”Anabolic Steroid Legality and the Physician,” January 28).
The Anabolic Steroid Act of 1990 created grave misunderstandings about the legal status of “steroids as medicines” to the public and to the physicians trying to help their patients. This law states only that anabolic steroids can not be prescribed for cosmetic or athletic purposes, but the impression it created was that steroids were off limits to everyone, and that they are basically illegal for any use. This is not the case. To compound this climate of fear, it seems that when this law was passed in 1990 several of the more conservative regional governing medical organizations made doctors uneasy, giving them impression that they would become the object of scrutiny if they prescribed steroids at all.
The scheduling of anabolic steroids as controlled substances was a medical catastrophe that pandered to anti-doping crusaders in sports while ignoring the medicinal value of androgens and the life-saving therapeutic potential this category of pharmaceutical drugs offered for HIV+ patients. The regulatory agencies in charge of scheduling of drugs strongly protested the inclusion of anabolic steroids in the Controlled Substances List. Legislators ignored the scientific advisors and experts from the American Medical Association (AMA), the Food and Drug Administration (FDA), the Department of Health and Human Services (DHHS) and the Drug Enforcement Enforcement (DEA) to pass the Anti-Drug Abuse Act of 1988 and the Anabolic Steroid Control Act of 1990.
The legislators were guided by the moral condemnation of athletes that use anabolic steroids and performance enhancing drugs rather than a rational empirical analysis of steroid use and abuse and the effects of such legislation on leigitmate medical research and anabolic therapy.
Unfortunately, the steroid hysteria has continued with the Congressional steroids and baseball hearings initiated by Henry Waxman (and former chief of staff Phil Schiliro) and the passage of more draconian steroid laws in recent years. California resident Mark A. Meier outlined the impact the steroid hearings in a letter to the Nancy Pelosi, Speaker of the House (”Representative Henry Waxman’s Hearings on Steroids in Sports and the Impact on Treatments for HIV and other Medical Conditions,” March 12).
The result, then, of Representative Waxman’s hearings has been an attack on an important, powerful, beneficial and legal therapy solely because professional athletes use it improperly. Patients with legitimate medical needs should not be made to suffer because of the improper actions of a few.
Nelson Vergel of the HIV Blog explains how political pressure and steroid hysteria have restricted the availability of anabolic steroids for HIV+ patients. The moral and political pressure resulted in the discontinuation of Deca Durabolin by Watson Pharmaceutical and the discontinuation of nandrolone decanoate by compounding pharmacies like Applied Pharmacy (”Important information about nandrolone in the U.S.” March 17).
Watson stopped making [nandrolone decanoate] because… Congress and the DEA are treating anabolics like the treat crack-cocaine and are closely watching every prescriber’s and manufacturer’s move. No HIV doc has ever got in trouble since many studies have shown nandrolone’s benefit and can justify its medical use. However, inexperienced HIV doctors who have not been around long enough to know its history shy away from prescribing due to the bad publicity and misconceptions around these medicines. [...]
Applied Pharmacy stopped all production due to DEA pressure. Some compounders are making doctors sign a waiver to say they will not prescribe nandrolone for non medical uses. Some doctors feel this represents extra liability.
The effects of anabolic steroids in treating HIV+ associated wasting syndrome by preserving and increasing lean body weight has been well documented by multiple studies. Unfortunately, Congressional leaders in the United States have based steroid policy on emotional testimony and moral objections to cheating in sports rather than scientifically-guided legislative policy; this has been to the detriment of individuals with AIDS/HIV+ associated wasting syndrome. The morally-guided steroid policy has effectively limited the availability of anabolic steroids for those individuals who use steroids as a matter of medical necessity. We urge Congress to reconsider and re-evaluate the Anabolic Steroid Control Act to address the address the adverse effects of current steroid policy on the advancement of anabolic therapies in medicine.
Wednesday, November 26, 2008
Happy Thanksgiving to All
To all of you in pozhealth:
I would like to take this opportunity to thank all of you who help each other daily on this list. It amazes me that we have been sharing since 2002 with more than 30,000 emails in 7 years. We now have close to 3000 members!
I am also thankful that new drugs for multidrug resistance were approved this year and that 3 million people are now in treatment around the world, although 7 more million need it to survive. Hopefully we will see treatment spreading faster to help those who need it most and cannot afford them.
The cure of HIV is now part of the research conversation for the first time. I see the word "cure" more frequently now, although it may take years to get there.
Side effects seem to be decreasing with better drugs, and for that I am very thankful.
I am also thankful that Obama won and that hope is slowly being restored in our hearts. I hope that he does not let us down and that we can support him fully while hoping that evil does not attempt to destroy him in his mission.
I am thankful for all the sweet emails I have received from many of you through my hard times this year. Although most of us have not met face-to-face, the love I feel through the electronic lines can certainly reach my heart.
Yes, there is a lot to do and a lot we should have done to save lives in the world. But today, I am thankful that we are here helping each other while we remember our friends and family who are no longer in our presence, but they are in our hearts.
Regards,
Nelson Vergel
powerusa.org
I would like to take this opportunity to thank all of you who help each other daily on this list. It amazes me that we have been sharing since 2002 with more than 30,000 emails in 7 years. We now have close to 3000 members!
I am also thankful that new drugs for multidrug resistance were approved this year and that 3 million people are now in treatment around the world, although 7 more million need it to survive. Hopefully we will see treatment spreading faster to help those who need it most and cannot afford them.
The cure of HIV is now part of the research conversation for the first time. I see the word "cure" more frequently now, although it may take years to get there.
Side effects seem to be decreasing with better drugs, and for that I am very thankful.
I am also thankful that Obama won and that hope is slowly being restored in our hearts. I hope that he does not let us down and that we can support him fully while hoping that evil does not attempt to destroy him in his mission.
I am thankful for all the sweet emails I have received from many of you through my hard times this year. Although most of us have not met face-to-face, the love I feel through the electronic lines can certainly reach my heart.
Yes, there is a lot to do and a lot we should have done to save lives in the world. But today, I am thankful that we are here helping each other while we remember our friends and family who are no longer in our presence, but they are in our hearts.
Regards,
Nelson Vergel
powerusa.org
Monday, November 24, 2008
Do we know enough about lipodystrophy?
Do we know enough about lipodystrophy?
Aug 26, 2008
Dear Nelson,
I have a quick question that I feel you can best answer for being an hiv survivor for 25 years. Is the the war on lipo able to be won??? I mean will working out bring muscle back or will my time be wasted??? Also what supplements do you suggest a person take??? I am taking the mv k-pax single strength. Thank You
Response from Nelson
I would asnwer: "yes, partially"
We now know that a lot that we did not know a few years ago.
1- D4T and AZT are two drugs that are linked to fat loss under the skin (lipoatrophy). Tenofovir (Viread) does not cause lipoatrophy in most patients (only 11% had a loss of 20% or more of fat under the skin when used they used tenofovir/3TC with Kaletra or Sustiva in one study)
2- That some protease inhibitors can negatively affect the job of insulin to help store glucose in muscle as glycogen ( insulin resistance) which may increase triglycerides and fat cell size in some patients
3- We know that exercise helps to build lean body mass
4- we know that anabolic steroids like nandrolone and oxandrolone can help those having a difficut at regaining normal weight
5- Statins and fibrates work at reducing lipids in poz people but sometimes not good enough to have them reach normal levels
6- That supplements like Omega 3 fish oils and niacin can help statins and fibrates improve their job at lowering LDL, triglycerides and increasing good cholesterol (HDL)
7- That those who start HAART with low CD4 cells tend to be more prone to having increased belly fat when their CD4 cells increase
8- That there are products like Sculptra, Silikon 1000 and Radiesse in the United States that can help people restore a healthy face
9- That supplements like K PAX and others have some promising but limited data in HIV that requires more studies
10- That growth hormone (Serostim) works at reducing visceral fat but we cannot use it for lipodystrophy because the FDA did not like growth hormone's side effects. Another less effective but lower side effect product may be approved in the future
11- That switching first line patients from Kaletra to Reyataz does not improve their bodies. Other "switch" studies showed the same results.
Unfortunately, we do not data on lower glycemic index diets, good comparison data of what happens to visceral fat when different protease inhibitors or non-nucleosides are used with Truvada in naives with low and higher CD4 at baseline, diet/exercise combinations, and other supplements like carnitine and others. Stay tuned for my upcoming review of studies to be presented at the Lipodystrophy Conference in London on Nov 2008.
You can read more about where we are now here:
http://www.thebody.com/content/art45454.html
I hope this helped
And yes, single strength K PAX is great as a supplement since it includes all minerals and antioxidants you need.
Nelson
Aug 26, 2008
Dear Nelson,
I have a quick question that I feel you can best answer for being an hiv survivor for 25 years. Is the the war on lipo able to be won??? I mean will working out bring muscle back or will my time be wasted??? Also what supplements do you suggest a person take??? I am taking the mv k-pax single strength. Thank You
Response from Nelson
I would asnwer: "yes, partially"
We now know that a lot that we did not know a few years ago.
1- D4T and AZT are two drugs that are linked to fat loss under the skin (lipoatrophy). Tenofovir (Viread) does not cause lipoatrophy in most patients (only 11% had a loss of 20% or more of fat under the skin when used they used tenofovir/3TC with Kaletra or Sustiva in one study)
2- That some protease inhibitors can negatively affect the job of insulin to help store glucose in muscle as glycogen ( insulin resistance) which may increase triglycerides and fat cell size in some patients
3- We know that exercise helps to build lean body mass
4- we know that anabolic steroids like nandrolone and oxandrolone can help those having a difficut at regaining normal weight
5- Statins and fibrates work at reducing lipids in poz people but sometimes not good enough to have them reach normal levels
6- That supplements like Omega 3 fish oils and niacin can help statins and fibrates improve their job at lowering LDL, triglycerides and increasing good cholesterol (HDL)
7- That those who start HAART with low CD4 cells tend to be more prone to having increased belly fat when their CD4 cells increase
8- That there are products like Sculptra, Silikon 1000 and Radiesse in the United States that can help people restore a healthy face
9- That supplements like K PAX and others have some promising but limited data in HIV that requires more studies
10- That growth hormone (Serostim) works at reducing visceral fat but we cannot use it for lipodystrophy because the FDA did not like growth hormone's side effects. Another less effective but lower side effect product may be approved in the future
11- That switching first line patients from Kaletra to Reyataz does not improve their bodies. Other "switch" studies showed the same results.
Unfortunately, we do not data on lower glycemic index diets, good comparison data of what happens to visceral fat when different protease inhibitors or non-nucleosides are used with Truvada in naives with low and higher CD4 at baseline, diet/exercise combinations, and other supplements like carnitine and others. Stay tuned for my upcoming review of studies to be presented at the Lipodystrophy Conference in London on Nov 2008.
You can read more about where we are now here:
http://www.thebody.com/content/art45454.html
I hope this helped
And yes, single strength K PAX is great as a supplement since it includes all minerals and antioxidants you need.
Nelson
How Can I Lower Cholesterol Without Drugs?
Lower cholesterol without drugs
Jun 6, 2008
My cholesterol levels have crept above 200 after three years on Reyataz & Epzicom. I'm in good condition with my aerobic exercise routine, take supplements that should help my cholesterol (like omega-3s and green tea extracts), and have a small glass of red wine most evenings with dinner. I avoid fried and overly-processed foods for the most part. How much can I reasonably expect my eating and exercise habits to be effective in lowering my cholesterol? Is there anything you recommend I add to my supplements to help (e.g. l-carnitine)?
Response from Mr. Vergel
It seems that you are doing everyting you can to lower cholesterol but I have a few suggestions:
Just make sure that you are taking at least 3000-4000 mg a day of Omega 3 capsules, that you sweat while doing cardio for at least 20 min a day, that your sweet consumptions is low, that you are eating oatmeal daily , and that you do not exceed two glasses of wine a day. L-Carnitine at 2000 mg a day can also help bring triglycerides and cholesterol down, specially taken with Omega 3 fatty acids. Niacin has also been shown to be effective decreasing cholesterol. In some studies, niacin at daily doses of 2-3 grams can lower LDL and total cholesterol by approximately 20-30%, lower triglycerides by 35-55%, and increase HDL cholesterol by 20-35%. It can cause "flushing" of the skin in some patients for 20-30 minutes that may make it uncomfortable for them to take it. Slow adjustment of the dosage, administration with food, and giving a baby aspirin before niacin may minimize these reactions. Niacin is available as an over-the-counter supplement and also as a prescription drug called Niaspan.
Some people do all they can to lower cholesterol naturally but are yet to get down to recommended levels. There are genetic factors involved in many cases. For those, taking lipid lowering meds is a good idea.
Keep up with the great work!
Nelson
Jun 6, 2008
My cholesterol levels have crept above 200 after three years on Reyataz & Epzicom. I'm in good condition with my aerobic exercise routine, take supplements that should help my cholesterol (like omega-3s and green tea extracts), and have a small glass of red wine most evenings with dinner. I avoid fried and overly-processed foods for the most part. How much can I reasonably expect my eating and exercise habits to be effective in lowering my cholesterol? Is there anything you recommend I add to my supplements to help (e.g. l-carnitine)?
Response from Mr. Vergel
It seems that you are doing everyting you can to lower cholesterol but I have a few suggestions:
Just make sure that you are taking at least 3000-4000 mg a day of Omega 3 capsules, that you sweat while doing cardio for at least 20 min a day, that your sweet consumptions is low, that you are eating oatmeal daily , and that you do not exceed two glasses of wine a day. L-Carnitine at 2000 mg a day can also help bring triglycerides and cholesterol down, specially taken with Omega 3 fatty acids. Niacin has also been shown to be effective decreasing cholesterol. In some studies, niacin at daily doses of 2-3 grams can lower LDL and total cholesterol by approximately 20-30%, lower triglycerides by 35-55%, and increase HDL cholesterol by 20-35%. It can cause "flushing" of the skin in some patients for 20-30 minutes that may make it uncomfortable for them to take it. Slow adjustment of the dosage, administration with food, and giving a baby aspirin before niacin may minimize these reactions. Niacin is available as an over-the-counter supplement and also as a prescription drug called Niaspan.
Some people do all they can to lower cholesterol naturally but are yet to get down to recommended levels. There are genetic factors involved in many cases. For those, taking lipid lowering meds is a good idea.
Keep up with the great work!
Nelson
How do I get my insurance to pay for my facial wasting treatment?
How do I get my insurance to pay for my facial wasting treatment?
Jun 28, 2008
Hello Nelson-
I hope this finds you well. I wanted to check in with you to see if you were aware if there is any insurance coverage for silicone treatments for facial wasting. I have had several sessions, and it works great. It is not cheap, of course. I am in need of a refresher treatment. I should mention that my insurance is Medicare A,B and D. I receive my meds through a Blue Cross-Part D plan, backed up by ADAP.
Neal
Response from Mr. Vergel
Neal,
It is difficult to get reimbursement for Silikon 1000 since it is an off-label use for facial wasting, but you have nothing to lose and a lot to gain if you have your doctor write a medical necessity letter to send to your insurance company.
Here is a letter that Dr. Doug Mest wrote for my web site facialwasting.org for Sculptra. You can have your doctor use this letter as a template and also to use these scientific references. You can also visit the wonderful resource guide that TheBody.com has created for trying to get coverage for facial lipoatrophy reconstruction options from your insurance:
http://www.thebody.com/lipo/insurance.html
References for silicone and facial lipoatrophy:
http://findarticles.com/p/articles/mi_m0PDG/is_2_4/ai_n13559216
SAMPLE LETTER:
Insurance Co Name
Insurance Co Address
Patient Name
Subscriber #
Date
To Whom It May Concern:
This letter is written in regards to the medical necessity of restorative treatment for the facial deformities this patient suffers from secondary to HIV-Associated Lipoatrophy. Facial fat loss is the most devastating aspect of this condition as it can not be disguised by clothing or other means. Although the exact underlying mechanism of HIV-Associated Lipoatrophy is unknown (1), the devastating effects of this condition are known (2,3). Patients suffering from this condition are at an increased risk of depression, socially withdrawn and potentially suicidal. Furthermore, patients have even stopped their life saving HAART therapy without consultation with their physician in an attempt to stop this side effect. The implications for viral mutations, increasing viral load and worsening of patients underlying condition requiring more expensive treatments cannot be stressed enough. Treatment of HIV-Associated Lipoatrophy with Sculptra (Poly-L-Lactic Acid) has been shown to improve anxiety and depression scores (4) as well as improve patient's quality of life as measured by visual analogue scale (5). The use of Sculptra is clearly indicated as a reconstructive procedure; that is, repair of abnormal facial structure caused by HIV or its treatment, in order to create a normal appearance.
The safety and efficacy of Sculptra in restoring the normal facial contours of patients suffering from HIV-Associated Facial Lipoatrophy has been evaluated by the US FDA (6). Based on the available scientific evidence (4,5), the FDA granted approval of Sculptra as a restorative medical device for the specific indication of HIV-Associated Facial Lipoatrophy in August 2004.
For your information. the ICD9 diagnosis code for lipodystrophy is 272.6. HIV-related lipodystrophy syndrome consists of lipo-hypertrophy (fat accumulation in the visceral area and dorsocervical pad) and lipoatrophy (subcutaneous fat loss in the face, extremities and buttocks).
Due to the medical necessity of this treatment and the availability of a safe and effective treatment option, pre-approval is hereby requested for treatment of this patient's HIV-Associated Facial Lipoatrophy with Sculptra.
As this approval is relatively recent, I would be happy to further educate your company on this issue in any way that you might deem helpful. Please feel free to contact me at the above office with any questions you may have.
Sincerely,
References:
1) Montessori, V. CMAJ. 2004;170:229-238.
2) James J, Carruthers, A. Dermatol Surg. 2002;28:979-986.
3) Martinez, E. Drug Saf. 2001;24:157-166.
4) Moyle, GJ. HIV Medicine. 2004;5:82-87.
5) Valantin, M. AIDS. 2003;17:2471-2477.
6) FDA Scientific Advisory Panel 3/25/2004 Washington DC
Jun 28, 2008
Hello Nelson-
I hope this finds you well. I wanted to check in with you to see if you were aware if there is any insurance coverage for silicone treatments for facial wasting. I have had several sessions, and it works great. It is not cheap, of course. I am in need of a refresher treatment. I should mention that my insurance is Medicare A,B and D. I receive my meds through a Blue Cross-Part D plan, backed up by ADAP.
