Aging Healthy While Surviving HIV
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Transcript of Aging Healthy While Surviving HIV
Copyright © 2011 by Nelson Vergel
Beyond Survival- A Breakthrough in Well-Being
Nelson VergelProgram for Wellness Restoration
This information (and any accompanying
printed material) is not intended to replace the
attention or advice of a physician or other
health care professional.
Anyone who wishes to embark on any dietary,
drug, exercise, or other lifestyle change
intended to prevent or treat a specific disease
or condition should first consult with and seek
clearance from a qualified health care
professional.
These Slides Are Available at
PoWeRUSA.org
AGENDA
• Update on lipodystrophy• How to prevent bone loss• Protecting yourself from anal cancer• Exercise: The best therapy• What you did not know about testosterone• Questions?
Dyslipidaemia
Hepatic steatosis
Abnormalities of body composition
CVD Bone & Kidney disease
The changing pattern of clinical spectrum of HIV: LIPODYSTROPHY and Non-infectious Co-MORBIDITIES depict the HIV specific Ageing phenotypes
HANDBody image alterations
Glucose metabolism impairment
Depression HT Vit D T2D CancerSexual Dysfunction
Background
Interactions among aging, HIV, and HIV drugs increase the risk of comorbidities. (Vance, Am J Nurs 2010)
Pp prevalence was higher in cases than controls in all age strata (all p-values <0.001) Pp prevalence seen cases aged 41-50 was similar to that observed among controls aged 51-60 controls (p=0.282)
Poly-pathology prevalence in cases and controls, stratified by age categories
Pp 3.9% 9.0% 20.0% 46.9% Pp 0.5% 1.9% 6.6% 18.7%
Visceral Fat Reduction
9
Abdominal Obesity and the Cardiometabolic Risk
Intra-abdominal fat is a strong correlate of
Cardiometabolic Risk
Intra-abdominal orVisceral Fat
INSIDE
Intra-abdominal Fat
OUTSIDE
Waist Circumference
10Pouliot et al. Diabetes. 1992;41:826-834.
310
248
186
124
62
0
60
45
30
(mg
/dl)
HDL-cholesterol
(mg
/dl)
Triglycerides
Nonobese NonobeseObese Obese
LowVAT
HighVAT
LowVAT
HighVAT
High visceral fat (VAT) increases cardiovascular risk
DAD Study: Lipodystrophy Incidence 2000-2002 vs 2003-2006
2000-2002
2003-2006
Visceral Fat:Sustiva vs Boosted Reyataz &
Truvada (Viread + Emtriva) vs Epzicom (Ziagen+Epivir)
A5224s
Truvada vs EpzicomSustiva vs Reyataz+Novir
Trunk Fat (Visceral + SubQ) (by DEXA)
Sustiva vs Boosted Reyataz &Truvada vs Epzicom
A5224s
Visceral Fat
Exercise
Low Carb, High Fiber Diet?
Egrifta
Metformin?Changing HIV Meds?Testosterone
Anabolic Steroids?
Supplements?
Weight Loss
Liposuction?
Researched Options to Decrease Visceral Fat
16
Reduction in Abdominal Subcutaneous and Visceral Fat In Response to a 7% Exercise-Induced Weight loss, 6 cm reduction in Waist Circumference
Adapted from Ross et al. Ann Intern Med. 2001; Obesity Research. 2004.
Visceral FatSubcutaneous Fat * p< 0.05 vs control
MEN WOMEN
Red
ucti
on
(%
)
Control Exercise
*
*
Red
ucti
on
(%
)
Control Exercise
*
*
0
10
20
30
0
10
20
30
DIET Study (Dietary Intervention:Effects on Tryglicerides
in HIV Lipodystrophy) Using food records that began from 6 to 24 months
before development of fat deposition the following factors were identified.
