Complementary Approaches to Treating Lipodystrophy

From the book: Built to Survive 12.  Complementary Approaches to Treating Lipodystrophy

By Michael Mooney (original version in Medibolics 2(2),Nov. 1997)

While the protease inhibitor (PI) cocktails can bring viral loads down to undetectable levels and have given many HIV(+) people a new lease on life, protease inhibitors are not always benign drugs. As we approach year four of the triple-combo era, numerous problems have appeared among people who are on protease inhibitors. One of the most common of these side effects (and perhaps the least understood) is the protease belly or Crix belly phenomenon. Crix belly, so named because it was mostly observed among people being treated with Crixivan, is a condition most notably marked by the appearance of a large protruding potbelly. (At the same time this is happening some people report that they feel like they are losing muscle mass and fat, too, especially in the arms and legs.) Another sometimes concurrent but rare condition is the so-called buffalo hump, which is a fat pad that grows on the back of the neck that resembles what is seen in Cushing’s syndrome. Women are also experiencing an increase in breast size as the breasts seem to gain fat (called lipoma), and many people are losing fat in their arms, legs, and cheeks while one or more of these other things are happening to them. Lipodystrophy is the medical term that has been given to this syndrome, but it can also simply be called bodyfat redistribution.

It now appears that lipodystrophy is not a side effect entirely specific to Crixivan. It may be seen with use of any of the available protease inhibitors, and nucleoside and non-nucleoside analogs. It has also been seen to a lesser degree in HIV(+) people before protease inhibitors were available. However, the various cocktails of powerful drugs being used today to combat HIV seem to increase the severity of this syndrome over the simpler drug combos of a few years ago, although there is discussion that one of the older drugs, D4T (Zerit) may play a central role in the problem (visit http://www.facialwasting.org/ pages/891053/index.htm ) . And in some cases, the addition of the appetite stimulant Megace to the protease inhibitors seems to increase the potential for bodyfat redistribution.

There are several reasons why this might happen. The “protease pouch belly” in many respects resembles the potbelly seen in disease states like Cushing’s syndrome, alcoholic hepatitis, and heart disease. In these diseases the potbelly is associated with the development of insulin resistance [i] [ii] [iii]  and is primarily composed of enlarged fat deposits surrounding the visceral organs, like the stomach, and liver, under the abdominal muscle wall and ribs.[iv] The potential for liver burden or toxicity induced by many of the common AIDS medications has been documented and the protease inhibitors are no exception to this rule. Elevated triglycerides, liver enzymes, and blood glucose and even diabetes have all been observed in patients on protease inhibitor therapy. All of these conditions are symptoms of diminished insulin sensitivity, and we are seeing that the protease inhibitors’ effects on liver metabolism are inducing a state of insulin resistance in many people who are on protease inhibitor therapy. Complications of insulin resistance include hyperglycemia (high blood sugar), diabetes, and cardiovascular disease, and the FDA has documented over 80 cases of diabetes that appear to be associated with protease inhibitor therapy.

Indeed, from early 1998, numerous studies have documented an association between the use of protease inhibitors and measurements that indicate insulin resistance is present including data by Kathleen Mulligan, Ph.D. of San Francisco General Hospital, confirming that protease inhibitors can cause the blood chemistry changes that are typical of insulin resistance;[v] Dr. Ravi Walli of Ludwig-Maximilians Universitat Munchen in Germany reporting that peripheral insulin resistance is common in patients on protease inhibitors;[vi] and Dr. Andrew Carr of St. Vincent’s Hospital of Sydney, Australia, detailing his hypothesis of the cytoplasmic (cellular) retinoic acid-binding protein type I (CRABP-1) biochemistry involved in the liver dysfunction that may promote insulin resistance.[vii] Additionally, some people who are using protease inhibitors are being found to have accelerated cardiovascular disease, which is also a common outcome of progressive insulin resistance.

A look at Harrison’s Principles of Internal Medicine shows us that lipodystrophy can be associated with insulin resistance, and so we see that the components in this puzzle, lipodystrophy; elevated triglycerides, elevated blood glucose, elevated insulin levels; diabetes; cardiovascular disease; and insulin resistance are all appearing.

While this chapter does not offer a cure for body fat redistribution as protease belly, buffalo hump, loss of facial fat, or lipoma, it offers tools that are documented to improve insulin sensitivity that may help people gain some control over this problem until medical science gains enough of an understanding to solve it.