Neal
Response from Mr. Vergel
Neal,
It is difficult to get reimbursement for Silikon 1000 since it is an off-label use for facial wasting, but you have nothing to lose and a lot to gain if you have your doctor write a medical necessity letter to send to your insurance company.
Here is a letter that Dr. Doug Mest wrote for my web site facialwasting.org for Sculptra. You can have your doctor use this letter as a template and also to use these scientific references. You can also visit the wonderful resource guide that TheBody.com has created for trying to get coverage for facial lipoatrophy reconstruction options from your insurance:
http://www.thebody.com/lipo/insurance.html
References for silicone and facial lipoatrophy:
http://findarticles.com/p/articles/mi_m0PDG/is_2_4/ai_n13559216
SAMPLE LETTER:
Insurance Co Name
Insurance Co Address
Patient Name
Subscriber #
Date
To Whom It May Concern:
This letter is written in regards to the medical necessity of restorative treatment for the facial deformities this patient suffers from secondary to HIV-Associated Lipoatrophy. Facial fat loss is the most devastating aspect of this condition as it can not be disguised by clothing or other means. Although the exact underlying mechanism of HIV-Associated Lipoatrophy is unknown (1), the devastating effects of this condition are known (2,3). Patients suffering from this condition are at an increased risk of depression, socially withdrawn and potentially suicidal. Furthermore, patients have even stopped their life saving HAART therapy without consultation with their physician in an attempt to stop this side effect. The implications for viral mutations, increasing viral load and worsening of patients underlying condition requiring more expensive treatments cannot be stressed enough. Treatment of HIV-Associated Lipoatrophy with Sculptra (Poly-L-Lactic Acid) has been shown to improve anxiety and depression scores (4) as well as improve patient's quality of life as measured by visual analogue scale (5). The use of Sculptra is clearly indicated as a reconstructive procedure; that is, repair of abnormal facial structure caused by HIV or its treatment, in order to create a normal appearance.
The safety and efficacy of Sculptra in restoring the normal facial contours of patients suffering from HIV-Associated Facial Lipoatrophy has been evaluated by the US FDA (6). Based on the available scientific evidence (4,5), the FDA granted approval of Sculptra as a restorative medical device for the specific indication of HIV-Associated Facial Lipoatrophy in August 2004.
For your information. the ICD9 diagnosis code for lipodystrophy is 272.6. HIV-related lipodystrophy syndrome consists of lipo-hypertrophy (fat accumulation in the visceral area and dorsocervical pad) and lipoatrophy (subcutaneous fat loss in the face, extremities and buttocks).
Due to the medical necessity of this treatment and the availability of a safe and effective treatment option, pre-approval is hereby requested for treatment of this patient's HIV-Associated Facial Lipoatrophy with Sculptra.
As this approval is relatively recent, I would be happy to further educate your company on this issue in any way that you might deem helpful. Please feel free to contact me at the above office with any questions you may have.
Sincerely,
References:
1) Montessori, V. CMAJ. 2004;170:229-238.
2) James J, Carruthers, A. Dermatol Surg. 2002;28:979-986.
3) Martinez, E. Drug Saf. 2001;24:157-166.
4) Moyle, GJ. HIV Medicine. 2004;5:82-87.
5) Valantin, M. AIDS. 2003;17:2471-2477.
6) FDA Scientific Advisory Panel 3/25/2004 Washington DC
Are Creatine Supplements Effective to increase muscle?
Creatine Supplement
Jul 29, 2008
I workout six times a week, take a teaspoon of creatine before each workout with some juice. Is there a problem taking this supplement pratically everyday. I noticed that on my recent labs that my creatine number was 1.4H, I've been taking this supplement for about 6 weeks.
Response from Nelson
Creatine is the most popular bodybuilding supplement out there. It has been shown in non HIV studies to increase lean body mass and strength. I have taken it once in a while and definitely feel more pumped and a little stronger. There are concerns about loading up the kidneys, however. Your creatinine blood level is higher than normal, so I would probably be careful if I was you.
We have some pilot data in HIV presented by Dr. Sakkas at the Lipodystrophy Workshop in Dublin in 2005. It was a placebo controlled study of the use of creatine or placebo plus exercise.
Strength did not differ much between the creatine arm and the placebo arm. But men taking creatine had a significant jump in triglycerides, a risk factor for heart disease. I am not sure if the creatine supplement used had sugar in it, which may explain the increase in triglycerides.
Lean body mass index rose in both groups, but significantly more with creatine (2.3 versus 0.9 kg, P = 0.01). Thigh muscle cross-sectional area also increased more with creatine, but not significantly more than with placebo (12.2 versus 9.3 cm2, P = 0.34).
What are your triglycerides? Talk to your doctor since you may have some reduction in kidney function that may not make you a good candidate for this supplement.
You may want to try Juven, another supplement that has arginine, HMB and glutamine that may not have a negative effect on the kidneys.
Reference:
G.K. Sakkas, K. Mulligan, MI. DeSilva, et al. Creatine supplementation fails to augment the benefits derived from resistance exercise training in patients with HIV infection. 7th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV. November 13-16, 2005. Dublin. Abstract 6.
Jul 29, 2008
I workout six times a week, take a teaspoon of creatine before each workout with some juice. Is there a problem taking this supplement pratically everyday. I noticed that on my recent labs that my creatine number was 1.4H, I've been taking this supplement for about 6 weeks.
Response from Nelson
Creatine is the most popular bodybuilding supplement out there. It has been shown in non HIV studies to increase lean body mass and strength. I have taken it once in a while and definitely feel more pumped and a little stronger. There are concerns about loading up the kidneys, however. Your creatinine blood level is higher than normal, so I would probably be careful if I was you.
We have some pilot data in HIV presented by Dr. Sakkas at the Lipodystrophy Workshop in Dublin in 2005. It was a placebo controlled study of the use of creatine or placebo plus exercise.
Strength did not differ much between the creatine arm and the placebo arm. But men taking creatine had a significant jump in triglycerides, a risk factor for heart disease. I am not sure if the creatine supplement used had sugar in it, which may explain the increase in triglycerides.
Lean body mass index rose in both groups, but significantly more with creatine (2.3 versus 0.9 kg, P = 0.01). Thigh muscle cross-sectional area also increased more with creatine, but not significantly more than with placebo (12.2 versus 9.3 cm2, P = 0.34).
What are your triglycerides? Talk to your doctor since you may have some reduction in kidney function that may not make you a good candidate for this supplement.
You may want to try Juven, another supplement that has arginine, HMB and glutamine that may not have a negative effect on the kidneys.
Reference:
G.K. Sakkas, K. Mulligan, MI. DeSilva, et al. Creatine supplementation fails to augment the benefits derived from resistance exercise training in patients with HIV infection. 7th International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV. November 13-16, 2005. Dublin. Abstract 6.
Provigil for Fatigue?
Provigil...what is your opinion?
Aug 4, 2008
I suffer from severe fatigue and my doctor wants me to try Provigil. What is your opinion? Thanks guru man
Response from Nelson
PROVIGIL is a prescription medicine used to improve wakefulness in adults who experience excessive sleepiness (ES) due to one of the following diagnosed sleep disorders: obstructive sleep apnea (OSA), shift work sleep disorder (SWSD), or narcolepsy.
It is used in HIV off label to treat fatigue. A pilot study done by Dr Judith G. Rabkin in NYC showed good results in increasing energy levels and mood in people with HIV. There is a larger study now recruiting :
http://clinicaltrials.gov/ct2/show/NCT00118378?intr=%22Modafinil%22&rank=32
I have taken Provigil for three years on and off and absolutely love it. I take a very small dose of 100 mg at morning time when I am too fatigued to work. I have mild sleep apnea and did not enjoy using a CPAP machine. I experience mood elevation also.
Two bad thing: it is expensive and many insurance companies do not wan to pay for it, and it is metabolized in the P450liver enzimatic path, so there may be interactions with HIV medications that use the same path. So far we have no interaction data since many pharmaceutical companies do not include this drug in their "normal" list of drugs to test.
Insurance companies that do not wan to pay for the drug argue that cheaper amphetamine-based products do the same thing. What they ignore is that Provigil is not an amphetamine and it has no habit forming properties. It is not classified as a Class II drug as amphetamines are. It also does not decrease appetite. The company has a patient assistance program (I have not audited it, however). You can have your questions about reimbursement answered by calling the PROVIGIL Reimbursement Assistance Hotline at 1-800-675-8415.
Some people are very sensitive to it and experience nervousness with it. I say if that happens try half a pill and build up from there.
Of course, Provigil is not a substitue for a good night sleep.
I hope this helps!
Nelson
Aug 4, 2008
I suffer from severe fatigue and my doctor wants me to try Provigil. What is your opinion? Thanks guru man
Response from Nelson
PROVIGIL is a prescription medicine used to improve wakefulness in adults who experience excessive sleepiness (ES) due to one of the following diagnosed sleep disorders: obstructive sleep apnea (OSA), shift work sleep disorder (SWSD), or narcolepsy.
It is used in HIV off label to treat fatigue. A pilot study done by Dr Judith G. Rabkin in NYC showed good results in increasing energy levels and mood in people with HIV. There is a larger study now recruiting :
http://clinicaltrials.gov/ct2/show/NCT00118378?intr=%22Modafinil%22&rank=32
I have taken Provigil for three years on and off and absolutely love it. I take a very small dose of 100 mg at morning time when I am too fatigued to work. I have mild sleep apnea and did not enjoy using a CPAP machine. I experience mood elevation also.
Two bad thing: it is expensive and many insurance companies do not wan to pay for it, and it is metabolized in the P450liver enzimatic path, so there may be interactions with HIV medications that use the same path. So far we have no interaction data since many pharmaceutical companies do not include this drug in their "normal" list of drugs to test.
Insurance companies that do not wan to pay for the drug argue that cheaper amphetamine-based products do the same thing. What they ignore is that Provigil is not an amphetamine and it has no habit forming properties. It is not classified as a Class II drug as amphetamines are. It also does not decrease appetite. The company has a patient assistance program (I have not audited it, however). You can have your questions about reimbursement answered by calling the PROVIGIL Reimbursement Assistance Hotline at 1-800-675-8415.
Some people are very sensitive to it and experience nervousness with it. I say if that happens try half a pill and build up from there.
Of course, Provigil is not a substitue for a good night sleep.
I hope this helps!
Nelson
What is better? Testosterone Injections or Gels?
What is better? Testosterone Injections or Gels?
Nov 6, 2008
I am currently on testosterone enanthate, one injection every two weeks. Is there an actual advantage to using testim, the gel? I have all options available to me. Ed
Response:
Dear Ed:
If you are used to the injections, you may not feel the same "lift" by the gels. The injections cost around $80 a month compared to $1100 a month for Testim or Androgel. Some people argue that gels are better to keep your testosterone blood levels more constant and to avoid "peaks and valleys"
Some people love the daily gels. I am an injection guy since I do not want to deal with daily application.
Some people cannot reach adequate testosterone blood levels (0ver 500 nanograms per deciliter of total testosterone) while using Testim or Androgel since these two only contain 1% testosterone. It is unfortunate that most people and their doctors do not know that you can get better and more concentrated (5%) testosterone gels from compounding pharmacies at around $60 a month. Some of the cheapest ones are apsmeds.com and newrx.com
More info on medibolics.com or our book Built to Survive, available at amazon.com
Nelson
Nov 6, 2008
I am currently on testosterone enanthate, one injection every two weeks. Is there an actual advantage to using testim, the gel? I have all options available to me. Ed
Response:
Dear Ed:
If you are used to the injections, you may not feel the same "lift" by the gels. The injections cost around $80 a month compared to $1100 a month for Testim or Androgel. Some people argue that gels are better to keep your testosterone blood levels more constant and to avoid "peaks and valleys"
Some people love the daily gels. I am an injection guy since I do not want to deal with daily application.
Some people cannot reach adequate testosterone blood levels (0ver 500 nanograms per deciliter of total testosterone) while using Testim or Androgel since these two only contain 1% testosterone. It is unfortunate that most people and their doctors do not know that you can get better and more concentrated (5%) testosterone gels from compounding pharmacies at around $60 a month. Some of the cheapest ones are apsmeds.com and newrx.com
More info on medibolics.com or our book Built to Survive, available at amazon.com
Nelson
Feeling bloated everyday What to eat?
Feeling bloated everyday What to eat?
Oct 28, 2008
I have an ongoing daily problem with bloatedness where I feel my stomach never empties properly ,and I never approach a meal feeling hungry.I have accumulated visceral fat as a pot belly through lipoatrophy and have been trying to eat well- high protein/calorie diet to build a bit of muscle tone on my arms and legs in particular.Can you advise me how to get some relief from the bloating,the fat accumulation around the gut, and how to maintain the weight I have?. Many thanks for any help. Regards John
Dear John:
I tell you, your problem is my main problem also.
I have researched options for ten years. Eating smaller meals that do not contain milk products or sweets seeem to help. I avoid beans and brocolli also. I take four pills of Beano before meals and that helps sometimes. Eating yogurt twice a day gives me relief also.
Try to snack instead of having three large meals. Be really aware of any food allergies you may have, particularly milk and whey protein products. Drink lots of water also.
I have also tried Ultrase, a prescription digestive enzyme taken before meals. That seems to help a lot. Glutamine at 15 grams a day seems to be helping a lot of people (I have problems with adherence with powder products that require several doses a day)
The problem comes and goes for me without reason. I really think that keeping a healthy gut flora is key, and avoiding gas producing foods. Sometimes I wonder if binders used in HIV medications have an effect on our guts. It has also been shown by certain studies that our gut integrity is impaired after years of HIV, so who knows if that is also a factor in bloating and that "full feeling" that many of us have.
I have also noticed that my bloating gets worse when I take pain killers like ibuprofen. They have been shown to decrease gut motility, so that may be a factor.
Some patients have insisted to their doctors that they want a one slice CT scan at the L4 L5 level to see how much visceral fat they have. I am not sure if this is something that insurance companies would pay for and what the use would be to have such information. It is my belief that visceral fat can push on our intestinal tissue and gives us that feeling of fullness, but this is just a speculation from my part.
Many of us are suffering from this problem. Many have gone through colonoscopies, endoscopies, etc without any clear answers. Unfortunately, I know of no researcher looking into this problem.
I would work out three to four times a week to try to decrease fat accumulation. Do not go crazy with so much protein intake that counteracts the effects of exercise. Too many calories, no matter if they come from protein, will end up stored as fat if your energy expenditure is not high enough to compensate for the extra food intake. As I said, small 300-400 calorie snacks 6 times a day, lots of water, and exercise should be your basic program to start with.
I hope this helped some. It has become one of the hottest topics in this column so stay tuned since I usually do not let go of a problem until answers are found somehow :)
Nelson
Oct 28, 2008
I have an ongoing daily problem with bloatedness where I feel my stomach never empties properly ,and I never approach a meal feeling hungry.I have accumulated visceral fat as a pot belly through lipoatrophy and have been trying to eat well- high protein/calorie diet to build a bit of muscle tone on my arms and legs in particular.Can you advise me how to get some relief from the bloating,the fat accumulation around the gut, and how to maintain the weight I have?. Many thanks for any help. Regards John
Dear John:
I tell you, your problem is my main problem also.
I have researched options for ten years. Eating smaller meals that do not contain milk products or sweets seeem to help. I avoid beans and brocolli also. I take four pills of Beano before meals and that helps sometimes. Eating yogurt twice a day gives me relief also.
Try to snack instead of having three large meals. Be really aware of any food allergies you may have, particularly milk and whey protein products. Drink lots of water also.
I have also tried Ultrase, a prescription digestive enzyme taken before meals. That seems to help a lot. Glutamine at 15 grams a day seems to be helping a lot of people (I have problems with adherence with powder products that require several doses a day)
The problem comes and goes for me without reason. I really think that keeping a healthy gut flora is key, and avoiding gas producing foods. Sometimes I wonder if binders used in HIV medications have an effect on our guts. It has also been shown by certain studies that our gut integrity is impaired after years of HIV, so who knows if that is also a factor in bloating and that "full feeling" that many of us have.
I have also noticed that my bloating gets worse when I take pain killers like ibuprofen. They have been shown to decrease gut motility, so that may be a factor.
Some patients have insisted to their doctors that they want a one slice CT scan at the L4 L5 level to see how much visceral fat they have. I am not sure if this is something that insurance companies would pay for and what the use would be to have such information. It is my belief that visceral fat can push on our intestinal tissue and gives us that feeling of fullness, but this is just a speculation from my part.
Many of us are suffering from this problem. Many have gone through colonoscopies, endoscopies, etc without any clear answers. Unfortunately, I know of no researcher looking into this problem.
I would work out three to four times a week to try to decrease fat accumulation. Do not go crazy with so much protein intake that counteracts the effects of exercise. Too many calories, no matter if they come from protein, will end up stored as fat if your energy expenditure is not high enough to compensate for the extra food intake. As I said, small 300-400 calorie snacks 6 times a day, lots of water, and exercise should be your basic program to start with.
I hope this helped some. It has become one of the hottest topics in this column so stay tuned since I usually do not let go of a problem until answers are found somehow :)
Nelson
Vitamin Research in HIV- anything exciting now?
Vitamin Research in HIV- anything exciting now?
Nov 12, 2008
I have been reading your emails about supplements and HIV and you seem to be concerned that the research has slowed down. My question is: what is being studied right now, if any?
Thanks
Tony
Dear Tony
I am glad you asked this question. I have done a search on clinical trials.gov and have actually found some really interesting studies that are currently enrolling:
Micronutrient Supplemented Probiotic Yogurt for HIV/AIDS and Other Immunodeficiencies
http://clinicaltrials.gov/ct2/show/NCT00517803?term=HIV&recr=Open&rank=441
Effects of Mixed Exercise Regime and L-Carnitine Supplementation in HIV Patients
http://clinicaltrials.gov/ct2/show/NCT00572429?term=HIV&recr=Open&rank=54
Chromium Picolinate to treat HIV related diabetes
http://clinicaltrials.gov/ct2/show/NCT00109746? term=HIV&recr=Open&rank=340
A Trial of Vitamins and HAART in HIV Disease Progression
http://clinicaltrials.gov/ct2/show/NCT00383669?term=HIV&recr=Open&rank=124
The Prevalence of Vitamin D Deficiency and Effects of Vitamin D Supplementation
http://clinicaltrials.gov/ct2/show/NCT00306410?term=HIV&recr=Open&rank=410
Acupuncture for Nausea in HIV
http://clinicaltrials.gov/ct2/show/NCT00624793?term=HIV&recr=Open&rank=390
So, I guess I was not 100% correct when I said there is little research on nutritional and complementary therapies in HIV
I encourage everyone to call these sites and support these studies
Nelson Vergel
Nov 12, 2008
I have been reading your emails about supplements and HIV and you seem to be concerned that the research has slowed down. My question is: what is being studied right now, if any?