When compared to people with HIV who developed fat deposition, patients without fat deposition had:
- greater overall energy intakes from their diet (p = 0.03)- greater intakes of total protein (p = 0.01)- more total dietary fiber (p = 0.01)- more soluble dietary fiber (p = 0.01)- insoluble dietary fiber (p = 0.03)- pectin (P = 0.02)
Those without fat deposition also were currently doing moreresistance training exercise and were less likely to be smoking (only borderline statistical significance (p = 0.05))
Hendricks at al, Am J Clin Nutr, 2003 Oct;78(4):790-5
Newly FDA Approved Product to Decrease Visceral Fat in HIV+ Patients
• 2 mg injections under the skin every day. Effect disappears when stopped
• A patient assistance program for those without insurance and incomes under $60K
• More information on Egrifta.com
Effect of HIV Drugs on Lipids
Cholesterol/Triglycerides
Higher Risk
Stavudine- D4TAZTDidanosine-DDILopinavir/r-KaletraAmprenavir-LexivaDuranavir-PrezistaSustiva (Atripla)
Lower RiskNevirapine- ViramuneTenofovir- VireadAbacavir- ZiagenLamivudine- 3TCEmtricitabine- EmtrivaEnfurvitide-FuzeonSaquinavir- InviraseAtazanavir- ReyatazRaltegravir- Isentress Maraviroc- SelzentryEtravirine-Intelence
DHS/PP
TempleFill
Cheek Augmentati
on
Lipoatrophy Deficits Requiring Correction
HIV Medications and Lipoatropy (Fat Wasting)
Lipoatrophy Fat Wasting
Higher Risk
Stavudine-D4T
AZT
Didanosine-DDI?
Low Risk
Nevirapine- Viramune
Atripla & Complera
Tenofovir- Viread/Truvada
Abacavir- ZiagenLamivudine- 3TC
Emtricitabine- Emtriva
Fuzeon
Isentress
Selzentry
All protease inhibitors
Carruthers Lipoatrophy Severity Scale
Stage 1 Stage 2
Stage 3 Stage 4James J et al. Dermatol Surg. 2002;28:979-986.
FDA Approved Facial Lipoatrophy Products
Off Label Use: Silicone Microdroplet, Artefill
Commonly Used Options for HIV-related Facial Lipoatrophy(From FacialWasting.org)
Product Type/Sessions Approved? Cost
Sculptra(New Fill-
PolyLactic Acid)
Non- permanent
3-7 sessions needed, the 1
touch up a year
FDA approved
Patient Assistance for Product onlyhttp://www.needymeds.org/drug_list.taf?_function=name&name=Sculptra
Labor cost avg. $500 per session. Full price: $1,100 per session for
product.
Radiesse (Calcium
hydroxylapitite (CaHA)
microspheres)
Non- permanent
2-3+ sessions needed, then 1 touch up a year
FDA approvedLimited Patient Assistance
Availablehttp://www.radiesse-fl.com/Physician-section/Patient-access-program/
Full Price: $1,200 per session.
Silikon 1000Microdroplets
Permanent
4-8+ sessions needed
Off label use-FDA approved for
intraocular injections to treat
CMV- related retinal detachment
No Patient Assistance-$700-900 per session
PMMA(Polymethyl-
methacrylate )
Permanent
1-2 sessions needed
Available inMexico, Brazil and
other countries.FDA approved: Artefill but too
expensive
$3,000+ avg. total cost for total reconstruction in Mexico:
http://www.avantiderma.com/
Number of sessions depends on severity of facial lipoatrophy
“Dermal injections for facial lipodystrophy syndrome are only reasonable and necessary using dermal fillers approved by FDA for this purpose, and then only in HIV infected beneficiaries who manifest depression secondary to the physical stigmata of HIV treatment. All other indications are noncovered.”