Women and Testosterone

Studies show that HIV(+) women who are losing lean body mass may also need testosterone, ⁸⁹ but the appropriate dosage of testosterone enanthate injections for women is usually much lower than the dosage for men, between 2.5 and 20 mg per week. This is something for a doctor to determine by taking blood tests, usually two to three days after the fourth weekly injection for a representative average level. A number of HIV(+) women are using testosterone creams that are compounded by a pharmacy like Women’s International Pharmacy (1-800-279-5708). However, testosterone enanthate injections deliver a longer-lasting blood level of testosterone than the creams, which have a relatively short life span in the body. If a cream is used, it is usually applied in a dose of between 2 and 5 mg two times per day, while the injections are best given once per week, as studies show that testosterone blood levels generally decline to baseline within about 10 days after injection.[xix]

As women are much more sensitive to side effects from testosterone, the physician should monitor a female closely for any virilizing side effects, which include oily skin, acne, peach fuzz, hair loss, and clitoral enlargement, and immediately lower the dose or cease the therapy if these kinds of symptoms start to occur.

Normal Testosterone Levels May Not Be Enough (Men Only)

I should also note that finding the correct testosterone dose for each individual is not always easy, as data from studies by researchers like Dr. Judith Rabkin suggest that being HIV(+) can mean that the normal range for testosterone measurements does not necessarily apply to men. In her study with HIV(+) hypogonadal men, Dr. Rabkin found that the dose of testosterone enanthate needed to be above 200 mg every two weeks, for good quality-of-life. The dosage she found to be effective was 400 mg every two weeks (which I suggest is best given as 200 mg per week for more consistent blood levels, less peak/trough effect, and reduced potential for side effects). At 400 mg given every two weeks the men’s blood testosterone levels averaged about 1100 ng/dL one week after the fourth injection (on a scale where the normal range is 300 to 990 ng/dL). In private correspondence Dr. Rabkin said that she is not sure whether 300 mg every two weeks would yield a satisfactory result or whether the men would respond satisfactorily if their average levels only reached 800 ng/dL. She said that some men did receive benefit at about 700 ng/dL though.[xx] Remember, the bottom of the normal scale was 300, so the normal scale didn’t seem to apply well to these HIV(+) men.

Free Testosterone

We assert that some men’s apparent need for testosterone at higher than the standard replacement dose of 100 mg per week (for HIV-negative hypogonadal men) may be the result of hormonal resistance to testosterone. Hormonal resistance appears to happen with several hormones in HIV pathology. However, studies suggest that the need for higher testosterone doses is most likely caused by elevated sex-hormone binding globulins and lowered free testosterone, which is common in HIV.⁸⁸ [xxi] When this is the case, total testosterone measurements do not adequately reflect the person’s state of health.

Supplementing testosterone to bring free testosterone levels in the body into an optimal range may be beneficial to hypogonadal men in general, by improving the partitioning of nutrients more towards lean tissue and less toward fat tissue, especially visceral fat.[xxii] Significant data also suggests that appropriate testosterone supplementation can improve blood lipid chemistry to reduce the potential for cardiovascular disease in men who are deficient.[xxiii]

Testosterone Patches or Creams

We have reports that application of the Testoderm TTS or Androderm testosterone patches directly on the buffalo hump appears to shrink it. If this works, testosterone creams or gels might work better as the dose of testosterone can be much greater than in a patch. While a study of adipocyte (fat cell) chemistry does provide a rationale as to why application through the skin might work, application of a cream would not be likely to work to reduce the belly because of the greater distance from the skin through the stomach muscles to the fat cells inside.

Anabolic Steroid Improves Insulin Sensitivity and Glucose Disposal

One study showed that the injectable anabolic steroid nandrolone decanoate (Deca Durabolin) improved glucose disposal and lowered insulin levels when administered at 300 mg per week, while it did not have any effect at 100 mg.[xxiv] While this injectable beta esterified anabolic steroid may have a beneficial effect on insulin sensitivity another study found that it appears to enhance non-insulin-mediated glucose disposal.[xxv] This study and other studies state that oral 17-alpha alkylated anabolic steroids, such as oxymetholone (Anadrol-50), oxandrolone (Oxandrin) and stanozolol (Winstrol) promote insulin resistance because of their effect on liver metabolism.[xxvi] [xxvii] This raises questions about using oral steroids when lipodystrophy is present.