Thanks
Tony
Dear Tony
I am glad you asked this question. I have done a search on clinical trials.gov and have actually found some really interesting studies that are currently enrolling:
Micronutrient Supplemented Probiotic Yogurt for HIV/AIDS and Other Immunodeficiencies
http://clinicaltrials.gov/ct2/show/NCT00517803?term=HIV&recr=Open&rank=441
Effects of Mixed Exercise Regime and L-Carnitine Supplementation in HIV Patients
http://clinicaltrials.gov/ct2/show/NCT00572429?term=HIV&recr=Open&rank=54
Chromium Picolinate to treat HIV related diabetes
http://clinicaltrials.gov/ct2/show/NCT00109746? term=HIV&recr=Open&rank=340
A Trial of Vitamins and HAART in HIV Disease Progression
http://clinicaltrials.gov/ct2/show/NCT00383669?term=HIV&recr=Open&rank=124
The Prevalence of Vitamin D Deficiency and Effects of Vitamin D Supplementation
http://clinicaltrials.gov/ct2/show/NCT00306410?term=HIV&recr=Open&rank=410
Acupuncture for Nausea in HIV
http://clinicaltrials.gov/ct2/show/NCT00624793?term=HIV&recr=Open&rank=390
So, I guess I was not 100% correct when I said there is little research on nutritional and complementary therapies in HIV
I encourage everyone to call these sites and support these studies
Nelson Vergel
Can Gardasil actually remove mild warts?
Question:Can Gardasil actually remove mild warts or is it only for preventing
infection in the first place? I was also wondering if a woman can take
Gardasil and the infection can be eliminated.>>
Answer:
Gardasil is a preventive vaccine, not a therapeutic vaccine, so it can't eliminate the infection once you have it. But since people can be coinfected with multiple types of HPV (some cause warts, some cause cancer) it can prevent you from acquiring additional HPV types you don't already have. Gardasil is a quadrivalent vaccine--meaning it prevents infection from 4 types of HPV--two causing warts, and two that cause the majority of cancers. Since most people with HIV are by definition sexually active, they've already been exposed to HPV--how many types depends on the extent of sexual activity, and how old you are. So in theory it could prevent you from being infected by the HPV types you don't already have, but it's hard to know what kinds you have since I don't think those tests are commercially available (they're only done as part of research)
Sorry I couldn't give you a simpler answer. So whether you should take the vaccine becomes a personal choice--mostly determined by whether you're willing to spend the money (I think it's about $300? Don't quote me on that) and it's a series of shots, not a one time deal.
The far more important thing to do is to get a regular PAP smear of your rectum (and cervix, if you have one) If the results come back abnormal (as they often do--esp in HIV positives) it's imperative that you follow it up with an anoscopy (or colposcopy for the cervix) and a biopsy of any suspicious areas. If the results come back grade 2 or higher they must be removed (don't let anyone convince you otherwise--HIV+ people are at much higher risk of rapid progression to cancer) Women know all about HPV and the cervix, and for the past 40 yrs PAP smears and followup testing have drastically lowered the cancer incidence & deaths. You need to be proactive and make sure you and your doctor do the same for your butt. For a list of certified anal PAP smear practitioners, go to http://www.analcancerinfo.ucsf.edu/
Hope this helps.
Jeff in Palm Springs
infection in the first place? I was also wondering if a woman can take
Gardasil and the infection can be eliminated.>>
Answer:
Gardasil is a preventive vaccine, not a therapeutic vaccine, so it can't eliminate the infection once you have it. But since people can be coinfected with multiple types of HPV (some cause warts, some cause cancer) it can prevent you from acquiring additional HPV types you don't already have. Gardasil is a quadrivalent vaccine--meaning it prevents infection from 4 types of HPV--two causing warts, and two that cause the majority of cancers. Since most people with HIV are by definition sexually active, they've already been exposed to HPV--how many types depends on the extent of sexual activity, and how old you are. So in theory it could prevent you from being infected by the HPV types you don't already have, but it's hard to know what kinds you have since I don't think those tests are commercially available (they're only done as part of research)
Sorry I couldn't give you a simpler answer. So whether you should take the vaccine becomes a personal choice--mostly determined by whether you're willing to spend the money (I think it's about $300? Don't quote me on that) and it's a series of shots, not a one time deal.
The far more important thing to do is to get a regular PAP smear of your rectum (and cervix, if you have one) If the results come back abnormal (as they often do--esp in HIV positives) it's imperative that you follow it up with an anoscopy (or colposcopy for the cervix) and a biopsy of any suspicious areas. If the results come back grade 2 or higher they must be removed (don't let anyone convince you otherwise--HIV+ people are at much higher risk of rapid progression to cancer) Women know all about HPV and the cervix, and for the past 40 yrs PAP smears and followup testing have drastically lowered the cancer incidence & deaths. You need to be proactive and make sure you and your doctor do the same for your butt. For a list of certified anal PAP smear practitioners, go to http://www.analcancerinfo.ucsf.edu/
Hope this helps.
Jeff in Palm Springs
Monday, November 10, 2008
An Anti-frailty Pill For Seniors? New Drug Increases Muscle Mass In Arms And Legs Of Older Adults
I bet this could compete with Theratecnologies/Serono's Tesamorelin eventually. But Merck is smart going after baby aging boomers
An Anti-frailty Pill For Seniors? New Drug Increases Muscle Mass In Arms And Legs Of Older Adults
ScienceDaily (Nov. 5, 2008) — Researchers at the University of Virginia Health System report that a daily single oral dose of an investigational drug, MK-677, increased muscle mass in the arms and legs of healthy older adults without serious side effects, suggesting that it may prove safe and effective in reducing age-related frailty.
Published in the November 4, 2008 issue of Annals of Internal Medicine, the study showed that levels of growth hormone (GH) and of insulin-like growth factor I (IGF- I) in seniors who took MK-677 increased to those found in healthy young adults. The drug restored 20 percent of muscle mass loss associated with normal aging.
"Our study opens the door to the possibility of developing treatments that avert the frailty of aging," explains Dr. Michael O. Thorner, a nationally recognized researcher of growth hormone regulation and a professor of internal medicine and neurosurgery at UVA. "The search for anti-frailty medications has become increasingly important because the average American is expected to live into his or her 80s, and most seniors want to stay strong enough to remain independent as they age."
Funded by the National Institutes of Health, the two-year, double-blind, placebo-controlled, modified-crossover study involved 65 men and women ranging in age from 60 to 81.
The study drug, MK-677, mimics the action of ghrelin, a peptide that stimulates the growth hormone secretagogue receptor (GHSR). Drug developers are focusing on GHSR because it plays an important role in the regulation of growth hormone and appetite. They think it may prove to be an excellent treatment target for metabolic disorders such as those related to body weight and body composition.
According to Dr. Thorner, the UVA research was a "proof-of-concept" study that sets the stage for a larger and longer clinical trial to determine whether MK-677 is effective in people who are frail and to assess its long term safety.
--------------------------------------------------------------------------------
University of Virginia Health System (2008, November 5). An Anti-frailty Pill For Seniors? New Drug Increases Muscle Mass In Arms And Legs Of Older Adults. ScienceDaily. Retrieved November 10, 2008, from http://www.sciencedaily.com /releases/2008/11/081104132902.htm
An Anti-frailty Pill For Seniors? New Drug Increases Muscle Mass In Arms And Legs Of Older Adults
ScienceDaily (Nov. 5, 2008) — Researchers at the University of Virginia Health System report that a daily single oral dose of an investigational drug, MK-677, increased muscle mass in the arms and legs of healthy older adults without serious side effects, suggesting that it may prove safe and effective in reducing age-related frailty.
Published in the November 4, 2008 issue of Annals of Internal Medicine, the study showed that levels of growth hormone (GH) and of insulin-like growth factor I (IGF- I) in seniors who took MK-677 increased to those found in healthy young adults. The drug restored 20 percent of muscle mass loss associated with normal aging.
"Our study opens the door to the possibility of developing treatments that avert the frailty of aging," explains Dr. Michael O. Thorner, a nationally recognized researcher of growth hormone regulation and a professor of internal medicine and neurosurgery at UVA. "The search for anti-frailty medications has become increasingly important because the average American is expected to live into his or her 80s, and most seniors want to stay strong enough to remain independent as they age."
Funded by the National Institutes of Health, the two-year, double-blind, placebo-controlled, modified-crossover study involved 65 men and women ranging in age from 60 to 81.
The study drug, MK-677, mimics the action of ghrelin, a peptide that stimulates the growth hormone secretagogue receptor (GHSR). Drug developers are focusing on GHSR because it plays an important role in the regulation of growth hormone and appetite. They think it may prove to be an excellent treatment target for metabolic disorders such as those related to body weight and body composition.
According to Dr. Thorner, the UVA research was a "proof-of-concept" study that sets the stage for a larger and longer clinical trial to determine whether MK-677 is effective in people who are frail and to assess its long term safety.
--------------------------------------------------------------------------------
University of Virginia Health System (2008, November 5). An Anti-frailty Pill For Seniors? New Drug Increases Muscle Mass In Arms And Legs Of Older Adults. ScienceDaily. Retrieved November 10, 2008, from http://www.sciencedaily.com /releases/2008/11/081104132902.htm
Sunday, November 09, 2008
A Cure for AIDS available now?
______________________________________________
The 'Cure' was NOT So Easy
attached is pdf of abstract from CROI 2008 conference.
You may have read a few days ago the story of a 40-year old HIV+ German man who had leukemia who received a bone marrow transplant and now they can't find HIV in him 600 days after the procedure. Well, this positive sounding headlines don't tell the whole story of what the patient had to go through. So here is some additional information and a link to the poster explaining more details.
Apparently, the patient had bad case of acute myeloid leukemia, was unresponsive to standard leukemia, so he had to get a bone marrow transplant. He had been undetectable (HIV viral load) for a long time on HAART. The German doctor found a matched donor who was CCR5 delta 32. they gave the German man ablative chemotherapy (tried to kill all the patient's cells) while on ART, then transplant delta 32 cells. ART was stopped. Now 600 days off ART there is no evidence of HIV, by standrad PCR and some other tests (DNA PCR, and HIV from PBMCs also negative).
Leukemia is still not totally gone, the patient is still cytopenic; unsure but he may still e getting chemo once in a while. There is graft vs host and graft vs tumor: that is the donor CCR5 delta 32 recognize any remaining patient cells as foreign and try to kill them whether or not these patient cells are normal or cancerous....this is the desired outcome in marrow transplant for cancer, and how it would clear cancer.
So, the results show a 'functional cure', but it seems that most people would not want to go through al this and you would have to find a matched donor who was CCR5 delta 32.
A number of researchers think there still is HIV remaining somewhere in this patients body but hasn't yet been found or surfaced. Of course this would be in line with the thinking that HIV reservoirs exist and they cannot be purged.
Jules Levin
Here is Wall Street Journal article
ovember 7, 2008, 8:35 am
Did a Bone Marrow Transplant Cure a Cancer Patient of AIDS?
Posted by Jacob Goldstein
A 42-year-old man who had both leukemia and AIDS received a bone marrow transplant — a common, late-stage treatment for that type of cancer. His doctor selected a bone marrow donor who had a rare genetic mutation that renders people virtually immune to HIV. The transplant appeared to cure the patient of AIDS.
We’re as wary as the next guy of inferring too much from a single case study. Maybe it was a fluke; maybe there were unknown factors at work. But this one is pretty intriguing.
The case was presented at a conference earlier this year (here’s the abstract), and written up in this morning’s WSJ.
As is common for bone marrow transplant recipients, the patient first had radiation and chemotherapy, which tends to kill off many of the immune cells that harbor HIV. After the transplant, the patient’s immune system was repopulated by cells created by the donor marrow.
The donor had a mutation, present in about 1% of Europeans, that creates immune system cells that lack a receptor molecule called CCR5. That receptor plays an important role in HIV’s ability to enter the cell. (Pfizer’s HIV drug Selzentry works by blocking CCR5.)
So the patient’s immune system was repopulated with immune cells that carried the mutation. And, nearly two years after undergoing the transplant, he shows no signs of having any HIV left in his body — despite the fact that he hasn’t taken any AIDS drugs since before the transplant.
Perhaps the most important caveat is just how risky bone marrow transplantation is: It’s given to cancer patients after other treatments fail, and it kills up to 30% of patients.
But researchers hope to apply the apparent lessons of this case to strategies using gene therapy (which carries its own risks) to try to induce the protective mutation in patients with HIV.
David Baltimore, who won a Nobel Prize for research on tumor viruses, has started a company to use gene therapy to target HIV. He calls this case “a very good sign” and a virtual “proof of principle” for gene-therapy approaches.
Image of HIV by C. Goldsmith via CDC
The 'Cure' was NOT So Easy
attached is pdf of abstract from CROI 2008 conference.
You may have read a few days ago the story of a 40-year old HIV+ German man who had leukemia who received a bone marrow transplant and now they can't find HIV in him 600 days after the procedure. Well, this positive sounding headlines don't tell the whole story of what the patient had to go through. So here is some additional information and a link to the poster explaining more details.
Apparently, the patient had bad case of acute myeloid leukemia, was unresponsive to standard leukemia, so he had to get a bone marrow transplant. He had been undetectable (HIV viral load) for a long time on HAART. The German doctor found a matched donor who was CCR5 delta 32. they gave the German man ablative chemotherapy (tried to kill all the patient's cells) while on ART, then transplant delta 32 cells. ART was stopped. Now 600 days off ART there is no evidence of HIV, by standrad PCR and some other tests (DNA PCR, and HIV from PBMCs also negative).
Leukemia is still not totally gone, the patient is still cytopenic; unsure but he may still e getting chemo once in a while. There is graft vs host and graft vs tumor: that is the donor CCR5 delta 32 recognize any remaining patient cells as foreign and try to kill them whether or not these patient cells are normal or cancerous....this is the desired outcome in marrow transplant for cancer, and how it would clear cancer.
So, the results show a 'functional cure', but it seems that most people would not want to go through al this and you would have to find a matched donor who was CCR5 delta 32.
A number of researchers think there still is HIV remaining somewhere in this patients body but hasn't yet been found or surfaced. Of course this would be in line with the thinking that HIV reservoirs exist and they cannot be purged.
Jules Levin
Here is Wall Street Journal article
ovember 7, 2008, 8:35 am
Did a Bone Marrow Transplant Cure a Cancer Patient of AIDS?
Posted by Jacob Goldstein
A 42-year-old man who had both leukemia and AIDS received a bone marrow transplant — a common, late-stage treatment for that type of cancer. His doctor selected a bone marrow donor who had a rare genetic mutation that renders people virtually immune to HIV. The transplant appeared to cure the patient of AIDS.
We’re as wary as the next guy of inferring too much from a single case study. Maybe it was a fluke; maybe there were unknown factors at work. But this one is pretty intriguing.
The case was presented at a conference earlier this year (here’s the abstract), and written up in this morning’s WSJ.
As is common for bone marrow transplant recipients, the patient first had radiation and chemotherapy, which tends to kill off many of the immune cells that harbor HIV. After the transplant, the patient’s immune system was repopulated by cells created by the donor marrow.
The donor had a mutation, present in about 1% of Europeans, that creates immune system cells that lack a receptor molecule called CCR5. That receptor plays an important role in HIV’s ability to enter the cell. (Pfizer’s HIV drug Selzentry works by blocking CCR5.)
So the patient’s immune system was repopulated with immune cells that carried the mutation. And, nearly two years after undergoing the transplant, he shows no signs of having any HIV left in his body — despite the fact that he hasn’t taken any AIDS drugs since before the transplant.
Perhaps the most important caveat is just how risky bone marrow transplantation is: It’s given to cancer patients after other treatments fail, and it kills up to 30% of patients.
But researchers hope to apply the apparent lessons of this case to strategies using gene therapy (which carries its own risks) to try to induce the protective mutation in patients with HIV.
David Baltimore, who won a Nobel Prize for research on tumor viruses, has started a company to use gene therapy to target HIV. He calls this case “a very good sign” and a virtual “proof of principle” for gene-therapy approaches.
Image of HIV by C. Goldsmith via CDC
Find out how much you can save on Medicare Part D
Everyone on Medicare Part D should check this out
I want to remind people that you can change providers starting Nov 15 until Dec 31
Go to this great comparison web site tool to type in your prescriptions to see how much you can save with different companies in your area.
medicare.giv/mpdpf
You can save your prescription list for later use. You can also see which meds require prior authorization
Medicare will soon add "star ratings" to each provider
I want to remind people that you can change providers starting Nov 15 until Dec 31
Go to this great comparison web site tool to type in your prescriptions to see how much you can save with different companies in your area.
medicare.giv/mpdpf
You can save your prescription list for later use. You can also see which meds require prior authorization
Medicare will soon add "star ratings" to each provider
Saturday, November 01, 2008
Doctors who work in lipodystrophy, and surveys from patients
SHARE YOUR EXPERIENCES WITH OTHERS ON
OPTIONS FOR LIPODYSTROPHY -
SURVEY RESULTS- OPTIONS USED BY PEOPLE WITH LIPODYSTROPHY -
http://www.surveymonkey.com/sr.aspx?sm=LYbzfgoEFlmgc1vkr3v_2bEWfscAbBPrjpRbaywPjqMqI_3d
DOCTORS AND PROVIDERS- COMMENTS FROM PEOPLE - Click on the "View" boxes for doctors' names
http://www.surveymonkey.com/sr.aspx?sm=rc8hHUnWoT5VVui7aS9Q_2fsfxahbyw7goBCGlfANmm4A_3d
IF YOU WANT TO ADD COMMENTS (POSITIVE OR NEGATIVE) ABOUT A PROVIDER THAT YOU HAVE USED FOR LIPODYSTROPHY -
http://www.surveymonkey.com/s.aspx?sm=dIXsY8YIuuh5f_2fMLZasLgA_3d_3d
Read our Newsletter
http://archive.constantcontact.com/fs020/1101823881298/archive/1101825972178.html
OPTIONS FOR LIPODYSTROPHY -
SURVEY RESULTS- OPTIONS USED BY PEOPLE WITH LIPODYSTROPHY -
http://www.surveymonkey.com/sr.aspx?sm=LYbzfgoEFlmgc1vkr3v_2bEWfscAbBPrjpRbaywPjqMqI_3d
DOCTORS AND PROVIDERS- COMMENTS FROM PEOPLE - Click on the "View" boxes for doctors' names
http://www.surveymonkey.com/sr.aspx?sm=rc8hHUnWoT5VVui7aS9Q_2fsfxahbyw7goBCGlfANmm4A_3d
IF YOU WANT TO ADD COMMENTS (POSITIVE OR NEGATIVE) ABOUT A PROVIDER THAT YOU HAVE USED FOR LIPODYSTROPHY -
http://www.surveymonkey.com/s.aspx?sm=dIXsY8YIuuh5f_2fMLZasLgA_3d_3d
Read our Newsletter
http://archive.constantcontact.com/fs020/1101823881298/archive/1101825972178.html
Comparative Analysis of HIV+ and HIV- Interaction with Testosterone on Bone Mineral Density
Thanks to Jules Levin for providing this paper
Comparative Analysis of HIV+ and HIV- Interaction with Testosterone on Bone Mineral Density
Reported by Jules Levin
ICAAC/IDSA Oct 28 2008 Wash DC
R.RAGHUNATHAN 1,2,J.SINACORE 2,K.RYCHLIK 2, J.FARANO 1,C.PACHUCKI 1,2,and N.AZAD 1,2
1 Edward Hines VA Hospital
Hines, VA 60141
2 Loyola University Health System,Maywood, IL 60153
AUTHOR CONCLUSIONS
In age-matched HIV-infected men, a lower free testosterone corresponds significantly to a lower T-score at the lumbar spine.