Proposed Decision Memo for Dermal injections for the treatment of facial lipodystrophy syndrome (FLS) (Jan 2010)
Pre- and Post-Silikon 100014 treatments over 2 years, 24 cc total
Protecting Your Bones
DEXA
BONE
SCAN
Bone Disorders in HIVTreatments for bone loss
– Resistance exercise, preventing wasting syndrome, and avoiding tobacco
– Calcium (1000- 1500 mg/day) and Vitamin D (400-1000 IU/day ). Get 20 minutes of sun daily
– Biophosphonates (Alendronate- Fosamax)– Calcitonin (Intranasal and oral)– Teriparatide (Forteo)– Testosterone and/or thyroid replacement
therapy
Bone Drugs
IVOnce a year
Subcutaneous, once daily
Once monthy
NNRTIs? Tenofovir?
Vitamin D Terminology
Serum 25-hydroxy vitamin D = 25-OHD
Indicator of vitamin D nutritional “status”
Vitamin D Status 25-OHD serum concentrationng/mL nmol/L
Deficient <12 <30Insufficient 12 to <20 30 to 50Sufficient >20 to 50 >50 to 125Excess >50 >125
http://books.nap.edu/openbook.php?record_id=13050&page=11
Vitamin D Therapy Decreases Parathyroid Hormone (PTH) in Patients Taking Viread
(tenofovir)
• Randomized trial of Vit D 50,000 IU/wk x 12 weeks vs. placebo in patients on (n=118) or not on (n=85) TDF
• Higher baseline PTH levels at baseline in TDF group• Vitamin D had no impact on PTH levels in patients not on TDF
TDF No TDF
Day 0 Change Day
0 Change
Vit D 47 -6 26 -2
PBO 37 +2 25 0
Changes in PTH on study
Havens P, et al. 18th CROI; Boston, MA; February 27-March 2, 2011. Abst. 80.
Mean Baseline PTH by Vitamin D status and Tenofovir Use PTH Differs by Tenofovir use, not Vitamin D status
52
35
43
27
P=0.001 P<0.001
Human Papiloma Virus (HPV) Related Cancers
ClearanceCommon; increases after the age of 40
(as the immune system clears the virus)
Re-infectionAssociated with
persistent risk factors
ReactivationMainly associated
withimmunosuppression
Persistent InfectionAssociated with the development of cancer
Cancers caused by HPV: Cervical, Vagino/vulvar, Penile, Anal, Oropharyngeal, Squamous cellHigher risk with sero-types: 16, 18, 45 and 56
HPV InfectionIncidence of HPV infection
increases with sexual exposure
Levine A, et al. 49th ICAAC; San Francisco, CA; Sept. 12-15, 2009; Abst. 400.
Methods to Detect Anal Warts, Cancer, and Dysplasia
Anal Cancer in HIV+ Men and WomenDiagnosis and Treatment
Pap-smears and simple anoscopy done in the office. Cytology obtained from pap smears.
Outpatient under anesthesia: after high resolution anoscopy (HRA) with vinegar, any lesions are treated with infrared coagulation (IRC), which involves inserting a light probe into the anal canal under direct visualization, touching the tip of this light probe to the lesion, and delivering a pre-specified amount of energy.