The Paradoxical Effects of Oral Steroids

However, oral steroids can decrease triglycerides (fats) because of their effect of increasing post-heparin hepatic triglyceride lipase, which breaks down triglycerides. [xxviii] [xxix] For this reason oral steroids may help to decrease visceral fat, although they promote insulin resistance, and I have heard reports of each of the oral steroids stanozolol, oxymetholone and oxandrolone reducing the protease belly in HIV(+) males. Indeed, data from a retrospective study of 700 patients recently released by Dr. Douglas Dieterich gave indication that the use of oral and injectable anabolic steroids may be effective in decreasing the potential for lipodystrophy-associated body habitus changes.[xxx]More study needs to be done to confirm this trend, though.

Human Growth Hormone (Serostim)

While the relative ineffectiveness of GH as a muscle-building anabolic hormone is detailed in later sections, GH does appear to have a role in reducing lipodystrophy because of its effect on lipid oxidation (fat burning), as was asserted by a poster presentation from Dr. Gabriel Torres of New York, that was presented at the XII International Conference on AIDS in Geneva.[xxxi]

It should be noted that Dr. Torres said that while five patients had partial of total reduction of fat redistribution on 5 and 6 mg doses of GH, which I assert are overdoses for most people, four of the patients (80 percent) had either elevated glucose, elevated pancreatic enzymes, or carpal tunnel syndrome, so GH at these doses increased the potential for serious health problems. Elevated blood glucose can lead to diabetes and the problems that result including cardiovascular problems, eye damage, and neuropathy; elevated pancreatic enzymes can lead to pancreatitis; and carpal tunnel syndrome is quite painful and may require surgery.

I suggest that if Serostim GH is implemented, it should be considered that Serono’s full vial dose is an overdose and this may be why 5 and 6 mg doses caused these problems. It is advisable to adjust the dose down for each individual, in an attempt to gain the benefit without increasing the problems. At this time I have reports of a reduction of protease belly and other types of lipodystrophy with doses as low as 1 mg per day and up to 3 mg per day with no side effects. I assert that lower daily doses are safer than higher doses administered every few days, and at a correct dose growth hormone can be an important part of the tools that address the underlying metabolic problem. While growth hormone will have a less powerful effect at a lower dose, at the proper individual dose there will still be a significant effect on fat cell metabolism with significantly less potential for side effects.

Exercise

Exercise, too, improves insulin sensitivity,[xxxii] so people with insulin resistance should consider some kind of regular exercise, especially weight-training, which also builds lean body mass. Aerobic exercise does not build significant lean body mass. Aerobics may be useful in an effort to reduce lipodystrophy but if a person is losing lean body mass it should be avoided at least until the person has regained any lost weight or stabilized. Aerobics will use energy that the body would normally use for rebuilding lean body mass, only accelerating the loss of lean body mass. If your weight is stable and not in danger of losing weight, to optimally burn fat and reduce lipodystrophy I suggest doing aerobics three times per week on alternate days to weight training days, first thing in the morning on an empty stomach. (See the exercise chapter on page 129.)

Nutritional Considerations

Carbohydrates

I would also suggest altering your diet so that it is balanced somewhat like what might be called an “evolutionary-type hunter-gatherer diet.” This means getting more protein and a moderate amount of the healthy types of fats, while eating fewer high-calorie, starchy, complex carbohydrates or high-glycemic, sugary, simple carbohydrates.

Currently, many progressive nutritionists are recommending that people with insulin resistance consider reducing their total calorie intake and intake of high-calorie complex carbohydrates that can release into the blood stream quickly,[xxxiii] including wheat breads and most processed wheat products. These kinds of carbohydrates actually are quite calorie dense and can upset insulin metabolism as much as sweets.[xxxiv] [xxxv] They are even more problematic when included in high fat foods. (Think pizza and ice cream.) Also on the list of carbohydrates to avoid is the sugar called fructose, which is known to promote insulin resistance, and raise cholesterol.[xxxvi] Look for it on ingredient panels as fructose or high-fructose corn syrup. I also underline that some people will experience a reduction in insulin resistance just by reducing the total calories in their diet, as many people simply eat too many calories. However, if you are having a hard time maintaining weight because of wasting or infection, getting plenty of healthy calories is essential for keeping and building lean body mass, so be careful about reducing your intake of food.