A normal free testosterone level was protective of bone mineral density in HIV-infected patients compared to the control population.
Among HIV-uninfected men, an increase in free testosterone level does not correspond to an increase in T-scores.
Further studies evaluating the interaction of low free testosterone and HIV infection need to be conducted to better understand the bone-related effects.
Background: Given an increasingly younger HIV population with osteopenia/osteoporosis a retrospective controlled study was conducted to investigate the effects of testosterone on bone mineral density (BMD) in HIV infected and HIV non-infected populations.
Methods: A chart review was done on a group of 80 male HIV patients and 154 male control patients. The following variables were obtained from the HIV group: age, race, employment status, smoking, body mass index (BMI), duration of HIV, CD4 levels, viral load, type of antiretroviral use, co-morbidities, use of prednisone, heroin, alcohol, methadone use, ever use of androgen, bisphosphanate use, calcium use, alpha reductase inhibitor use, phosphodiesterase inhibitor use, lipids, and biochemical markers. The same variables were obtained from the control group except those pertaining to HIV and employment status. T-scores were used in both HIV and control groups to evaluate BMD.
Results: A univariate analysis of variance was used controlling for the following factors: age, race, BMI, prednisone, heroin, alcohol, smoking, methadone, androgen use, alpha reductase inhibitor use, phosphodiesterase inhibitor use, bisphosphanate use, and calcium use.
Conclusions: A normal testosterone level was protective of bone mineral density in HIV-infected patients compared to the control population. At the L-spine, HIV patients with low testosterone had a lower bone mineral density (p < 0.05). Treatment of osteopenia/osteoporosis with testosterone in HIV patients needs further evaluation.
BACKGROUND
Prevalence of osteoporosis in HIV-uninfected hypogonadal men is reported to be 12.3% vs. 6.0% in men with normal testosterone levels1.
Among patients enrolled in the Study to Understand the Natural History of HIV and AIDS (SUN), 52% had osteopenia and 10% had osteoporosis. Among these patients 78% were men, 25% were black, and 80% of patients received antiretrovirals (ART)2.
Up to 70% of treatment-naive HIV-infected men are reported to have low free testosterone3.
Whether an isolated HIV-related hypogonadism interaction plays a role in developing osteopenia/osteoporosis is unknown.
It remains unclear how HIV itself or other known attributable factors (such as age, sex, race, duration of HIV, ART, hypogonadism, etc.) lead to the development of osteopenia/osteoporosis.
There is a renewed interest in the pathogenesis, diagnosis, and management of osteoporosis in this population.
HYPOTHESIS
We hypothesize that patients with HIV with low free testosterone levels have lower T-scores.
METHODS/STATISTICAL ANALYSIS
A retrospective chart review was performed on two groups: 80 HIV-infected men and 154 HIVuninfected men (see Table 1 for epidemiologic characteristics in each population).
HIV-specific information was obtained in those men who were HIV-infected with low and normal testosterone (see Table 2).
An analysis of covariance was done controlling for the following factors: age, race, BMI, smoking, and use of prednisone, heroin, cocaine, alcohol, methadone, androgen, alpha reductase inhibitor, phosphodiesterase inhibitor, bisphosphanate, and calcium (see Figs 1 – 3, Table 4).
The serum free testosterone (FT) levels were measured by Quest diagnostics (using dialysis method Wood Dale II). The normal FT ranges 35 – 210 pg/mL (see Fig 4 for free vs. total testosterone correlations in HIV-infected and HIV-uninfected patients).
REFERENCES
1. Fink H.A., Ewing S.K., Orwoll E.S., et al. Association of Testosterone and Estradiol Deficiency with Osteoporosis and Rapid Bone Loss in Older Men. The Journal of Clinical Endocrinology and Metabolism 2006; 91(10): 3908 – 3915.
2. Calza L., Tampellini L., Chiodo F., et al. Bone Mass Loss in Patients with
HIV Type 1 Infection. Infectious Diseases in Clinical Practice 2007; 15(3):
160 – 166.
3.Wunder D.M., Bersinger N.A., Furrer H., et al. Hypogonadism in HIV 1-infected men is common and does not resolve during antiretroviral therapy. Antiviral Therapy 2007; 12:261 – 265.
Comparative Analysis of HIV+ and HIV- Interaction with Testosterone on Bone Mineral Density
Reported by Jules Levin
ICAAC/IDSA Oct 28 2008 Wash DC
R.RAGHUNATHAN 1,2,J.SINACORE 2,K.RYCHLIK 2, J.FARANO 1,C.PACHUCKI 1,2,and N.AZAD 1,2
1 Edward Hines VA Hospital
Hines, VA 60141
2 Loyola University Health System,Maywood, IL 60153
AUTHOR CONCLUSIONS
In age-matched HIV-infected men, a lower free testosterone corresponds significantly to a lower T-score at the lumbar spine.
A normal free testosterone level was protective of bone mineral density in HIV-infected patients compared to the control population.
Among HIV-uninfected men, an increase in free testosterone level does not correspond to an increase in T-scores.
Further studies evaluating the interaction of low free testosterone and HIV infection need to be conducted to better understand the bone-related effects.
Background: Given an increasingly younger HIV population with osteopenia/osteoporosis a retrospective controlled study was conducted to investigate the effects of testosterone on bone mineral density (BMD) in HIV infected and HIV non-infected populations.
Methods: A chart review was done on a group of 80 male HIV patients and 154 male control patients. The following variables were obtained from the HIV group: age, race, employment status, smoking, body mass index (BMI), duration of HIV, CD4 levels, viral load, type of antiretroviral use, co-morbidities, use of prednisone, heroin, alcohol, methadone use, ever use of androgen, bisphosphanate use, calcium use, alpha reductase inhibitor use, phosphodiesterase inhibitor use, lipids, and biochemical markers. The same variables were obtained from the control group except those pertaining to HIV and employment status. T-scores were used in both HIV and control groups to evaluate BMD.
Results: A univariate analysis of variance was used controlling for the following factors: age, race, BMI, prednisone, heroin, alcohol, smoking, methadone, androgen use, alpha reductase inhibitor use, phosphodiesterase inhibitor use, bisphosphanate use, and calcium use.
Conclusions: A normal testosterone level was protective of bone mineral density in HIV-infected patients compared to the control population. At the L-spine, HIV patients with low testosterone had a lower bone mineral density (p < 0.05). Treatment of osteopenia/osteoporosis with testosterone in HIV patients needs further evaluation.
BACKGROUND
Prevalence of osteoporosis in HIV-uninfected hypogonadal men is reported to be 12.3% vs. 6.0% in men with normal testosterone levels1.
Among patients enrolled in the Study to Understand the Natural History of HIV and AIDS (SUN), 52% had osteopenia and 10% had osteoporosis. Among these patients 78% were men, 25% were black, and 80% of patients received antiretrovirals (ART)2.
Up to 70% of treatment-naive HIV-infected men are reported to have low free testosterone3.
Whether an isolated HIV-related hypogonadism interaction plays a role in developing osteopenia/osteoporosis is unknown.
It remains unclear how HIV itself or other known attributable factors (such as age, sex, race, duration of HIV, ART, hypogonadism, etc.) lead to the development of osteopenia/osteoporosis.
There is a renewed interest in the pathogenesis, diagnosis, and management of osteoporosis in this population.
HYPOTHESIS
We hypothesize that patients with HIV with low free testosterone levels have lower T-scores.
METHODS/STATISTICAL ANALYSIS
A retrospective chart review was performed on two groups: 80 HIV-infected men and 154 HIVuninfected men (see Table 1 for epidemiologic characteristics in each population).
HIV-specific information was obtained in those men who were HIV-infected with low and normal testosterone (see Table 2).
An analysis of covariance was done controlling for the following factors: age, race, BMI, smoking, and use of prednisone, heroin, cocaine, alcohol, methadone, androgen, alpha reductase inhibitor, phosphodiesterase inhibitor, bisphosphanate, and calcium (see Figs 1 – 3, Table 4).
The serum free testosterone (FT) levels were measured by Quest diagnostics (using dialysis method Wood Dale II). The normal FT ranges 35 – 210 pg/mL (see Fig 4 for free vs. total testosterone correlations in HIV-infected and HIV-uninfected patients).
REFERENCES
1. Fink H.A., Ewing S.K., Orwoll E.S., et al. Association of Testosterone and Estradiol Deficiency with Osteoporosis and Rapid Bone Loss in Older Men. The Journal of Clinical Endocrinology and Metabolism 2006; 91(10): 3908 – 3915.
2. Calza L., Tampellini L., Chiodo F., et al. Bone Mass Loss in Patients with
HIV Type 1 Infection. Infectious Diseases in Clinical Practice 2007; 15(3):
160 – 166.
3.Wunder D.M., Bersinger N.A., Furrer H., et al. Hypogonadism in HIV 1-infected men is common and does not resolve during antiretroviral therapy. Antiviral Therapy 2007; 12:261 – 265.
Tuesday, October 21, 2008
LA LIPODISTROFIA Y EL VIH
LA LIPODISTROFIA Y EL VIH
¿DÓNDE ESTAMOS LUEGO DE DIEZ AÑOS?Por Nelson Vergel, Director del Program for Wellness Restoration,powerusa.org
La primera vez que apareció un informe acerca de la Lipodistrofia en una Conferencia sobre el VIH fue hace diez años. La excitación y la esperanza de una vida más larga que vino aparejada con la aparición de los protocolos de Terapia Antirretroviral Altamente Activa (Highly Active Antiretroviral Therapy - HAART -) fueron atemperadas con reportes de jorobas, panzas y enflaquecimiento facial. Una década ya ha transcurrido y muchas de las preguntas y conceptos erróneos acerca de la lipodistrofia asociada con el VIH persisten aún hoy en dÃa, con tan solo un puñado de tratamientos alternativos disponibles. Mucha gente que padece de lipodistrofia, frustrada y cansada de esperar respuestas de la comunidad médica, se ha volcado al Internet para tratar de encontrar consejos, tratamiento y ayuda, con la esperanza de revertir algunos de los devastadores efectos de este sÃndrome que es causa de gran estigma.
La lipodistrofia es una condición que implica una redistribución anormal de tejido adiposo. Dicha redistribución puede conducir ya sea a una lipohiperatrofia (acumulación de tejido adiposo en áreas especÃficas del cuerpo, tales como el cuello, la barriga, la parte superior del torso y las mamas) o bien a una lipoatrofia (pérdida de tejido adiposo en la cara, glúteos, brazos y piernas). Un encuesta que se realizó a través del Internet con 695 individuos (predominantemente varones de raza blanca, mayores de cuarenta años de edad, que han estado viviendo con el VIH por lo menos por diez años y que han mantenido su terapia HAART por lo menos por diez años) descubrió que un 20% ha considerado el suicidio por cambios corporales asociados con la lipodistrofia. Alrededor del 90% de los encuestados opinaron que los medicamentos que están tomando para combatir el VIH son la causa de la lipodistrofia y un 20% de los encuestados dijeron haber abandonado su medicación por completo debido a este problema. Aparte, más del 60% de los encuestados afirmaron haber sido rechazados por parejas potenciales para sexo debido a este sÃndrome. Un número similar de encuestados indicó que inclusive habÃan dejado de mirarse al espejo porque la imagen que veÃan les causaba una sensación de invalidez. Casi todos los individuos encuestados indicaron haber tratado de minimizar los efectos de la lipodistrofia a través de dieta y ejercicio fÃsico o utilizando procedimientos de reconstrucción facial de un costo sumamente elevado, suplementos y hormonas (todos éstos, tratamientos que no son tÃpicamente cubiertos por los seguros médicos o por programas de asistencia médica).
La Lipoatrofia y los Medicamentos contra el VIH.
En 1999 la droga contra el VIH denominada Zerit fue asociada con el desarrollo de lipoatrofia relacionada con la pérdida de tejido adiposo bajo la piel1. Desde entonces, un número de estudios ha concluido que el Zerit puede afectar la forma en que la mitocondria (que es la fábrica de energÃa de la célula) de nuestras células trabaja y se multiplica. Posteriormente, otros estudios concluyeron que el AZT ocasionaba un problema similar, aunque a una menor tasa que el Zerit. Medicamentos clasificados como Inhibidores de la Transcriptasa Reversa Análogos de los Nucleósidos o Nucleótidos (NRTIs) tales como el Zerit o el AZT impiden que el VIH altere el material genético de los Linfocitos T saludables, y a través de dicho proceso, detienen la reproducción de nuevas células virales. Adicionalmente, los NRTIs afectan también la mitocondria de las células adiposas que se encuentran bajo la piel, impidiendo que se multipliquen y causando su muerte. Por otra parte, individuos que han estado bajo la terapia combinada de Zerit y Videx (otro NRTI) han mostrado una incidencia más aguda de lipoatrofia que aquellos que han estado tomando solamente Zerit. La combinación de Zerit y Videx no es aconsejada por grupos consejeros. Pareciera ser que el Zerit y el AZT empeoran la acumulación de tejido adiposo cuando se los utilizan combinados con Inhibidores de la Proteasa o No-Nucleótidos Análogos (NNRTIs) tales como Sustiva, lo que ha llevado a los investigadores médicos a sospechar que sus efectos negativos pueden funcionar en forma combinada. Sin embargo, la ingesta de Sustiva con Viread (Tenofovir) y Epivir (3TC) parece causar menos lipoatrofia. Debido al alto riesgo de producir lipoatrofia y neuropatÃas, la comisión de guÃas directivas del Departamento de Salud y Servicios Humanos de los Estados Unidos eliminó al Zerit de la lista de medicamentos recomendados como primera lÃnea de ataque para pacientes que han sido recientemente incorporados a la HAART.
El Viread (Tenofovir) y el Ziagen (Abacavir), que son dos drogas pertenecientes al mismo grupo NRTIs que el Zerit y el AZT, parecen no mostrar una correlación tan severa con el desarrollo de la lipoatrofia. Algunas personas inclusive han reportado una lenta reversión de la pérdida de tejido adiposo luego de haber dejado de tomar Zerit o AZT y cambiado ya sea a Ziagen o Viread. Sin embargo, la mayorÃa de los pacientes han reportado que, a pesar de haber transcurrido un número de años desde que abandonaran la terapia de Zerit o AZT, no experimentaron ningún tipo de re-acumulación de tejido adiposo en el rostro. Es importante destacar que una nueva y paradójica información obtenida de un reciente estudio realizado por el AIDS Clinical Trials Group2 ha señalado que una pérdida de tejido adiposo subcutáneo (pérdida del tejido adiposo más cercano a la superficie de la piel) del 20% ocurrió en un pequeño porcentaje de pacientes que habÃan recién entrado en la terapia HAART por primera vez utilizando una combinación de Sustiva, Viread y Epivir. Se va a necesitar un mayor número de estudios para determinar por qué la lipodistrofia todavÃa es un fenómeno que ocurre en algunos pacientes donde existe una ausencia de Zerit o AZT.
Las ventas de Zerit y de AZT en los paÃses industrializados han disminuido considerablemente recientemente debido al efecto que estas drogas tienen sobre la lipodistrofia. Desafortunadamente, estas dos drogas figuran entre los principales medicamentos contra el VIH utilizados en los paÃses en vÃa de desarrollo, lo cual implica que millones de personas en paÃses más pobres van a tener que continuar padeciendo transformaciones corporales.
Opciones Para el Tratamiento de la Lipodistrofia.
Desde hace algunos años a la fecha, muchos varones han dependido de un anabólico esteroide inyectable genérico denominado decanoato de nandrolona (su denominación comercial es Deca DurabolÃn), a fin de tratar de balancear sus cuerpos, añadiendo masa muscular a las extremidades y glúteos que estaban perdiendo volumen, afectados por lipodistrofia. A pesar que los Laboratorios Watson dejaron de producir la nandrolona en Marzo de 2007, es posible adquirirla (expendio bajo receta) a través de farmacias mayoristas por un costo relativamente bajo3.
Existe un suplemento denominado Uridine (Nucleomaxx), elaborado a partir de la caña de azúcar y accesible a través de un distribuidor alemán4. Este suplemento puede ayudar a disminuir la lipodistrofia en pacientes que están tomando Zerit, pero también puede ocasionar acumulación de depósitos de grasas en la zona abdominal e incrementar el nivel de triglicéridos. Debido a estos efectos colaterales, su elevado costo y mal sabor, Uridine no ha tenido una amplia recepción. Sin embargo, para aquellos de deben tomar Zerit, Uridine puede ser una opción viable para prevenir o inclusive revertir lipodistrofia. Adicionalmente, para aquellos individuos que han dejado de tomar Zerit, la droga contra diabetes denominada Rosiglitazone (Avandia) ofrece muy buenos resultados para revertir los efectos de lipodistrofia. Existen, sin embargo, efectos colaterales, incluyendo el aumento de peso y triglicéridos elevados.
