What are the management options for lipodystrophy?

From the Guidelines

Lipodystrophy management should prioritize a multidisciplinary approach, focusing on lifestyle modifications, medical treatments, and cosmetic interventions to address metabolic complications and psychological impacts. Management options for lipodystrophy include both general approaches and specific treatments tailored to the type and severity of the condition.

General Management

First-line management involves lifestyle modifications such as a balanced diet, regular exercise, and avoiding alcohol.

Medical Treatments

Medical treatments include metformin (500-2000 mg daily) for insulin resistance, fibrates like fenofibrate (145 mg daily) or gemfibrozil (600 mg twice daily) for hypertriglyceridemia, and statins for hypercholesterolemia, as guided by the National Cholesterol Education Program treatment decisions based on low-density lipoprotein (LDL) cholesterol level 1.

Specific Treatments

For generalized lipodystrophy, metreleptin (Myalept) is FDA-approved at doses of 0.06-0.13 mg/kg daily subcutaneously to replace leptin deficiency, improving metabolic abnormalities. Growth hormone may be used for HIV-associated lipodystrophy at 0.1-0.3 mg/day. Cosmetic procedures like liposuction or fat grafting can address localized fat loss or accumulation. Tesamorelin (Egrifta, 2 mg daily subcutaneous injection) specifically targets HIV-associated abdominal fat accumulation.

Key Considerations

Management should be multidisciplinary, addressing both the metabolic complications and psychological impact of altered body appearance. Early intervention is crucial as lipodystrophy can lead to serious complications including diabetes, pancreatitis, and cardiovascular disease due to the metabolic dysregulation caused by abnormal fat distribution and function. The metabolic syndrome, which overlaps with features of HIV treatment–associated lipodystrophy, should be managed through weight loss using dietary modification and increased physical activity, while avoiding excessive weight loss that could exacerbate lipoatrophy 1.

From the FDA Drug Label

At Week 26, treatment with a 2 mg dose of EGRIFTA (1 mg/vial formulation) resulted in a reduction from baseline in mean trunk fat of 1.0 kg in Study 1 and 0.8 kg in Study 2, respectively (compared with an increase of 0.4 kg in Study 1 and of 0.2 kg in Study 2, respectively, in patients receiving placebo). Patients treated with a 2 mg dose of EGRIFTA (1 mg/formulation) for 52 weeks (T-T group) showed no change between Weeks 26 and 52 in mean trunk fat (increase of 0.1 kg in Study 1 and decrease of 0.5 kg in Study 2, respectively, compared with an increase of 1.4 kg in patients in the T-P group in Study 1 and an increase of 1.09 kg in Study 2, respectively)

The management options for lipodystrophy include treatment with tesamorelin (EGRIFTA), which has been shown to reduce trunk fat and increase lean body mass in patients with HIV-associated lipodystrophy 2.

• Reduction in trunk fat: 1.0 kg in Study 1 and 0.8 kg in Study 2 at Week 26
• Increase in lean body mass: 1.3 kg in Study 1 and 1.2 kg in Study 2 at Week 26 The use of tesamorelin for 52 weeks resulted in no significant change in trunk fat between Weeks 26 and 52, suggesting a potential long-term management option for lipodystrophy 2.

From the Research

Management Options for Lipodystrophy

The management of lipodystrophy involves a range of strategies, including:

• Switching from thymidine analogues to tenofovir or abacavir in lipoatrophy, or switching from protease inhibitors associated with hyperlipidaemia to a protease-sparing option 3
• Injection into the face with either biodegradable fillers such as poly-L-lactic acid and hyaluronic acid or permanent fillers such as bio-alcamid 3
• Structured treatment interruption with the risk of loss of virological control and disease progression 3
• Leptin replacement therapy (metreleptin) to improve metabolic parameters in patients with lipodystrophy 4
• Lifestyle changes and aggressive, evidence-based treatment of comorbidities 4
• Adipocytokines, uridine supplementation, glitazones, growth hormone (or growth hormone-releasing hormone analogues), metformin and statins (used alone or in combination) as alternative therapeutic options 3

Diagnostic Strategies

Diagnosing lipodystrophy involves a stepwise approach, including:

• Clinical presentation and history 4, 5, 6
• Physical exam and patient and family member photos 6
• Routine blood tests, leptin levels, skinfold measurements, imaging studies, and genetic testing 6
• A basic diagnostic algorithm to distinguish lipodystrophy from other diseases with similar clinical features 4

Treatment and Monitoring

Treatment of lipodystrophy syndromes involves:

• Prompt action by clinical teams to improve disease outcomes 6
• A set of recommendations regarding screening and monitoring for metabolic diseases and end-organ abnormalities 6
• Targeted interventions, including leptin replacement therapy and management of comorbidities 4, 7
• Holistic work-up and management of patients with lipodystrophy syndromes to improve outcomes 6