At the same time, I recommend an increase in the intake of complex carbohydrates sources that contain less total calories but lots of fluid and nutrients, like vegetables. Compared to grains, vegetables are more nutrient dense, and less calorie dense. While some glycemic indexes vegetables like potatoes and carrots have high, they supply good amounts of nutrients per calorie, and they do not contain a great amount of calories for their volume like grains or sweets do, so their effect on insulin production, insulin resistance and body fat accumulation is not as great. (Carrots contain only 195 calories per pound, boiled potatoes contain 450 calories per pound, while breads contain about 1200 to 1500 calories per pound, and sugar and sweets contain about 1700 calories per pound.)

Other good carbohydrate sources are beans, yams and green peas, and whole fruits like oranges, grapes, apples, pears, and cherries. In other words try to eat natural food carbohydrate sources that are one step away from nature.

If you do want to include grains in your diet, barley, cream of rye, oatmeal and brown rice have relatively lower glycemic indexes than most wheat products, but be careful to moderate the total amount of these high calorie starch sources. If you include them in your diet, I suggest eating servings that are about one third as much you’d really like to eat. (Again, try to moderate your total carbohydrate calories if your goal is to reduce insulin resistance.)

While a high-carbohydrate diet has been recommended by some nutritionists for conditions of insulin resistance (diabetes), a study by Chen of Stanford University, showed that a lower-fat, higher-carbohydrate diet led to higher day-long blood glucose, insulin, and triglycerides, as well as post-prandial (after a meal) accumulation of triglycerides, and increased VLDLs (very low density lipoproteins),[xxxvii] which can increase the risk of cardiovascular disease. The idea that lower carbohydrates diets are superior is supported in an article in Nutrition Reviews by dietitian Nancy Sheard, who said, “Recent studies indicate that a diet high in monounsaturated fat and low in carbohydrate can produce a more desirable plasma glucose, lipid, and insulin profile.”[xxxviii] A study published in the Journal of the American Medical Association further supported this approach when it showed significantly elevated triglycerides and LDL cholesterol levels with a high carbohydrate diet, while a high-monounsaturated fat diet let to a lower-risk lipid profile.[xxxix]

Fats

While it is also best to reduce any excessive intake of fats, I don’t advocate a very low-fat diet, but a reduction in excess saturated fats, found in animal fat products like butter and lard, and excess omega-6 fats, which are found in common vegetable oils, like corn, safflower, and sunflower oils. Excess saturated fats and omega-6 fats can promote insulin resistance.¹¹⁵ [xl] [xli] [xlii] At the same time I recommend a moderate intake of fresh food sources of the essential fatty acid called omega-3, which can reduce insulin resistance,[xliii] and reduce the potential for atherosclerosis and heart attacks.[xliv] [xlv] Omega-3 fats are found abundantly in cold water fish like salmon, sardines, tuna, rainbow trout, anchovies, and herring, and in lesser amounts in flax seed oil, some nuts and seeds and beans, like walnuts, pumpkin seeds and soy beans, and in much smaller quantities in dark green leafy vegetables. Consider also including some daily consumption of monounsaturated fats from sources like olive oil. These too reduce the risk of cardiovascular disease.

Data also suggests that high saturated fat in the diet promotes more bodyfat accumulation compared to polyunsaturated fats like omega-3 fats,[xlvi] [xlvii] so if you want to be lean, eat clean.

Finally, avoid eating any food that contain artificial fats or processed fats, like hydrogenated or partially hydrogenated oils. Partially hydrogenated oils are found in foods like margarine, french fries, potato chips, shortening, many baked goods, and mayonnaise. Harvard researchers have found a very strong link between these types of unhealthy fats and cardiovascular disease.[xlviii]

Protein

HIV has protein malnutrition as a common theme; a lack of optimal protein contributes to the loss of lean body mass and trouble maintaining it. To reduce the loss of lean body mass and to increase it, I suggest that your diet include extra protein that totals at least 3/4 gram per pound of body weight per day. If you lift weights, studies of HIV(-) subjects by world-renowned protein scientist Dr. Peter Lemon show that you may need a total of at least 0.8 grams of protein per pound of body weight per day for optimal increases in lean body mass.[xlix] [l] If you are not allergic to dairy protein, consider eating cottage cheese as a “best” protein for building muscle, as it contains a great amount of the amino acid L-glutamine, which is discussed below. (Note: dairy allergy can cause diarrhea.)

Also consider supplementing your food protein with a protein powder drink two or three times per day. Note that the dairy protein called casein, seen on labels as calcium caseinate, appears to have the potential to be somewhat more effective for improving lean body mass than other proteins, like whey.[li]

The Zone Diet

Although I do not agree with some of his more dogmatic concepts, my recommendations for nutrition have some similarities to the “zone” diet outlined in the book Mastering the Zone, by Dr. Barry Sears. While aspects of the zone diet can be criticized scientifically, I have had numerous reports that the use of the zone diet has helped people with HIV reduce cholesterol, the potbelly, triglycerides, and lipodystrophy symptoms, in general.