Desde el año 2002 han aparecido un par de procedimientos de reconstrucción temporal para tratar la lipodistrofia facial. Una de estas opciones es Sculptra (ácido poli láctico, cuyo nombre comercial anterior era New Fill), la cual implica una serie de sesiones múltiples de costo elevado , y requiere de retoques adicionales. Sculptra puede ser utilizada por aquellos individuos que han sido moderadamente afectados por lipodistrofia. Radiesse es otra opción aprobada por el FDA en los Estados Unidos. Radiesse requiere un mayor número de sesiones, y es más caro que Sculptra, requiriendo de 3 a 5 sesiones y retoques anuales. Algunos pacientes tratados por enflaquecimiento facial con este tipo de productos han experimentado efectos colaterales, tales como hematomas y granulomas tratables (nódulos que tienen la apariencia de espinillas endurecidas).
Existen algunos programas de asistencia para el paciente, disponibles tanto para Sculptra como para Radiesse5.
No existe ningún tipo de solución permanente para la lipoatrofia facial aprobada por el FDA de los Estados Unidos. Sin embargo, muchos individuos en este paÃs utilizan unas inyecciones minúsculas de silicona (Silikon 1000), aplicadas por un especialista. El Silikon 1000 puede ser utilizado legalmente como una substancia genérica para el tratamiento de lipoatrofia facial. Las micro-inyecciones de Silikon 1000 pueden reconstruir lentamente los rostros de los pacientes, en unas cinco sesiones, espaciadas por un mes entre sesión y sesión. No existe ningún tipo de programa de asistencia para el paciente para esta opción, cuyo costo por sesión puede oscilar entre U$D 600.- y U$D 900.- Lamentablemente, también para el caso de Silikon 1000 se requieren múltiples sesiones. Hay que tener muy presente que hay tan solamente muy pocos profesionales en los Estados Unidos que están bien entrenados en la aplicación de este procedimiento.
Existe otro producto para la reconstrucción facial permanente, denominado Polimetil-metacrilato (PMMA). Este producto ha sido utilizado en Brasil durante ocho años y en Méjico durante tres con resultados relativamente positivos, aunque se va a necesitar más tiempo para determinar los efectos en el largo plazo de este procedimiento. Requiere generalmente de dos a cuatro sesiones, sin tener que incurrir en retoques anuales. Hemos visto en el corto plazo que para algunos pacientes el PMMA puede endurecerse y tomar forma grumosa, aunque muchos pacientes parecen muy satisfechos con los resultados. El Artefill es un producto con base PMMA, y tiene la aprobación del FDA en los Estados Unidos para propósitos cosméticos, pero no para el tratamiento de lipoatrofia relacionada con el VIH. Artefill es extremadamente caro en las cantidades necesarias para tratar lipoatrofia, por lo que pacientes seropositivos en los Estados Unidos van a Méjico o Brasil para tener acceso a dicho tratamiento, donde el costo puede oscilar de U$D 2.000,- a U$D 6.000,-. El PMMA es permanente (no se lo puede remover una vez inyectado).
BioAlcamid (poli alkilamida gel), es otra opción también permanente. Es una substancia inyectable que se encuentra disponible en los Estados Unidos (algunos pacientes viajan a Méjico o Brasil para tener acceso al tratamiento a un menor costo). Lamentablemente, BioAlcamid genera un “bolsillo” en la cara y en los glúteos, el cual es permeable para el acceso de bacterias, por lo que presenta un alto riesgo de infección. Como tal, aconsejamos extremado cuidado antes de decidir seguir esta opción.
No existe ninguna base de datos de largo plazo en lo referente a estos procedimientos experimentales para reconstrucción facial, por lo que los riesgos de inyectar una substancia extraña al organismo deben ser cuidadosamente considerados. Desafortunadamente, mucha gente siente que el costo emocional, sicológico y social que trae aparejado vivir con lipodistrofia es tan elevado, que para muchos se justifica tomar estos riesgos.
Opciones Experimentales para el Tratamiento de la Lipohiperatrofia.
A diferencia de la lipoatrofia, los investigadores médicos no han podido llegar a atribuir la lipohiperatrofia (acumulación de tejido adiposo en la barriga, parte posterior del cuello y mamas) a ningún medicamento o clase de droga en particular. En una ocasión se pensó que los inhibidores de la proteasa eran los principales causantes. Sin embargo, recientemente se ha descubierto que la acumulación de tejido adiposo en la zona abdominal puede estar relacionada con una respuesta inflamatoria del sistema inmunológico cuando baja el número de los linfocitos T CD4. Esto significa que aquellos que comienzan el tratamiento de terapia HAART con una menor base de linfocitos T CD4, se pueden encontrar con casos más pronunciados de lipodistrofia. Por otra parte, datos recientes han revelado que pacientes con un nivel de linfocitos T CD4 superior a 250 y que están comenzando la terapia HAART con inhibidores de la proteasa amplificados con la ayuda de Norvir más Viread y Epivir, no han experimentado incremento en el nivel de grasa visceral (tejido adiposo que rodea a los órganos internos). Es aún muy temprano para aventurarse a decir qué va a ocurrir con individuos que comienzan el régimen con niveles bajos de linfocitos T CD4. Algunos estudios han mostrado que aquellos que comienzan tomando inhibidores de la proteasa combinados con Zerit, AZT o Zerit y Videz, tienen una mayor tendencia a incrementar el volumen de grasa visceral y una joroba que aquellos que comenzaron los inhibidores de la proteasa con otras drogas. Es factible que las mismas drogas que están vinculadas con la lipoatrofia puedan también hacer que el incremento de la cantidad de tejido adiposo sea aún mayor, especialmente en pacientes que comienzan la terapia HAART con un bajo número de linfocitos T CD4.
Un concepto erróneo promovido por algunas compañÃas farmacéuticas y que encontró eco en algunos profesionales médicos es que los medicamentos para tratar el VIH no incrementan el nivel de colesterol y que los triglicéridos no causan incrementos en el tejido adiposo. Por el contrario, varios estudios han señalado que pacientes que toman medicamentos que son congeniales con los lÃpidos tales como Reyataz combinados con Viread también experimentan un incremento en la cantidad de tejido adiposo en la barriga luego de comenzar la terapia HAART.
Se le preguntó al doctor David Nolan (clÃnico e investigador en el Royal Perth Hospital de Western Australia y experto en el metabolismo de lÃpidos y VIH) por qué el tejido adiposo visceral no “desaparecÃa” luego de la introducción de Zerit y AZT (tal como ocurre con el tejido adiposo subcutáneo). El doctor Nolan tuvo la hipótesis que es factible que el tejido adiposo que rodea los órganos internos no sea igualmente susceptible a la toxicidad generada por el Zerit y el AZT que el tejido adiposo subcutáneo.
El incremento en el tejido adiposo puede ser correlacionado a la resistencia a la insulina. La resistencia a la insulina puede causar intolerancia a la glucosa, la cual ha sido asociada con incrementos en el tejido adiposo, incrementos en los triglicéridos, y el desarrollo de diabetes. La insulina es una hormona producida por el páncreas para controlar el nivel de azúcar-glucosa en sangre. Los medicamentos contra el VIH pueden bloquear o desacelerar el proceso por el cual la insulina convierte la glucosa en energÃa. En estudios de laboratorio, el Crixivan y dosis más elevadas de Norvir y Zerit han mostrado su capacidad para atrofiar la acción de la insulina tanto en el tejido adiposo como en el muscular. En este caso, el páncreas va a producir mayores cantidades de insulina a fin de tratar de compensar la disminución en la función. Se pueden presentar elevados niveles de insulina durante años antes de que se desarrolle diabetes del tipo 2. Un análisis de tolerancia a la glucosa puede indicar este problema fácilmente, pero raramente se lo utiliza en la práctica. Adicionalmente, algunos individuos pueden tener una predisposición genética a la resistencia a la insulina. Un tipo de vida sedentaria y una dieta rica en azúcares y grasas de origen animal puede contribuir en forma cumulativa a este problema. En cualquier caso, la resistencia a la insulina puede ser tan solamente una parte del misterio de la lipohiperatrofia. No existe un acuerdo generalizado entre los investigadores sobre si monitorear o no los niveles de insulina en pacientes seropositivos es un instrumento confiable para determinar la resistencia a la insulina y el incremento de tejido graso.
Una absorciometrÃa de rayos X duales para cuerpo completo es el instrumento ideal para casos de lipodistrofia. Es un análisis de gran importancia que puede proveer información acerca de la composición corporal (masa grasa, masa muscular y densidad ósea). La baja densidad ósea ha sido asociada con el VIH en varios estudios. Tanto el Medicare como seguros médicos privados generalmente cubren este análisis, el cual es relativamente económico. En tanto que este análisis no puede diferenciar entre la grasa acumulada en la barriga o la subcutánea en el área abdominal, puede ser muy útil como punto de partida para evaluar cambios corporales y para justificar terapias reembolsables para grasas, músculo y masa ósea.
Intervenciones en el Tratamiento para casos de Lipohiperatrofia.
Algunos pacientes han cambiado de inhibidores de la proteasa a Viramune o a Sustiva para combatir incrementos en la grasa visceral, pero esto no ha mostrado producir diferencia alguna. TodavÃa no se sabe qué ocurre con la grasa del abdomen cuando un paciente cambia de Zerit o AZT a Viread o Ziagen mientras aún se encuentra tomando inhibidores de la proteasa o NNRTIs tales como Sustiva o Viramune.
La hormona de crecimiento humano Serostim es una droga inyectable que se aplica en forma diaria, y ha sido aprobada por el FDA para el tratamiento del sÃndrome de desgaste asociado con el VIH. Con un costo mensual aproximado de U$D 3.000,- es una opción muy cara para el tratamiento de la lipodistrofia. El Serostim ha demostrado buenos resultados en materia de disminución de grasa abdominal, pero presenta una serie de efectos colaterales, incluyendo dolores en las articulaciones, retención de agua, sÃndrome de túnel carpiano, y diabetes irreversible. La combinación de todos estos efectos con la carencia de información acerca de beneficios comprobables para la salud en el largo plazo ha hecho que el FDA no haya aprobado el Serostim para el tratamiento de acumulación de grasas relacionados con el VIH.
El Tesamorelin -TH9507, elaborado por Theratecnologies- es un precursor de la hormona de crecimiento, inyectable en forma diaria, que se encuentra en las últimas etapas para aprobación por el FDA. El Tesamorelin aparenta tener menos efectos colaterales que el Serostim, pero puede necesitar de un mayor lapso de tiempo para comenzar a mostrar sus beneficios en los pacientes. Lamentablemente, la grasa previamente incrementada regresa a sus niveles existentes previos a la utilización de tanto el Serostim como el Tesamorelin, una vez que se descontinúen cualquiera de ellos.
Un nuevo elemento que ha aparecido en la carrera para encontrar una solución para disminuir la acumulación de grasa visceral es Leptin. Leptin es una hormona producida por las células adiposas. Los investigadores han descubierto que los niveles de leptin en sangre son proporcionales al nivel de grasa corporal del individuo. El leptin trabaja en la parte del cerebro que controla el apetito y otras funciones básicas. Elevadas concentraciones de leptin generalmente traen aparejadas una disminución del apetito a la vez que estimulan al organismo para que queme grasas. El leptin no aparenta tener impacto negativo alguno en la tolerancia a la glucosa.
Actualmente, los médicos prefieren prescribir testosterona bajo la forma de gel, inyecciones y comprimidos subcutáneos. El gel de testosterona aplicado sobre la barriga puede reducir el tamaño de la cintura en varones seropositivos. Esta disminución de tamaño es usualmente el resultado de la disminución de tejido adiposo subcutáneo y no de la grasa visceral. En contraste, un pequeño estudio piloto realizado con Oxandrin (un esteroide anabólico de ingesta oral) ha mostrado resultados significativos en materia de reducción de grasa visceral. Incrementos en las lipoproteÃnas de baja densidad (el denominado “colesterol malo”) y reducciones en las lipoproteÃnas de alta densidad (el denominado “colesterol bueno”) se correlacionan con una pequeña disminución en el tejido adiposo subcutáneo. No existe ninguna información hasta el momento que conecte un anabólico muy popular, el decanoato de nandrolona, con reducciones en la grasa visceral.
Algunos individuos que han estado buscando elementos que ayuden a quemar las grasas han sido vÃctimas de las técnicas publicitarias que tratan de impulsar suplementos de hormona de crecimiento o distintos elementos que se publicitan como efectivos para eliminar grasas. Estos productos generalmente tienen un efecto insignificante en lo que respecta a la eliminación de grasas, pero elevan la presión arterial y los niveles de ansiedad, y son generalmente considerados como una estafa.
La Metformin (comercializada bajo la denominación Glucophage) es una droga genérica contra la diabetes que ha mostrado ayudar a mejorar la tolerancia a la glucosa y para disminuir la grasa visceral en la parte inferior. Sus efectos se pueden inclusive incrementar cuando se la combina con un programa de ejercicio fÃsico. La Metformin mejora la sensibilidad a la insulina, los triglicéridos y la grasa hepática, pero puede causar diarrea y conducir a una pérdida de peso. Se han reportado incluso algunos casos de bajos niveles de azúcar en sangre y episodios de mareos asociados con esta droga.
En adición a todos los tratamientos anteriormente mencionados, los pacientes siempre pueden optar por otro tratamiento: liposucción. La liposucción asistida por ultrasonido puede ser utilizada para remover exitosamente el tejido adiposo acumulado con la forma de una joroba de búfalo en la parte posterior del cuello.
Algunos pacientes han reportado el incremento de tamaño en las glándulas salivares en los costados de la cara, un efecto comúnmente denominado “cara de ardilla”. A pesar de que existen muy pocos radiólogos que saben cómo utilizar este procedimiento en forma correcta, unas bajas dosis de radiación de electrones han producido resultados muy satisfactorios en el tratamiento para la reducción de tamaño de las glándulas salivares en la parótida. Lo que no se tiene claro todavÃa es si este fenómeno de incremento de tamaño en las glándulas salivares está relacionado con la lipodistrofia o si es causado por una reconstitución inmunológica.
Otra alternativa sobre la que no se han hecho muchos estudios todavÃa es dieta y ejercicio. Un estudio realizado en la Tufts University mostró una tendencia hacia una menor lipodistrofia para aquellos individuos que tenÃan una mayor ingesta de fibras solubles (frutas y vegetales) y que hacÃan ejercicios fÃsicos en forma habitual. A pesar de ello, se necesitan estudios en mayor profundidad en lo relativo a la utilización de dietas de carbohidratos simples. Estas dietas han mostrado su habilidad para mejorar la resistencia a la insulina y la reducción de la grasa visceral en estudios no relacionados con el VIH. Un estudio observacional mostró que los pacientes seropositivos tienden a ingerir mayores cantidades de grasas saturadas. Un pequeño estudio piloto combinando ejercicios cardiovasculares y ejercicios de resistencia mostró una disminución en triglicéridos y grasa visceral. Sin embargo, el problema es la continuidad en este tipo de programas, la cual constituye el mayor reto para la mayorÃa de la gente. Los estudios relacionando los efectos de ejercicio con casos de VIH se encuentran todavÃa en su infancia.
Incrementos en los LÃpidos: Las LipoproteÃnas de Baja Densidad (LDL) y Los Triglicéridos.
Las anormalidades más comunes en pacientes seropositivos son cantidades elevadas de triglicéridos y de LDL, o colesterol “malo”, y bajos números en lo que respecta a LipoproteÃnas de Alta Densidad (HDL), o colesterol “bueno”. Es muy posible que individuos seropositivos antes de que comiencen la terapia contra el VIH por primera vez, tengan niveles inferiores a los normales tanto para las lipoproteÃnas de alta y de baja densidad. Sin embargo, luego de que se comience la terapia con drogas contra el VIH, en algunos casos se ha visto un incremento en las lipoproteÃnas de alta y de baja densidad, asà como también en los triglicéridos. Algunos estudios han señalado que el nivel de lÃpidos de baja densidad (LDL) se incrementa para alcanzar los niveles existentes antes de la seroconversión, en tanto que los niveles de lÃpidos de alta densidad (HDL) nunca retornan a los niveles normales. El incremento en triglicéridos es el cambio más fuertemente asociado en materia de lÃpidos causado por medicamentos contra el VIH tales como inhibidores de la proteasa, Zerit, AZT o Sustiva. Dentro de todos los inhibidores de la proteasa, Reyataz parece ser el que se correlaciona con el menor incremento de lÃpidos.
Muchos pacientes prefieren comenzar a tomar suplementos antes de comenzar a tomar medicamentos para bajar el nivel de lÃpidos en sangre. Los únicos suplementos que han mostrado resultados sólidos en estudios sobre lÃpidos son los ácidos grasos Omega-3 (aceites de pescado), asà como también la niacina (también conocida como Niaspan). Los aceites de pescado pueden disminuir los triglicéridos, pero algunos pacientes encuentran que sus estómagos no lo toleran muy bien. La niacina es mejor que cualquier medicamento para disminuir lÃpidos en cuanto a sus efectos para incrementar el colesterol “bueno”. Puede causar rubor en la cara y una sensación de calor que dura alrededor de una media hora, pero la mayorÃa de la gente se acostumbra a estos efectos. Recientemente ha aparecido una versión de Niacina que no causa rubor en la cara, pero su efectividad es desconocida a la fecha.
No está claro si Raltegravir (Isentress) o si Maraviroc (Celsentry -un inhibidor de punto de entrada CCR5-) tienen efecto alguno sobre la composición corporal. Hasta el momento, aparentan tener una buena correlación con los lÃpidos cuando se los toma en forma conjunta con Viread o Epivir. Fuzeon (un inhibidor de punto de entrada inyectable) también aparenta ser compatible con lÃpidos, pero se lo utiliza frecuentemente en forma combinada con inhibidores de la proteasa que pueden causar incremento en los lÃpidos. Pareciera ser que existen algunos factores genéticos que hacen que algunos pacientes presenten una tendencia a tener niveles más elevados de triglicéridos y de lipoproteÃnas de baja densidad (colesterol “malo”).
Agentes reductores de lÃpidos tales como las estatinas (Lipitor, etc.) o fibratos (Tricor, etc.) pueden tener unos efectos fabulosos en algunos pacientes, pero aún cuando se los utilice, algunos pacientes nunca llegan a niveles “normales” en el panel de lÃpidos. Se utiliza habitualmente una combinación de niacina, baja ingesta de azúcares y grasas animales, ejercicio, suplementos de aceite de pescado o un incremento en la ingesta de pescados aceitosos de aguas frÃas (salmón, por ejemplo) y fibras solubles (frutas, vegetales y avena) para tratar los lÃpidos. Algunos individuos han tratado la combinación de estatinas y fibratos, pero dicha combinación puede conducir a un incremento en desórdenes musculares para algunos pacientes.