Trained Physicians by UCSF’s anal neoplasia and research group web site :
http://www.analcancerinfo.ucsf.edu/
Signs and Symptoms of Low Testosterone
Loss of muscle mass and strength Loss of libido and erectile dysfunction Depression Lethargy (fatigue, lack of focus) Bone loss Some regression of secondary sexual
characteristics (body hair loss, etc) Low or no sperm count
Tenover JL. Endocrinol Metab Clin North Am. 1998;27:969-987Petak SM, et al. AACE Clinical Practice Guidelines. Available at: http://www.aace.com/clin/guides/hypogonadism.html
Testosterone and Aging
Albumin-bound T38%
Free T2%
Sex Hormone Binding GlobulinSHBG-bound T
60%
T = testosteroneOnly 2% is free testosteroneand 98% is bound
Testosterone Fractions in the Blood
(binds testosterone)
Testosterone Deficiency (Hypogonadism)
• Normal levels in blood: Men... Total test. 300-1100 ng/dL,
Free test. 5 - 21 ng/dL
Women... Total test. 10-50 ng/dL
Free test. 0.10-0.85 ng/dL
• Symptoms of testosterone deficiency:
Fatigue, low or lack of sex drive, poor appetite,
loss of muscle mass & strength, depression
The HPT Hormonal Axis
H
P
T
TestosteroneReplacement Benefits
Sexual function
Mentalfocus
Stamina and Bone Strength
LeanBodyMass
Testosterone Metabolites and Their Functions
Testosterone5-7
mg/day
Androgen
Receptor
Androgen
Receptor
EstrogenReceptor
Dehydro Testosterone(DHT) (by 5α-reductase)
Estradiol (by aromatase)
Direct Effect
LH
Oxidation by LiverElimination by Kidneys
Skin, Prostate
Hair, Brain, Bone
Muscle, Brain
Testosterone Options
Injections
Patch
Pellets
Buccal
Gels
Gels
Potentially Approved in the Next 12-24 Months
Side Effect: Gynecomastia (breast enlargement in men)
Treatment: Estrogen Blocker Medications or surgery (in worst cases)
Side Effect: Increased number of red blood cells (polycythemia)
Watch out for hematocrit over 52 !
Solution: Donate blood or therapeutic phlebotomy (4-5 units every 3-4 months)
Side Effect: Testicular Shrinkage (atrophy)
Treatment: Human Chorionic Gonadotropin(hCG)
Side Effect : Increased prostate size (benign prostatic hypertrophy)
Prevention:Digital Rectal Exam (DRE)Prostatic Specific Antigen (PSA) blood test
For More Information:TestosteroneWisdom.c
om
Exercise, the Best Therapy for Most Health Problems
Low Arm Muscle is associated with highest population-level mortality risk in multivariable analysis
Arm SM Tertile 1
Leg SM Tertile 1
VAT Tertile 30%
5%
10%
15%
20%
15.1%
7.2% 6.5%
Tertile of Skeletal Muscle or Adipose Tissue
Pop
ula
tion
Att
rib
uta
ble
R
isk
Exercise: The Best Medicine
Benefits: total and abdominal fatimproves insulin sensitivityimproves glucose toleranceincreases HDL cholesterol
triglycerides and LDL increases muscle massimproves enduranceimproves strength
improves bone density improves mood decreases frailty
EXERCISE FOR BEST RESULTS
Aerobic (Cardiovascular)
Exercise Start with a brisk walk every day if
tired Concentrate in low impact or no
impact exercises (e.g. Elliptical Trainers)
Do what you enjoy (bicycling, roller skating, etc)
Good for burning fat, triglycerides, blood sugar, but it may decrease muscle mass
20 - 30 minutes 3-4 times a week is enough for many people
Cardiovascular exercise may increase fat loss under the skin
Progressive Resistance Exercise (PRE)
Warm up and stretch before a session Start with compounded exercises Lift maximum weight for muscular failure
(exhaustion) at 8-12 repetitions One body part per week One hour sessions 3-4 times a week One light set and two heavier sets per body
part If no access to a gym, start with crunches,
push ups, and squats at home. Use stairs! For more details, visit www.medibolics.com
Best Exercise Sites with videos, etc
www.exrx.netwww.MyFit.ca
Ipod exercise routine downloads:
http://www.menshealth.com/download/
For More Information More details in “Built To Survive” and ”Testosterone-
A Man’s Guide” (amazon.com or testosteronewisdom.com)
Email:
Nelson Vergel – [email protected] Websites: www.powerusa.com
www.facialwasting.orgwww.tpan.com
www.TheBody.com
Join my Internet discussion group by sending a blank email to [email protected]
Questions?