The Atkins Diet

The Atkins diet is a very low carbohydrate, high protein, high fat diet that can decrease bodyfat significantly. I have reports of people successfully using the Atkins diet to reduce lipodystrophy symptoms. Consider that it is basically impossible to get the RDA of vitamins, minerals or fiber from this diet, so if you use it, take strong multi-vitamins and extra fiber, and consider that it shouldn’t be used long-term. Also be sure to favor monounsaturated and omega-3 fats over omega-6 and saturated fats.

Dietary Supplements

Supplements that have been shown to improve insulin sensitivity include chromium,[lii] and I recommend 200 to 400 micrograms (mcg) of chromium three times per day in the polynicotinate or picolinate form, as one recent (non-HIV) study showed that 1,000 mcg of chromium per day increased insulin sensitivity by about 40 percent without toxicity.[liii]

The herb silymarin (milk thistle) as a standardized extract in a dose of 200 mg three times per day has been shown to be effective in improving liver function and improving insulin sensitivity.[liv] There has been talk that silymarin can alter liver function in a way that might affect the metabolism of protease inhibitors, so it is possible that people who are taking protease inhibitors should not take silymarin. There is no conclusive data on this yet.

But the best supplement for improving insulin sensitivity and glucose disposal may be the antioxidant called alpha lipoic acid (ALA), at 100 to 300 mg three times per day.[lv] In diabetic studies ALA improves insulin dependent and non-insulin dependent glucose uptake, and it has been shown to effectively lower blood sugar comparable to insulin itself.[lvi] I believe this is one very important reason ALA is a must for anyone taking HIV medications, especially protease inhibitors. HIV-nutrition expert Lark Lands, Ph.D., asserts that ALA is a must for people with HIV because of its effect on improving glutathione production and recycling.[lvii] Studies last year at Stanford University showed that glutathione levels directly correlate with increased survival for people with HIV.[lviii]

As noted by the late Canadian protein chemist Chester Myers, Ph.D., N-acetyl cysteine (NAC) can be a valuable addition to the supplements that address lipodystrophy, because of its effect on improving glutathione, which is necessary for glucose metabolism. I suggest 500 to 1,000 mg of NAC three times per day.

Also carnitine, as the prescription version called Carnitor, would be beneficial in higher doses, about 500 to 1,000 mg three times per day, as it helps to lower triglycerides,[lix] which are generally elevated when lipodystrophy is present. Note that the acetyl-L-carnitine form of carnitine may be more effective than plain carnitine, but it is more expensive.

Also worth considering is the omega-3 dietary supplement called EPA (fish oil), which has been shown to reduce insulin resistance,¹¹⁵ and lower triglycerides somewhat in a study with HIV(+) men.[lx]

And taking a strong multivitamin, multimineral supplement that includes chromium, vitamins A, D, E and calcium and magnesium will help improve insulin sensitivity.[lxi] [lxii] [lxiii] [lxiv] [lxv] [lxvi] I recommend taking a supplement that contains doses that are much higher than the RDAs, though, as numerous studies have shown that higher nutrient levels are required in HIV disease.[lxvii] [lxviii]

Finally, high dose biotin supplementation is frequently prescribed by nutritionally-oriented medical doctors to improve glucose metabolism in diabetes.[lxix] [lxx] High dose biotin is also known to improve diabetic neuropathy.[lxxi] The dose of biotin that is commonly used is 1,000 mcg three times per day.

Cardiovascular Disease

As I mentioned in the beginning of this article, we are also beginning to see cardiovascular disease in people on protease inhibitors. When cardiovascular disease is a consideration, we want to make sure that specific preventive nutrients are included. While there are many that can be included for this purpose, to keep it simple I suggest the following: vitamin E at 400 to 800 IU three times per day to reduce the potential for oxidation of blood fats that can contribute to atherosclerosis;[lxxii] vitamin C at 1,000 to 2,000 mg three times per day to assist vitamin E in reducing blood fat oxidation;[lxxiii] folic acid at 800 mcg three times per day to reduce the potential for elevated homocysteine, which appears to be another major contributory factor to cardiovascular disease.[lxxiv] [lxxv] It should also be noted that vitamins B6 at 50 mg three times per day and vitamin B12 at 100 to 500 mcg three times per day help to reduce homocysteine. Of course, all HIV(+) people should consider taking high doses of supplemental B vitamins, as studies by Dr. Marianna Baum, of the University of Miami, showed that HIV(+) people frequently require 6 to 25 times the RDA of these essential nutrients to stay healthy.^{139 140}