Conclusión.
Hemos aprendido mucho en los últimos diez años acerca de los cambios corporales que vienen aparejados con el VIH, pero quedan aún muchas preguntas sin contestar. Es de anhelar que aquellos que recién están siendo introducidos a las nuevas terapias HAART no tengan que sufrir los devastadores efectos colaterales que sus predecesores tuvieron que enfrentar en los últimos veinte años. Como pacientes, es nuestra responsabilidad educarnos en la mayor medida posible y aprender de otras fuentes e individuos acerca de nuevas opciones que vayan apareciendo y que puedan hacer posible algún dÃa el llevar una vida plena sin ninguno de los cambios corporales ni tampoco ninguno de los efectos colaterales que vienen asociados con el VIH.
Para mayor información, por favor visite el sitio: www.facialwasting.org, o si desea subscribirse al mayor grupo de discusión en el Internet acerca de temas de salud vinculados con el VIH, simplemente envÃe un email en blanco a pozhealth-subscribe@yahoogroups.com.
1 A syndrome of peripheral fat wasting (lipodystrophy) in patients receiving long-term nucleoside analogue therapy. Saint-Marc T, Partisani M, Poizot-Martin I, Bruno F, Rouviere O, Lang JM, Gastaut JA, Touraine JL. AIDS. 1999 Sep 10; 13(13):1659-67.
2 Metabolic Outcomes of ACTG 5142: A Prospective, Randomized, Phase III Trial of NRTI-, PI-, and NNRTI- sparing Regimens for Initial Treatment of HIV-1 Infection. Richard H. Haunbrich, S Riddler, G DiRienzo et al.
3 More information is available at www.medibolics.com
4 More information is available at www.nucleomaxx.com
5 More information is available at www.facialwasting.org.
¿DÓNDE ESTAMOS LUEGO DE DIEZ AÑOS?Por Nelson Vergel, Director del Program for Wellness Restoration,powerusa.org
La primera vez que apareció un informe acerca de la Lipodistrofia en una Conferencia sobre el VIH fue hace diez años. La excitación y la esperanza de una vida más larga que vino aparejada con la aparición de los protocolos de Terapia Antirretroviral Altamente Activa (Highly Active Antiretroviral Therapy - HAART -) fueron atemperadas con reportes de jorobas, panzas y enflaquecimiento facial. Una década ya ha transcurrido y muchas de las preguntas y conceptos erróneos acerca de la lipodistrofia asociada con el VIH persisten aún hoy en dÃa, con tan solo un puñado de tratamientos alternativos disponibles. Mucha gente que padece de lipodistrofia, frustrada y cansada de esperar respuestas de la comunidad médica, se ha volcado al Internet para tratar de encontrar consejos, tratamiento y ayuda, con la esperanza de revertir algunos de los devastadores efectos de este sÃndrome que es causa de gran estigma.
La lipodistrofia es una condición que implica una redistribución anormal de tejido adiposo. Dicha redistribución puede conducir ya sea a una lipohiperatrofia (acumulación de tejido adiposo en áreas especÃficas del cuerpo, tales como el cuello, la barriga, la parte superior del torso y las mamas) o bien a una lipoatrofia (pérdida de tejido adiposo en la cara, glúteos, brazos y piernas). Un encuesta que se realizó a través del Internet con 695 individuos (predominantemente varones de raza blanca, mayores de cuarenta años de edad, que han estado viviendo con el VIH por lo menos por diez años y que han mantenido su terapia HAART por lo menos por diez años) descubrió que un 20% ha considerado el suicidio por cambios corporales asociados con la lipodistrofia. Alrededor del 90% de los encuestados opinaron que los medicamentos que están tomando para combatir el VIH son la causa de la lipodistrofia y un 20% de los encuestados dijeron haber abandonado su medicación por completo debido a este problema. Aparte, más del 60% de los encuestados afirmaron haber sido rechazados por parejas potenciales para sexo debido a este sÃndrome. Un número similar de encuestados indicó que inclusive habÃan dejado de mirarse al espejo porque la imagen que veÃan les causaba una sensación de invalidez. Casi todos los individuos encuestados indicaron haber tratado de minimizar los efectos de la lipodistrofia a través de dieta y ejercicio fÃsico o utilizando procedimientos de reconstrucción facial de un costo sumamente elevado, suplementos y hormonas (todos éstos, tratamientos que no son tÃpicamente cubiertos por los seguros médicos o por programas de asistencia médica).
La Lipoatrofia y los Medicamentos contra el VIH.
En 1999 la droga contra el VIH denominada Zerit fue asociada con el desarrollo de lipoatrofia relacionada con la pérdida de tejido adiposo bajo la piel1. Desde entonces, un número de estudios ha concluido que el Zerit puede afectar la forma en que la mitocondria (que es la fábrica de energÃa de la célula) de nuestras células trabaja y se multiplica. Posteriormente, otros estudios concluyeron que el AZT ocasionaba un problema similar, aunque a una menor tasa que el Zerit. Medicamentos clasificados como Inhibidores de la Transcriptasa Reversa Análogos de los Nucleósidos o Nucleótidos (NRTIs) tales como el Zerit o el AZT impiden que el VIH altere el material genético de los Linfocitos T saludables, y a través de dicho proceso, detienen la reproducción de nuevas células virales. Adicionalmente, los NRTIs afectan también la mitocondria de las células adiposas que se encuentran bajo la piel, impidiendo que se multipliquen y causando su muerte. Por otra parte, individuos que han estado bajo la terapia combinada de Zerit y Videx (otro NRTI) han mostrado una incidencia más aguda de lipoatrofia que aquellos que han estado tomando solamente Zerit. La combinación de Zerit y Videx no es aconsejada por grupos consejeros. Pareciera ser que el Zerit y el AZT empeoran la acumulación de tejido adiposo cuando se los utilizan combinados con Inhibidores de la Proteasa o No-Nucleótidos Análogos (NNRTIs) tales como Sustiva, lo que ha llevado a los investigadores médicos a sospechar que sus efectos negativos pueden funcionar en forma combinada. Sin embargo, la ingesta de Sustiva con Viread (Tenofovir) y Epivir (3TC) parece causar menos lipoatrofia. Debido al alto riesgo de producir lipoatrofia y neuropatÃas, la comisión de guÃas directivas del Departamento de Salud y Servicios Humanos de los Estados Unidos eliminó al Zerit de la lista de medicamentos recomendados como primera lÃnea de ataque para pacientes que han sido recientemente incorporados a la HAART.
El Viread (Tenofovir) y el Ziagen (Abacavir), que son dos drogas pertenecientes al mismo grupo NRTIs que el Zerit y el AZT, parecen no mostrar una correlación tan severa con el desarrollo de la lipoatrofia. Algunas personas inclusive han reportado una lenta reversión de la pérdida de tejido adiposo luego de haber dejado de tomar Zerit o AZT y cambiado ya sea a Ziagen o Viread. Sin embargo, la mayorÃa de los pacientes han reportado que, a pesar de haber transcurrido un número de años desde que abandonaran la terapia de Zerit o AZT, no experimentaron ningún tipo de re-acumulación de tejido adiposo en el rostro. Es importante destacar que una nueva y paradójica información obtenida de un reciente estudio realizado por el AIDS Clinical Trials Group2 ha señalado que una pérdida de tejido adiposo subcutáneo (pérdida del tejido adiposo más cercano a la superficie de la piel) del 20% ocurrió en un pequeño porcentaje de pacientes que habÃan recién entrado en la terapia HAART por primera vez utilizando una combinación de Sustiva, Viread y Epivir. Se va a necesitar un mayor número de estudios para determinar por qué la lipodistrofia todavÃa es un fenómeno que ocurre en algunos pacientes donde existe una ausencia de Zerit o AZT.
Las ventas de Zerit y de AZT en los paÃses industrializados han disminuido considerablemente recientemente debido al efecto que estas drogas tienen sobre la lipodistrofia. Desafortunadamente, estas dos drogas figuran entre los principales medicamentos contra el VIH utilizados en los paÃses en vÃa de desarrollo, lo cual implica que millones de personas en paÃses más pobres van a tener que continuar padeciendo transformaciones corporales.
Opciones Para el Tratamiento de la Lipodistrofia.
Desde hace algunos años a la fecha, muchos varones han dependido de un anabólico esteroide inyectable genérico denominado decanoato de nandrolona (su denominación comercial es Deca DurabolÃn), a fin de tratar de balancear sus cuerpos, añadiendo masa muscular a las extremidades y glúteos que estaban perdiendo volumen, afectados por lipodistrofia. A pesar que los Laboratorios Watson dejaron de producir la nandrolona en Marzo de 2007, es posible adquirirla (expendio bajo receta) a través de farmacias mayoristas por un costo relativamente bajo3.
Existe un suplemento denominado Uridine (Nucleomaxx), elaborado a partir de la caña de azúcar y accesible a través de un distribuidor alemán4. Este suplemento puede ayudar a disminuir la lipodistrofia en pacientes que están tomando Zerit, pero también puede ocasionar acumulación de depósitos de grasas en la zona abdominal e incrementar el nivel de triglicéridos. Debido a estos efectos colaterales, su elevado costo y mal sabor, Uridine no ha tenido una amplia recepción. Sin embargo, para aquellos de deben tomar Zerit, Uridine puede ser una opción viable para prevenir o inclusive revertir lipodistrofia. Adicionalmente, para aquellos individuos que han dejado de tomar Zerit, la droga contra diabetes denominada Rosiglitazone (Avandia) ofrece muy buenos resultados para revertir los efectos de lipodistrofia. Existen, sin embargo, efectos colaterales, incluyendo el aumento de peso y triglicéridos elevados.
Desde el año 2002 han aparecido un par de procedimientos de reconstrucción temporal para tratar la lipodistrofia facial. Una de estas opciones es Sculptra (ácido poli láctico, cuyo nombre comercial anterior era New Fill), la cual implica una serie de sesiones múltiples de costo elevado , y requiere de retoques adicionales. Sculptra puede ser utilizada por aquellos individuos que han sido moderadamente afectados por lipodistrofia. Radiesse es otra opción aprobada por el FDA en los Estados Unidos. Radiesse requiere un mayor número de sesiones, y es más caro que Sculptra, requiriendo de 3 a 5 sesiones y retoques anuales. Algunos pacientes tratados por enflaquecimiento facial con este tipo de productos han experimentado efectos colaterales, tales como hematomas y granulomas tratables (nódulos que tienen la apariencia de espinillas endurecidas).
Existen algunos programas de asistencia para el paciente, disponibles tanto para Sculptra como para Radiesse5.
No existe ningún tipo de solución permanente para la lipoatrofia facial aprobada por el FDA de los Estados Unidos. Sin embargo, muchos individuos en este paÃs utilizan unas inyecciones minúsculas de silicona (Silikon 1000), aplicadas por un especialista. El Silikon 1000 puede ser utilizado legalmente como una substancia genérica para el tratamiento de lipoatrofia facial. Las micro-inyecciones de Silikon 1000 pueden reconstruir lentamente los rostros de los pacientes, en unas cinco sesiones, espaciadas por un mes entre sesión y sesión. No existe ningún tipo de programa de asistencia para el paciente para esta opción, cuyo costo por sesión puede oscilar entre U$D 600.- y U$D 900.- Lamentablemente, también para el caso de Silikon 1000 se requieren múltiples sesiones. Hay que tener muy presente que hay tan solamente muy pocos profesionales en los Estados Unidos que están bien entrenados en la aplicación de este procedimiento.
Existe otro producto para la reconstrucción facial permanente, denominado Polimetil-metacrilato (PMMA). Este producto ha sido utilizado en Brasil durante ocho años y en Méjico durante tres con resultados relativamente positivos, aunque se va a necesitar más tiempo para determinar los efectos en el largo plazo de este procedimiento. Requiere generalmente de dos a cuatro sesiones, sin tener que incurrir en retoques anuales. Hemos visto en el corto plazo que para algunos pacientes el PMMA puede endurecerse y tomar forma grumosa, aunque muchos pacientes parecen muy satisfechos con los resultados. El Artefill es un producto con base PMMA, y tiene la aprobación del FDA en los Estados Unidos para propósitos cosméticos, pero no para el tratamiento de lipoatrofia relacionada con el VIH. Artefill es extremadamente caro en las cantidades necesarias para tratar lipoatrofia, por lo que pacientes seropositivos en los Estados Unidos van a Méjico o Brasil para tener acceso a dicho tratamiento, donde el costo puede oscilar de U$D 2.000,- a U$D 6.000,-. El PMMA es permanente (no se lo puede remover una vez inyectado).
BioAlcamid (poli alkilamida gel), es otra opción también permanente. Es una substancia inyectable que se encuentra disponible en los Estados Unidos (algunos pacientes viajan a Méjico o Brasil para tener acceso al tratamiento a un menor costo). Lamentablemente, BioAlcamid genera un “bolsillo” en la cara y en los glúteos, el cual es permeable para el acceso de bacterias, por lo que presenta un alto riesgo de infección. Como tal, aconsejamos extremado cuidado antes de decidir seguir esta opción.
No existe ninguna base de datos de largo plazo en lo referente a estos procedimientos experimentales para reconstrucción facial, por lo que los riesgos de inyectar una substancia extraña al organismo deben ser cuidadosamente considerados. Desafortunadamente, mucha gente siente que el costo emocional, sicológico y social que trae aparejado vivir con lipodistrofia es tan elevado, que para muchos se justifica tomar estos riesgos.
Opciones Experimentales para el Tratamiento de la Lipohiperatrofia.
A diferencia de la lipoatrofia, los investigadores médicos no han podido llegar a atribuir la lipohiperatrofia (acumulación de tejido adiposo en la barriga, parte posterior del cuello y mamas) a ningún medicamento o clase de droga en particular. En una ocasión se pensó que los inhibidores de la proteasa eran los principales causantes. Sin embargo, recientemente se ha descubierto que la acumulación de tejido adiposo en la zona abdominal puede estar relacionada con una respuesta inflamatoria del sistema inmunológico cuando baja el número de los linfocitos T CD4. Esto significa que aquellos que comienzan el tratamiento de terapia HAART con una menor base de linfocitos T CD4, se pueden encontrar con casos más pronunciados de lipodistrofia. Por otra parte, datos recientes han revelado que pacientes con un nivel de linfocitos T CD4 superior a 250 y que están comenzando la terapia HAART con inhibidores de la proteasa amplificados con la ayuda de Norvir más Viread y Epivir, no han experimentado incremento en el nivel de grasa visceral (tejido adiposo que rodea a los órganos internos). Es aún muy temprano para aventurarse a decir qué va a ocurrir con individuos que comienzan el régimen con niveles bajos de linfocitos T CD4. Algunos estudios han mostrado que aquellos que comienzan tomando inhibidores de la proteasa combinados con Zerit, AZT o Zerit y Videz, tienen una mayor tendencia a incrementar el volumen de grasa visceral y una joroba que aquellos que comenzaron los inhibidores de la proteasa con otras drogas. Es factible que las mismas drogas que están vinculadas con la lipoatrofia puedan también hacer que el incremento de la cantidad de tejido adiposo sea aún mayor, especialmente en pacientes que comienzan la terapia HAART con un bajo número de linfocitos T CD4.
Un concepto erróneo promovido por algunas compañÃas farmacéuticas y que encontró eco en algunos profesionales médicos es que los medicamentos para tratar el VIH no incrementan el nivel de colesterol y que los triglicéridos no causan incrementos en el tejido adiposo. Por el contrario, varios estudios han señalado que pacientes que toman medicamentos que son congeniales con los lÃpidos tales como Reyataz combinados con Viread también experimentan un incremento en la cantidad de tejido adiposo en la barriga luego de comenzar la terapia HAART.
Se le preguntó al doctor David Nolan (clÃnico e investigador en el Royal Perth Hospital de Western Australia y experto en el metabolismo de lÃpidos y VIH) por qué el tejido adiposo visceral no “desaparecÃa” luego de la introducción de Zerit y AZT (tal como ocurre con el tejido adiposo subcutáneo). El doctor Nolan tuvo la hipótesis que es factible que el tejido adiposo que rodea los órganos internos no sea igualmente susceptible a la toxicidad generada por el Zerit y el AZT que el tejido adiposo subcutáneo.
El incremento en el tejido adiposo puede ser correlacionado a la resistencia a la insulina. La resistencia a la insulina puede causar intolerancia a la glucosa, la cual ha sido asociada con incrementos en el tejido adiposo, incrementos en los triglicéridos, y el desarrollo de diabetes. La insulina es una hormona producida por el páncreas para controlar el nivel de azúcar-glucosa en sangre. Los medicamentos contra el VIH pueden bloquear o desacelerar el proceso por el cual la insulina convierte la glucosa en energÃa. En estudios de laboratorio, el Crixivan y dosis más elevadas de Norvir y Zerit han mostrado su capacidad para atrofiar la acción de la insulina tanto en el tejido adiposo como en el muscular. En este caso, el páncreas va a producir mayores cantidades de insulina a fin de tratar de compensar la disminución en la función. Se pueden presentar elevados niveles de insulina durante años antes de que se desarrolle diabetes del tipo 2. Un análisis de tolerancia a la glucosa puede indicar este problema fácilmente, pero raramente se lo utiliza en la práctica. Adicionalmente, algunos individuos pueden tener una predisposición genética a la resistencia a la insulina. Un tipo de vida sedentaria y una dieta rica en azúcares y grasas de origen animal puede contribuir en forma cumulativa a este problema. En cualquier caso, la resistencia a la insulina puede ser tan solamente una parte del misterio de la lipohiperatrofia. No existe un acuerdo generalizado entre los investigadores sobre si monitorear o no los niveles de insulina en pacientes seropositivos es un instrumento confiable para determinar la resistencia a la insulina y el incremento de tejido graso.
Una absorciometrÃa de rayos X duales para cuerpo completo es el instrumento ideal para casos de lipodistrofia. Es un análisis de gran importancia que puede proveer información acerca de la composición corporal (masa grasa, masa muscular y densidad ósea). La baja densidad ósea ha sido asociada con el VIH en varios estudios. Tanto el Medicare como seguros médicos privados generalmente cubren este análisis, el cual es relativamente económico. En tanto que este análisis no puede diferenciar entre la grasa acumulada en la barriga o la subcutánea en el área abdominal, puede ser muy útil como punto de partida para evaluar cambios corporales y para justificar terapias reembolsables para grasas, músculo y masa ósea.