Glutamine

For any loss of muscle, Judy Shabert, M.D., M.P.H., R.D., asserts that supplementing with high doses of the amino acid L-glutamine, will help reduce the catabolic process of breaking down muscle tissue,[lxxvi] and a recent study of wasting HIV patients by Prang showed that this might be true. (See Dr. Shabert’s article in the August 1997 issue of POZ magazine.) For frank wasting, HIV(+) people are using between 12 and 36 grams per day of L-glutamine. (One tablespoon is 12 grams.) I have friends who have halted their random diarrhea and improved their lean body mass using these kinds of L-glutamine doses, and in Prang’s study wasting and diarrhea and were checked by using 30 to 40 grams of glutamine per day. Glutamine too, has been shown to have a powerful effect on improving glutathione production,[lxxvii] and glutamine improves insulin sensitivity.[lxxviii] [lxxix]

If you are losing weight I suggest that you supplement your diet with a tablespoon of L-glutamine added to each serving of supplemental protein two or three times per day between meals. If your weight is stable, L-glutamine may be supplemented at lower doses, such as one or more teaspoons per day.

(Important note: most dietary supplements only stay in the blood for a few hours, so it is wise to take them several times per day.)

Metformin (Glucophage)

Realize that while taking dietary supplements, especially alpha lipoic acid, may help, it is wise to investigate the use of the drugs that are prescribed to improve insulin sensitivity. Ask your doctor about these drugs, which include metformin.[lxxx] New data presented by Saint-Marc at the 6th Retrovirus Conference, in February, 1999 indicates that metformin may decrease visceral fat while decreasing blood glucose, insulin, and lipid levels. ¹⁰² Serostim can increase blood glucose, insulin and insulin resistance.[lxxxi] [lxxxii] This means that metformin might be found to be superior to Serostim growth hormone because it not only addresses fat redistribution, but reduces some of the underlying metabolic problems that growth hormone can promote. An important consideration is that while 6 mg per day of Serostim is priced at about $6,000 per month, which makes it inaccessible for a majority of people who have lipodystrophy, metformin is available with a doctor’s prescription at any pharmacy, and if a person has to pay for it themselves. Realize that while taking dietary supplements, especially alpha lipoic acid, may help, it is wise to investigate the use of the drugs that are prescribed to improve insulin sensitivity. Ask your doctor about these drugs, which include metformin.¹⁵² New data presented by Saint-Marc at the 6th Retrovirus Conference, in February, 1999 indicates that metformin may decrease visceral fat while decreasing blood glucose, insulin, and lipid levels.¹⁰² Serostim can increase blood glucose, insulin and insulin resistance.^{153 154}  This means that metformin might be found to be superior to Serostim growth hormone because it not only addresses fat redistribution, but reduces some of the underlying metabolic problems that growth hormone can promote. An important consideration is that while Serostim is priced at $6,000 per month, which makes it inaccessible for a majority of people who have lipodystrophy, metformin is available with a doctor’s prescription at any pharmacy, and if a person has to pay for it themselves, it only costs about $35 per month.

However, cautions about the use of metformin are warranted. Dr. Michael Dube, of the University of Southern California at Los Angeles says, “Lactic acidosis is a rare side effect of metformin that is more likely to occur when there is some impairment of kidney function. Lactic acidosis, which can be fatal, is also a rare side effect of use of nucleoside analogs. There is no way to know at this time if using the two together might result in more frequent, or more severe lactic acidosis problems. In my opinion anyway, metformin and NRTI’s therefore should only be used together with great caution. Also, keep in mind that metformin can lower vitamin B₁₂ levels.”

I should also note that some people are finding that switching antivirals causes a marked reduction in some lipodystrophy symptoms. This is an area that is currently receiving a considerable amount of study. 

For a good and simple brochure on lipodystrophy, visit http://www.vhconcepts.com/pdfs/2002.changes.pdf . For an update of lipodystrophy issues go to www.medibolics.com , www.powerusa.org and subscribe to Nelson’s free email list by sending a blank email to pozhealth-subscribe@yahoogroups.com

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