Intervenciones en el Tratamiento para casos de Lipohiperatrofia.
Algunos pacientes han cambiado de inhibidores de la proteasa a Viramune o a Sustiva para combatir incrementos en la grasa visceral, pero esto no ha mostrado producir diferencia alguna. TodavÃa no se sabe qué ocurre con la grasa del abdomen cuando un paciente cambia de Zerit o AZT a Viread o Ziagen mientras aún se encuentra tomando inhibidores de la proteasa o NNRTIs tales como Sustiva o Viramune.
La hormona de crecimiento humano Serostim es una droga inyectable que se aplica en forma diaria, y ha sido aprobada por el FDA para el tratamiento del sÃndrome de desgaste asociado con el VIH. Con un costo mensual aproximado de U$D 3.000,- es una opción muy cara para el tratamiento de la lipodistrofia. El Serostim ha demostrado buenos resultados en materia de disminución de grasa abdominal, pero presenta una serie de efectos colaterales, incluyendo dolores en las articulaciones, retención de agua, sÃndrome de túnel carpiano, y diabetes irreversible. La combinación de todos estos efectos con la carencia de información acerca de beneficios comprobables para la salud en el largo plazo ha hecho que el FDA no haya aprobado el Serostim para el tratamiento de acumulación de grasas relacionados con el VIH.
El Tesamorelin -TH9507, elaborado por Theratecnologies- es un precursor de la hormona de crecimiento, inyectable en forma diaria, que se encuentra en las últimas etapas para aprobación por el FDA. El Tesamorelin aparenta tener menos efectos colaterales que el Serostim, pero puede necesitar de un mayor lapso de tiempo para comenzar a mostrar sus beneficios en los pacientes. Lamentablemente, la grasa previamente incrementada regresa a sus niveles existentes previos a la utilización de tanto el Serostim como el Tesamorelin, una vez que se descontinúen cualquiera de ellos.
Un nuevo elemento que ha aparecido en la carrera para encontrar una solución para disminuir la acumulación de grasa visceral es Leptin. Leptin es una hormona producida por las células adiposas. Los investigadores han descubierto que los niveles de leptin en sangre son proporcionales al nivel de grasa corporal del individuo. El leptin trabaja en la parte del cerebro que controla el apetito y otras funciones básicas. Elevadas concentraciones de leptin generalmente traen aparejadas una disminución del apetito a la vez que estimulan al organismo para que queme grasas. El leptin no aparenta tener impacto negativo alguno en la tolerancia a la glucosa.
Actualmente, los médicos prefieren prescribir testosterona bajo la forma de gel, inyecciones y comprimidos subcutáneos. El gel de testosterona aplicado sobre la barriga puede reducir el tamaño de la cintura en varones seropositivos. Esta disminución de tamaño es usualmente el resultado de la disminución de tejido adiposo subcutáneo y no de la grasa visceral. En contraste, un pequeño estudio piloto realizado con Oxandrin (un esteroide anabólico de ingesta oral) ha mostrado resultados significativos en materia de reducción de grasa visceral. Incrementos en las lipoproteÃnas de baja densidad (el denominado “colesterol malo”) y reducciones en las lipoproteÃnas de alta densidad (el denominado “colesterol bueno”) se correlacionan con una pequeña disminución en el tejido adiposo subcutáneo. No existe ninguna información hasta el momento que conecte un anabólico muy popular, el decanoato de nandrolona, con reducciones en la grasa visceral.
Algunos individuos que han estado buscando elementos que ayuden a quemar las grasas han sido vÃctimas de las técnicas publicitarias que tratan de impulsar suplementos de hormona de crecimiento o distintos elementos que se publicitan como efectivos para eliminar grasas. Estos productos generalmente tienen un efecto insignificante en lo que respecta a la eliminación de grasas, pero elevan la presión arterial y los niveles de ansiedad, y son generalmente considerados como una estafa.
La Metformin (comercializada bajo la denominación Glucophage) es una droga genérica contra la diabetes que ha mostrado ayudar a mejorar la tolerancia a la glucosa y para disminuir la grasa visceral en la parte inferior. Sus efectos se pueden inclusive incrementar cuando se la combina con un programa de ejercicio fÃsico. La Metformin mejora la sensibilidad a la insulina, los triglicéridos y la grasa hepática, pero puede causar diarrea y conducir a una pérdida de peso. Se han reportado incluso algunos casos de bajos niveles de azúcar en sangre y episodios de mareos asociados con esta droga.
En adición a todos los tratamientos anteriormente mencionados, los pacientes siempre pueden optar por otro tratamiento: liposucción. La liposucción asistida por ultrasonido puede ser utilizada para remover exitosamente el tejido adiposo acumulado con la forma de una joroba de búfalo en la parte posterior del cuello.
Algunos pacientes han reportado el incremento de tamaño en las glándulas salivares en los costados de la cara, un efecto comúnmente denominado “cara de ardilla”. A pesar de que existen muy pocos radiólogos que saben cómo utilizar este procedimiento en forma correcta, unas bajas dosis de radiación de electrones han producido resultados muy satisfactorios en el tratamiento para la reducción de tamaño de las glándulas salivares en la parótida. Lo que no se tiene claro todavÃa es si este fenómeno de incremento de tamaño en las glándulas salivares está relacionado con la lipodistrofia o si es causado por una reconstitución inmunológica.
Otra alternativa sobre la que no se han hecho muchos estudios todavÃa es dieta y ejercicio. Un estudio realizado en la Tufts University mostró una tendencia hacia una menor lipodistrofia para aquellos individuos que tenÃan una mayor ingesta de fibras solubles (frutas y vegetales) y que hacÃan ejercicios fÃsicos en forma habitual. A pesar de ello, se necesitan estudios en mayor profundidad en lo relativo a la utilización de dietas de carbohidratos simples. Estas dietas han mostrado su habilidad para mejorar la resistencia a la insulina y la reducción de la grasa visceral en estudios no relacionados con el VIH. Un estudio observacional mostró que los pacientes seropositivos tienden a ingerir mayores cantidades de grasas saturadas. Un pequeño estudio piloto combinando ejercicios cardiovasculares y ejercicios de resistencia mostró una disminución en triglicéridos y grasa visceral. Sin embargo, el problema es la continuidad en este tipo de programas, la cual constituye el mayor reto para la mayorÃa de la gente. Los estudios relacionando los efectos de ejercicio con casos de VIH se encuentran todavÃa en su infancia.
Incrementos en los LÃpidos: Las LipoproteÃnas de Baja Densidad (LDL) y Los Triglicéridos.
Las anormalidades más comunes en pacientes seropositivos son cantidades elevadas de triglicéridos y de LDL, o colesterol “malo”, y bajos números en lo que respecta a LipoproteÃnas de Alta Densidad (HDL), o colesterol “bueno”. Es muy posible que individuos seropositivos antes de que comiencen la terapia contra el VIH por primera vez, tengan niveles inferiores a los normales tanto para las lipoproteÃnas de alta y de baja densidad. Sin embargo, luego de que se comience la terapia con drogas contra el VIH, en algunos casos se ha visto un incremento en las lipoproteÃnas de alta y de baja densidad, asà como también en los triglicéridos. Algunos estudios han señalado que el nivel de lÃpidos de baja densidad (LDL) se incrementa para alcanzar los niveles existentes antes de la seroconversión, en tanto que los niveles de lÃpidos de alta densidad (HDL) nunca retornan a los niveles normales. El incremento en triglicéridos es el cambio más fuertemente asociado en materia de lÃpidos causado por medicamentos contra el VIH tales como inhibidores de la proteasa, Zerit, AZT o Sustiva. Dentro de todos los inhibidores de la proteasa, Reyataz parece ser el que se correlaciona con el menor incremento de lÃpidos.
Muchos pacientes prefieren comenzar a tomar suplementos antes de comenzar a tomar medicamentos para bajar el nivel de lÃpidos en sangre. Los únicos suplementos que han mostrado resultados sólidos en estudios sobre lÃpidos son los ácidos grasos Omega-3 (aceites de pescado), asà como también la niacina (también conocida como Niaspan). Los aceites de pescado pueden disminuir los triglicéridos, pero algunos pacientes encuentran que sus estómagos no lo toleran muy bien. La niacina es mejor que cualquier medicamento para disminuir lÃpidos en cuanto a sus efectos para incrementar el colesterol “bueno”. Puede causar rubor en la cara y una sensación de calor que dura alrededor de una media hora, pero la mayorÃa de la gente se acostumbra a estos efectos. Recientemente ha aparecido una versión de Niacina que no causa rubor en la cara, pero su efectividad es desconocida a la fecha.
No está claro si Raltegravir (Isentress) o si Maraviroc (Celsentry -un inhibidor de punto de entrada CCR5-) tienen efecto alguno sobre la composición corporal. Hasta el momento, aparentan tener una buena correlación con los lÃpidos cuando se los toma en forma conjunta con Viread o Epivir. Fuzeon (un inhibidor de punto de entrada inyectable) también aparenta ser compatible con lÃpidos, pero se lo utiliza frecuentemente en forma combinada con inhibidores de la proteasa que pueden causar incremento en los lÃpidos. Pareciera ser que existen algunos factores genéticos que hacen que algunos pacientes presenten una tendencia a tener niveles más elevados de triglicéridos y de lipoproteÃnas de baja densidad (colesterol “malo”).
Agentes reductores de lÃpidos tales como las estatinas (Lipitor, etc.) o fibratos (Tricor, etc.) pueden tener unos efectos fabulosos en algunos pacientes, pero aún cuando se los utilice, algunos pacientes nunca llegan a niveles “normales” en el panel de lÃpidos. Se utiliza habitualmente una combinación de niacina, baja ingesta de azúcares y grasas animales, ejercicio, suplementos de aceite de pescado o un incremento en la ingesta de pescados aceitosos de aguas frÃas (salmón, por ejemplo) y fibras solubles (frutas, vegetales y avena) para tratar los lÃpidos. Algunos individuos han tratado la combinación de estatinas y fibratos, pero dicha combinación puede conducir a un incremento en desórdenes musculares para algunos pacientes.
Conclusión.
Hemos aprendido mucho en los últimos diez años acerca de los cambios corporales que vienen aparejados con el VIH, pero quedan aún muchas preguntas sin contestar. Es de anhelar que aquellos que recién están siendo introducidos a las nuevas terapias HAART no tengan que sufrir los devastadores efectos colaterales que sus predecesores tuvieron que enfrentar en los últimos veinte años. Como pacientes, es nuestra responsabilidad educarnos en la mayor medida posible y aprender de otras fuentes e individuos acerca de nuevas opciones que vayan apareciendo y que puedan hacer posible algún dÃa el llevar una vida plena sin ninguno de los cambios corporales ni tampoco ninguno de los efectos colaterales que vienen asociados con el VIH.
Para mayor información, por favor visite el sitio: www.facialwasting.org, o si desea subscribirse al mayor grupo de discusión en el Internet acerca de temas de salud vinculados con el VIH, simplemente envÃe un email en blanco a pozhealth-subscribe@yahoogroups.com.
1 A syndrome of peripheral fat wasting (lipodystrophy) in patients receiving long-term nucleoside analogue therapy. Saint-Marc T, Partisani M, Poizot-Martin I, Bruno F, Rouviere O, Lang JM, Gastaut JA, Touraine JL. AIDS. 1999 Sep 10; 13(13):1659-67.
2 Metabolic Outcomes of ACTG 5142: A Prospective, Randomized, Phase III Trial of NRTI-, PI-, and NNRTI- sparing Regimens for Initial Treatment of HIV-1 Infection. Richard H. Haunbrich, S Riddler, G DiRienzo et al.
3 More information is available at www.medibolics.com
4 More information is available at www.nucleomaxx.com
5 More information is available at www.facialwasting.org.
Anabolic Steroid Induced Hypogonadism
I am helping Dr Scally publish his book about how to get off anabolic steroids safely. Hopefully this information will help some HIV patients who have been using steroids since they reversed their wasting years ago, and also help people like Cansenco and other athletes. The book should be out in a month or so. I will inform everyone about where to get it. Dr Scally is, in my opinion, the country's best expert on this subject. He lives in Houston and lost his license because of using his protocol to reverse hypogonadism after anabolic use. He has made great progress convincing other doctors about his program and now will make it public in his book. We both presented a paper at the Lipodystrophy conference a few years ago on this topic.
Jose Canseco Suffering from Anabolic Steroid Induced Hypogonadism
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Written by millardbaker on Oct-20-08 11:23am
From: www.mesomorphosis.com
Jose Canseco admits to health problems resulting from the discontinuation of anabolic steroids in the A&E documentary “Jose Canseco: The Last Shot” premiering Monday night, October 20th.
Jose Canseco, the former baseball superstar who blew the whistle on the game’s steroid scandal, has used steroids himself for the past 24 years. Now Jose wants to finally get clean, but he’s terrified about what may happen when he goes through the process. There has been no medically documented case of someone quitting steroids after using them for so long, and the doctors have different opinions about what Jose will go through physically and mentally. Viewers watch Jose play guinea pig as he tries to end his long addiction.
Canseco has made the decision to permanently stop using steroids for whatever reason. During the documentary, Canseco describes classical post-cessation symptoms of anaboic steroid induced hypogonadism (ASIH) such as low libido and depression (”It’s broke, scared & contrite Jose Canseco in TV documentary,” October 18).
The show also follows Canseco through a series of medical appointments with Santa Monica physician Dr. Brent Michael. Canseco tells Michael he wants to wean himself off steroids for good and restore his testosterone levels, since quitting cold turkey isn’t working.
“I have no sex drive whatsoever. Zero,” says Canseco, who is filmed in one sequence meeting Michael with current girlfriend Heidi Northcott present. Canseco admits to bouts of depression and wanting to be left alone.
Our society has demonized anabolic steroids. The highly politicized steroid hysteria has led the medical community to abandon treatment for the non-prescription steroid user. Our society tells steroid users that it is imperative that they stop using steroids immediately to avoid catastrophic damage to their health. But once they stop using steroids, professionals in the medical community are clueless to the consequences of steroid cessation and are ignorant to the treatment options and necessary post cycle therapy (PCT). Then steroid users like Jose Canseco are ridiculed for the post cycle side effects after discontinuing steroids.
Dr. Michael Scally explains the abysmal failure of the medical community to recognize and treat anabolic steroid induced hypogonadism:
For the greater part of 10 years I have found that the medical treatment provided for the condition termed anabolic steroid induced hypogonadism (ASIH), is nonexistent or ignored by the great majority of medical professionals. As predicted since my entry into this field in 1995 more and more cases of ASIH would appear due to this negligence. Clear and convincing evidence of this is demonstrated by recent articles in peer-reviewed medical literature affirming concerns for the long term effects of untreated ASIH, rapidity and severity of symptoms in ASIH, and inappropriate treatment with AAS based upon a flawed clinical study design.
Anabolic steroids have known side effects. But overall, anabolic steroids are remarkably safe and have been used in medicine for over 50 years. The greatest risk is associated with untreated anabolic steroid induced hypogonadism. But the medical community doesn’t officially recognize this condition much less established a medically accepted treatment to restore endogenous testosterone levels.
In the documentary, Jose Canseco receives a testosterone gel from his physician as a treatment for his low testosterone. The average steroid using gymrat knows that testosterone is suppressive to the HPTA axis and will continue to prevent the restoration of endogenous testosterone production.
Michael prescribes a gel supplement that is “not a performance-enhancing steroid,” but after using the gel for a month, Canseco discovers his natural testosterone levels are still well below normal.
Michael prescribes a gel supplement that is “not a performance-enhancing steroid,” but after using the gel for a month, Canseco discovers his natural testosterone levels are still well below normal.
“My body forgot how to make testosterone,” says Canseco, which may explain his recent trip to Mexico.
It appears Jose Canseco has given up on the medical community. Physicians spend so much time telling people to stop using anabolic steroids. But they seem to care less about what happens to them when they stop. So Canseco, suffering from ASIH, is making attempts to take treatment into his own hands. This would explain his recent trip to Mexico and importation of human chorionic gonadotropin (hCG). HCG is often used by steroid users to stimulate their own natural production of testosterone.
I hope Jose Canseco will find a way to contact Dr. Michael Scally, founder of HPT/Axis and ASIH.net. Dr. Scally has dedicated his professional career to help steroid users restore their endogenous testosterone production after stopping the use of steroids (and has had his medical license revoked as a result of the anti-steroid crusade in the medical profession). But Scally continues to work on ways towards helping non-medical users of anabolic steroids, like Jose Canseco, return to normal physiology.
Jose Canseco Suffering from Anabolic Steroid Induced Hypogonadism
Written by millardbaker on Oct-20-08 11:23am
From: www.mesomorphosis.com
Jose Canseco admits to health problems resulting from the discontinuation of anabolic steroids in the A&E documentary “Jose Canseco: The Last Shot” premiering Monday night, October 20th.
Jose Canseco, the former baseball superstar who blew the whistle on the game’s steroid scandal, has used steroids himself for the past 24 years. Now Jose wants to finally get clean, but he’s terrified about what may happen when he goes through the process. There has been no medically documented case of someone quitting steroids after using them for so long, and the doctors have different opinions about what Jose will go through physically and mentally. Viewers watch Jose play guinea pig as he tries to end his long addiction.
Canseco has made the decision to permanently stop using steroids for whatever reason. During the documentary, Canseco describes classical post-cessation symptoms of anaboic steroid induced hypogonadism (ASIH) such as low libido and depression (”It’s broke, scared & contrite Jose Canseco in TV documentary,” October 18).
The show also follows Canseco through a series of medical appointments with Santa Monica physician Dr. Brent Michael. Canseco tells Michael he wants to wean himself off steroids for good and restore his testosterone levels, since quitting cold turkey isn’t working.
“I have no sex drive whatsoever. Zero,” says Canseco, who is filmed in one sequence meeting Michael with current girlfriend Heidi Northcott present. Canseco admits to bouts of depression and wanting to be left alone.
Our society has demonized anabolic steroids. The highly politicized steroid hysteria has led the medical community to abandon treatment for the non-prescription steroid user. Our society tells steroid users that it is imperative that they stop using steroids immediately to avoid catastrophic damage to their health. But once they stop using steroids, professionals in the medical community are clueless to the consequences of steroid cessation and are ignorant to the treatment options and necessary post cycle therapy (PCT). Then steroid users like Jose Canseco are ridiculed for the post cycle side effects after discontinuing steroids.
Dr. Michael Scally explains the abysmal failure of the medical community to recognize and treat anabolic steroid induced hypogonadism:
For the greater part of 10 years I have found that the medical treatment provided for the condition termed anabolic steroid induced hypogonadism (ASIH), is nonexistent or ignored by the great majority of medical professionals. As predicted since my entry into this field in 1995 more and more cases of ASIH would appear due to this negligence. Clear and convincing evidence of this is demonstrated by recent articles in peer-reviewed medical literature affirming concerns for the long term effects of untreated ASIH, rapidity and severity of symptoms in ASIH, and inappropriate treatment with AAS based upon a flawed clinical study design.
Anabolic steroids have known side effects. But overall, anabolic steroids are remarkably safe and have been used in medicine for over 50 years. The greatest risk is associated with untreated anabolic steroid induced hypogonadism. But the medical community doesn’t officially recognize this condition much less established a medically accepted treatment to restore endogenous testosterone levels.
In the documentary, Jose Canseco receives a testosterone gel from his physician as a treatment for his low testosterone. The average steroid using gymrat knows that testosterone is suppressive to the HPTA axis and will continue to prevent the restoration of endogenous testosterone production.
Michael prescribes a gel supplement that is “not a performance-enhancing steroid,” but after using the gel for a month, Canseco discovers his natural testosterone levels are still well below normal.
Michael prescribes a gel supplement that is “not a performance-enhancing steroid,” but after using the gel for a month, Canseco discovers his natural testosterone levels are still well below normal.
“My body forgot how to make testosterone,” says Canseco, which may explain his recent trip to Mexico.
It appears Jose Canseco has given up on the medical community. Physicians spend so much time telling people to stop using anabolic steroids. But they seem to care less about what happens to them when they stop. So Canseco, suffering from ASIH, is making attempts to take treatment into his own hands. This would explain his recent trip to Mexico and importation of human chorionic gonadotropin (hCG). HCG is often used by steroid users to stimulate their own natural production of testosterone.
I hope Jose Canseco will find a way to contact Dr. Michael Scally, founder of HPT/Axis and ASIH.net. Dr. Scally has dedicated his professional career to help steroid users restore their endogenous testosterone production after stopping the use of steroids (and has had his medical license revoked as a result of the anti-steroid crusade in the medical profession). But Scally continues to work on ways towards helping non-medical users of anabolic steroids, like Jose Canseco, return to normal physiology.
OFF TOPIC; Wall Street's 'Disaster Capitalism for Dummies'
Yes, we're dummies. You. Me. All 300 million of us. Clueless. We should be
ashamed. We're obsessed about the slogans and rituals of "democracy,"
distracted by the campaign, polls, debates, rhetoric, half-truths and outright
lies. McCain? Obama? Sorry to pop your bubble folks, but it no longer matters
who's president. See Paul B. Farrell.
PAUL B. FARRELL
Wall Street's 'Disaster Capitalism for Dummies'
14 reasons Main Street loses big while Wall Street sabotages democracy
By Paul B. Farrell, MarketWatch
Last update: 7:10 p.m. EDT Oct. 20, 2008
ARROYO GRANDE, Calif. (MarketWatch) -- Yes, we're dummies. You. Me. All 300 million of us. Clueless. We should be ashamed. We're obsessed about the slogans and rituals of "democracy," distracted by the campaign, polls, debates, rhetoric, half-truths and outright lies. McCain? Obama? Sorry to pop your bubble folks, but it no longer matters who's president.
Why? The real "game changer" already happened. Democracy has been replaced by Wall Street's new "disaster capitalism." That's the big game-changer historians will remember about 2008, masterminded by Wall Street's ultimate "Trojan Horse," Hank Paulson. Imagine: Greed, arrogance and incompetence create a massive bubble, cost trillions, and still Wall Street comes out smelling like roses, richer and more powerful!
Yes, we're idiots: While distracted by the "illusion of democracy" in the endless campaign, Congress surrendered the powers we entrusted to it with very little fight. Congress simply handed over voting power and the keys to trillions in the Treasury to Wall Street's new "Disaster Capitalists" who now control "democracy."
Why did this happen? We're in denial, clueless wimps, that's why. We let it happen. In one generation America has been transformed from a democracy into a strange new form of government, "Disaster Capitalism." Here's how it happened:
Three decades of influence peddling in Washington has built an army of 42,000 special-interest lobbyists representing corporations and the wealthy. Today these lobbyists manipulate America's 537 elected officials with massive campaign contributions that fund candidates who vote their agenda.
This historic buildup accelerated under Reaganomics and went into hyperspeed under Bushonomics, both totally committed to a new disaster capitalism run privately by Wall Street and Corporate America. No-bid contracts in wars and hurricanes. A housing-credit bubble -- while secretly planning for a meltdown.
Finally, the coup de grace: Along came the housing-credit crisis, as planned. Press and public saw a negative, a crisis. Disaster capitalists saw a huge opportunity. Yes, opportunity for big bucks and control of America. Millions of homeowners and marginal banks suffered huge losses. Taxpayers stuck with trillions in debt. But giant banks emerge intact, stronger, with virtual control over government and the power to use taxpayers' funds. They're laughing at us idiots!
Amazing isn't it, Wall Street's Disaster Capitalists screwed up, likely planned or let happen this meltdown and recession. Yet America's clueless taxpayers just reward them by giving the screw-ups massive bailouts, control over more than $2 trillion of tax money, and the power to clean up the mess they made. Oh yes, we are dummies!
This end game was planned for years in secret war rooms on Wall Street, in Corporate America, in Washington and the Forbes 400. Democracy is too cumbersome. It had to be marginalized for Disaster Capitalism to take over. Reagan, Bush and Paulson were Wall Street's "Trojan Horses."
Naomi Klein summarizes the game in "Shock Doctrine: the Rise of Disaster Capitalism." This "new economy" generates enormous profits feeding off other peoples' misery: Wars, terror attacks, natural catastrophes, poverty, trade sanctions, subprime housing meltdowns and all kinds of economic, financial and political disasters. Natural (Katrina) or manmade (Iraq), either way "disaster capitalism" creates fortunes.
So you, me and the other 300 million better get out of denial. America is no longer a democracy. Voting is irrelevant. Best case scenario: We're a plutocracy, a government ruled by the wealthy, the richest 1%, the Forbes 400, the influential wealthy elite, while the other 99% are their "servants." Meanwhile, the inflation-adjusted income of wage-earners has declined for three decades.
Worst case scenario: America's no democracy and as a result of the meltdown and the surrender of our power to Wall Street's new Disaster Capitalism we are morphing into what one WWII dictator called "corporatism," a "merger of state and corporate power," kind of like what's going on now with Goldman Sachs' ex-boss as de facto president.
Wolves in sheep's clothing
Yes, a strong charge. But like a lot of our readers, I don't like what's happening to America. I'm a patriot. I volunteered for the Marines. Served four years. Volunteered for Korea. I don't like how our freedoms, rights and value system are being subverted in the name of greed, arrogance, self-righteous intolerance and other false gods.
We know for the last eight years disaster capitalists ignored obvious warnings of a coming meltdown. They apparently planned it. They road the bull, got very rich. Now they have the ultimate disaster capitalist weapons, trillions in tax money, virtual control of government.
That's why I fear we're on the edge of a dangerous line between Wall Street's version of disaster capitalism and a toxic "merger of state and corporate power." The wolf is in sheep's clothing. Wall Street pretends we're a democracy. Yet America more closely resembles the kind of "corporatism" that Laurence W. Britt wrote about five years ago in Free Inquiry magazine.
We adapted his historical analysis of 14 key traits for today's discussion. Notice how they have a huge impact your investments and retirement:
1. Wall Street rich get first priority
Think "bailout." Wall Street's greedy con game spins out of control globally. Millions of homeowners misled, lose. Who gets hundreds of billions first? Wall Street's con men.
2. National security obsession
Think of the expansion of executive powers in the name of national security: Preemptive wars, wiretapping private citizens, Gitmo, torture; driven by a dark wealthy neocon elite.
3. Superpower with massive military
Think of our $3 trillion Iraq/Afghan War. Disaster capitalists love the thrill of military power. We outspend all nations, over half the federal budget to strut before the world.
4. Extreme nationalism
Signs are everywhere: Flags, lapel pins, "support the troops" slogans, all to get huge military budgets passed. Challenge them and you're un-American and unpatriotic.
5. Rally the masses by scapegoating enemies
Think "axis of evil," mushroom clouds, "Islamofascists," more terrorist attacks on the homeland. Propaganda creates "enemies" in the public's mind and distracts from real issues.
6. Corruption and cronyism
Think earmarks, no-bid defense contracts, paid mercenaries outnumbering military in Iraq, superlobbyist Jack Abramoff, biofuels, bridge to nowhere, millions donated to campaigns.
7. Obsession with crime
Think of prison-building as just another investment opportunity, rather than focusing on reforming our criminal justice system. Stoke irrational fear of criminals and extremists.
8. Labor and low wages
Think corporate earnings versus the wages paid to workers. No "trickling down," leaves more for tricklers: Rich insiders, stockholders. Wages dropping as CEO salaries skyrocket.
9. Contempt for human rights
Think of abuses of habeas corpus, loss of right to trial, bogus charges, plus "demonizing" the victims, all in the name of national defense and homeland security.
10. Mass media manipulation
Think of leaking false information, Joseph Wilson, Valerie Plame, Scooter Libby, Colin Powell's United Nation's testimony, Condoleezza Rice's mushroom clouds, WMDs, all to suppress the truth.
11. Obsession with sexism
Think of paternalism, antigays, antiabortion, subordinate women -- then codify the system as the law of the land reinforcing a male-dominated society, punish violators.
12. Disdain for intellectuals
Think of conservative intellectuals Francis Fukuyama and Bill Buckley. Contrast them to Sarah Palin and Joe Sixpack conservatism, Bush's funding cuts for arts and science education.
13. Religion in government
Think of all the faith-based programs versus antiscience in drug approvals, creationism vs. evolution, Ten Commandments enshrined in public buildings, public money to churches.
14. Fraudulent elections
Think of police and prosecutorial intimidation and threats to voters, challenging minority voters, ballots disappearing, party election officials committing outright fraud.
Yes, officially America is still a democracy. We have enough signs and rituals to support that illusion. But the truth is America has become a plutocracy run by and for the wealthy. And since Wall Street's Disaster Capitalism coup de grace, we are rapidly morphing into a dangerous new government.
For more, read Britt's original article, then add comments here: Was the meltdown planned by Wall Street's Disaster Capitalists?
ashamed. We're obsessed about the slogans and rituals of "democracy,"
distracted by the campaign, polls, debates, rhetoric, half-truths and outright
lies. McCain? Obama? Sorry to pop your bubble folks, but it no longer matters
who's president. See Paul B. Farrell.
PAUL B. FARRELL
Wall Street's 'Disaster Capitalism for Dummies'
14 reasons Main Street loses big while Wall Street sabotages democracy
By Paul B. Farrell, MarketWatch
Last update: 7:10 p.m. EDT Oct. 20, 2008
ARROYO GRANDE, Calif. (MarketWatch) -- Yes, we're dummies. You. Me. All 300 million of us. Clueless. We should be ashamed. We're obsessed about the slogans and rituals of "democracy," distracted by the campaign, polls, debates, rhetoric, half-truths and outright lies. McCain? Obama? Sorry to pop your bubble folks, but it no longer matters who's president.
Why? The real "game changer" already happened. Democracy has been replaced by Wall Street's new "disaster capitalism." That's the big game-changer historians will remember about 2008, masterminded by Wall Street's ultimate "Trojan Horse," Hank Paulson. Imagine: Greed, arrogance and incompetence create a massive bubble, cost trillions, and still Wall Street comes out smelling like roses, richer and more powerful!
Yes, we're idiots: While distracted by the "illusion of democracy" in the endless campaign, Congress surrendered the powers we entrusted to it with very little fight. Congress simply handed over voting power and the keys to trillions in the Treasury to Wall Street's new "Disaster Capitalists" who now control "democracy."
Why did this happen? We're in denial, clueless wimps, that's why. We let it happen. In one generation America has been transformed from a democracy into a strange new form of government, "Disaster Capitalism." Here's how it happened:
Three decades of influence peddling in Washington has built an army of 42,000 special-interest lobbyists representing corporations and the wealthy. Today these lobbyists manipulate America's 537 elected officials with massive campaign contributions that fund candidates who vote their agenda.
This historic buildup accelerated under Reaganomics and went into hyperspeed under Bushonomics, both totally committed to a new disaster capitalism run privately by Wall Street and Corporate America. No-bid contracts in wars and hurricanes. A housing-credit bubble -- while secretly planning for a meltdown.
Finally, the coup de grace: Along came the housing-credit crisis, as planned. Press and public saw a negative, a crisis. Disaster capitalists saw a huge opportunity. Yes, opportunity for big bucks and control of America. Millions of homeowners and marginal banks suffered huge losses. Taxpayers stuck with trillions in debt. But giant banks emerge intact, stronger, with virtual control over government and the power to use taxpayers' funds. They're laughing at us idiots!
Amazing isn't it, Wall Street's Disaster Capitalists screwed up, likely planned or let happen this meltdown and recession. Yet America's clueless taxpayers just reward them by giving the screw-ups massive bailouts, control over more than $2 trillion of tax money, and the power to clean up the mess they made. Oh yes, we are dummies!
This end game was planned for years in secret war rooms on Wall Street, in Corporate America, in Washington and the Forbes 400. Democracy is too cumbersome. It had to be marginalized for Disaster Capitalism to take over. Reagan, Bush and Paulson were Wall Street's "Trojan Horses."
Naomi Klein summarizes the game in "Shock Doctrine: the Rise of Disaster Capitalism." This "new economy" generates enormous profits feeding off other peoples' misery: Wars, terror attacks, natural catastrophes, poverty, trade sanctions, subprime housing meltdowns and all kinds of economic, financial and political disasters. Natural (Katrina) or manmade (Iraq), either way "disaster capitalism" creates fortunes.
So you, me and the other 300 million better get out of denial. America is no longer a democracy. Voting is irrelevant. Best case scenario: We're a plutocracy, a government ruled by the wealthy, the richest 1%, the Forbes 400, the influential wealthy elite, while the other 99% are their "servants." Meanwhile, the inflation-adjusted income of wage-earners has declined for three decades.
Worst case scenario: America's no democracy and as a result of the meltdown and the surrender of our power to Wall Street's new Disaster Capitalism we are morphing into what one WWII dictator called "corporatism," a "merger of state and corporate power," kind of like what's going on now with Goldman Sachs' ex-boss as de facto president.
Wolves in sheep's clothing
Yes, a strong charge. But like a lot of our readers, I don't like what's happening to America. I'm a patriot. I volunteered for the Marines. Served four years. Volunteered for Korea. I don't like how our freedoms, rights and value system are being subverted in the name of greed, arrogance, self-righteous intolerance and other false gods.
We know for the last eight years disaster capitalists ignored obvious warnings of a coming meltdown. They apparently planned it. They road the bull, got very rich. Now they have the ultimate disaster capitalist weapons, trillions in tax money, virtual control of government.
That's why I fear we're on the edge of a dangerous line between Wall Street's version of disaster capitalism and a toxic "merger of state and corporate power." The wolf is in sheep's clothing. Wall Street pretends we're a democracy. Yet America more closely resembles the kind of "corporatism" that Laurence W. Britt wrote about five years ago in Free Inquiry magazine.
We adapted his historical analysis of 14 key traits for today's discussion. Notice how they have a huge impact your investments and retirement:
1. Wall Street rich get first priority
Think "bailout." Wall Street's greedy con game spins out of control globally. Millions of homeowners misled, lose. Who gets hundreds of billions first? Wall Street's con men.
2. National security obsession
Think of the expansion of executive powers in the name of national security: Preemptive wars, wiretapping private citizens, Gitmo, torture; driven by a dark wealthy neocon elite.
3. Superpower with massive military
Think of our $3 trillion Iraq/Afghan War. Disaster capitalists love the thrill of military power. We outspend all nations, over half the federal budget to strut before the world.
4. Extreme nationalism
Signs are everywhere: Flags, lapel pins, "support the troops" slogans, all to get huge military budgets passed. Challenge them and you're un-American and unpatriotic.
5. Rally the masses by scapegoating enemies
Think "axis of evil," mushroom clouds, "Islamofascists," more terrorist attacks on the homeland. Propaganda creates "enemies" in the public's mind and distracts from real issues.
6. Corruption and cronyism
Think earmarks, no-bid defense contracts, paid mercenaries outnumbering military in Iraq, superlobbyist Jack Abramoff, biofuels, bridge to nowhere, millions donated to campaigns.
7. Obsession with crime
Think of prison-building as just another investment opportunity, rather than focusing on reforming our criminal justice system. Stoke irrational fear of criminals and extremists.
8. Labor and low wages
Think corporate earnings versus the wages paid to workers. No "trickling down," leaves more for tricklers: Rich insiders, stockholders. Wages dropping as CEO salaries skyrocket.
9. Contempt for human rights
Think of abuses of habeas corpus, loss of right to trial, bogus charges, plus "demonizing" the victims, all in the name of national defense and homeland security.
10. Mass media manipulation
Think of leaking false information, Joseph Wilson, Valerie Plame, Scooter Libby, Colin Powell's United Nation's testimony, Condoleezza Rice's mushroom clouds, WMDs, all to suppress the truth.
11. Obsession with sexism
Think of paternalism, antigays, antiabortion, subordinate women -- then codify the system as the law of the land reinforcing a male-dominated society, punish violators.
12. Disdain for intellectuals
Think of conservative intellectuals Francis Fukuyama and Bill Buckley. Contrast them to Sarah Palin and Joe Sixpack conservatism, Bush's funding cuts for arts and science education.
13. Religion in government
Think of all the faith-based programs versus antiscience in drug approvals, creationism vs. evolution, Ten Commandments enshrined in public buildings, public money to churches.
14. Fraudulent elections
Think of police and prosecutorial intimidation and threats to voters, challenging minority voters, ballots disappearing, party election officials committing outright fraud.
Yes, officially America is still a democracy. We have enough signs and rituals to support that illusion. But the truth is America has become a plutocracy run by and for the wealthy. And since Wall Street's Disaster Capitalism coup de grace, we are rapidly morphing into a dangerous new government.
For more, read Britt's original article, then add comments here: Was the meltdown planned by Wall Street's Disaster Capitalists?
Tuesday, October 07, 2008
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