hiv and the endocrine system
DESCRIPTION
Topics Endocrine issues with & without HIV treatment: Adrenal Gonadal Lipids Glucose BoneTRANSCRIPT
HIV and the Endocrine System
Katherine Marx, MS, MPH, FNP-BC
Topics
Endocrine issues with & without HIV treatment:• Adrenal• Gonadal• Lipids• Glucose• Bone
http://www.uchospitals.edu/
Brown, TT. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.
Endocrine issueswith & without HIV treatment
http://www.uchospitals.edu/
CRH
HPA Axis
http://www.uchospitals.edu/
CRH
ACTH
HPA Axis
http://www.uchospitals.edu/
CRH
ACTHCortisol
HPA Axis
Brown, TT. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.
Adrenal issueswith & without HIV treatment
Without antiretrovirals• Direct infiltration
– Opportunistic infection– Malignancy– HIV
• Medications – Ketoconazole– Megestrol
With antiretrovirals• Iatrogenic adrenal
suppression– Steroid/ antiretroviral
interactions
Signs and symptoms of AISymptoms Orthostatic symptoms
Salt cravingFatigue, WeaknessNausea, vomiting, diarrhea
Signs HyperpigmentationHypotension
Labs HyperkalemiaHyponatremiaHypoglycemia
reference
CASE STUDYAdrenal Insufficiency
49 yo black male with newly diagnosed AIDS (CD4 6, VL >100,000)• Past medical history includes:
– Hypertension– Diabetes– BPH
• Discharged from the hospital 2 weeks ago • Treated for cryptococcal meningitis
CASE STUDYAdrenal Insufficiency
You see him for a clinic visit after discharge.All of the following are signs and symptoms of adrenal insufficiency, except:A. Near-syncope walking to the exam roomB. Potassium of 3.2 mEq/lC. Diarrhea every day since dischargeD. Glucose of 56 mg/dl
CASE STUDYAdrenal Insufficiency
All are possible causes of his adrenal insufficiency, except:A. Cryptococcal meningitis B. Treatment of cryptococcal meningitis with
fluconazoleC. Self-treatment of a rash with hydrocortisone
1% topical cream for a weekD. Mass lesion in the brain
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CRH
ACTHCortisol
ACTH Stimulation test for AI
Treatment of AI
• Daily glucocorticoid replacement• Consider mineralcorticoid replacement• Increase glucocorticoids for surgery and illness
Brown, T. The PRN Notebook; Volume 12, December 2007.
http://www.uchospitals.edu/
GnRH
HPG Axis
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GnRH
LHFSH
HPG Axis
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GnRH
LHFSH
TestosteroneEstrogen
HPG AxisFemale
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GnRH
LHFSH
Testosterone(Estrogen)
HPG AxisMale
Brown, TT. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.Cotter AG, et al. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.
Hypogonadismwith & without HIV treatment
Without antiretrovirals• Direct infiltration
– Opportunistic infection– HIV
• Medications/drugs– Opiates– Megestrol
• Inflammation• Wasting/malnutrition
With antiretrovirals• Medications/drugs
– Opiates– Marijuana– Alcohol– Anabolic steroids
• Inflammation• Age
Signs and symptoms male hypogonadismSymptoms Libido
DepressionLow energyPoor concentration
Signs Face & body hair Muscle bulk & strengthTesticular atrophyGynecomastia
Diagnostics Testosterone Bone mineral density
Bhasin S. et al, J Clin Endocrinol Metab 2010;95(6):2536.
Testing for male hypogonadism
Treatment for hypogonadism
Testosterone replacement therapy• Low libido and/or hypogonadal symptoms• Low bone mineral density• Low body mass/ weight loss on HIV treatmentMonitoring• Hemoglobin/hematocrit• Liver function• Prostate specific antigenwww.hivguidelines.org
Wasting
Obiako O, Muktar HM. 2010. openi.hlm.nih.gov
Treatment for wasting
• Antiretrovirals• Increased caloric intake• Physical exercise• Hormonal therapy
– Testosterone– Anabolic steroids– Megestrol– Growth hormone
http://www.uchospitals.edu/
GHRHGHIH
IGF-1/GH Axis
Liver
GH Muscle
IGF-1
Lipodystrophy
Carr A. Nature Reviews Drug Discovery 2, 624-634 (August 2003)
Fat cells are endocrine organs
Ravussin, E. The Pharmacogenetics Journal (2002) 2:4-7.
Brown, TT. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.
Lipid metabolism issueswith & without HIV treatment
Without antiretrovirals• Inflammation
– High triglycerides– Low HDL
With antiretrovirals• Antiretrovirals
– High triglycerides– High LDL
Pancreatic hormones
Brown, TT. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.
Glucose metabolism issueswith & without HIV treatment
Without antiretrovirals• ? HIV/ inflammation• Medications
– Pentamidine
With antiretrovirals• Antiretrovirals• Inflammation
Feeney ER. . Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.
Screen for lipid and glucose metabolism abnormality
Metabolic assessment
• Fasting blood glucose• Fasting lipid profile
On ART: • before start• 3-6 months• annuallyNo ART: • baseline• annually
www.hivguidelines.org
CASE STUDYDiabetes44 year old white male with diabetes and HIV• Glucose 345, HBAIC 9.2 on routine lab • Asymptomatic, previously diet-controlled
with prior Glucose 120, HBAIC 6.2
CASE STUDYDiabetesPE:• BMI 25• Scaling lesions between toes and on sides
of feet, no exudate, no erythema, non-tender
CASE STUDYDiabetesMedication reconciliation indicates he has started HIV treatment with his HIV specialistWhat class of antiretrovirals do you suspect:
A. Integrase inhibitorsB. NRTIsC. Protease inhibitorsD. NNRTIs
CASE STUDYDiabetesWhat are your treatment options?
A. Stop the antiretroviralsB. Continue the antiretrovirals and start antidiabetic agent(s)C. Call the HIV specialistD. Send the patient to the emergency room
Are there other options?
Brown, TT. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.
Bone metabolism issueswith & without HIV treatment
Without antiretrovirals• HIV• Inflammation
With antiretrovirals• Antiretrovirals
– Acceleration of bone turnover with ARV initiation
– ARV-specific effects on bone
Normal bone remodeling
www.medscape.com
Risk factors for low BMD HIV-infected patients:• Low weight• Length of HIV infection• Older age• Smoking• Stavudine exposure• Female• HIV RNA• Tenofovir exposure• Protease inhibitor exposure• Duration of NRTI use
Cotter AG, et al. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13
Screen for low bone mineral density
Bone densitrometry (DXA, DEXA)• Post-menopausal women• Men >= 50 years of ageCheck for secondary causes• Vitamin D deficiency• Hyperparathyroidism• Hypogonadism• Adrenal insufficiencyAberg JA, et al. CID. (2013).Cotter AG, et al. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13
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44 yo latina female with AIDSCD4 450, VL undetectable, nadir CD4 45Medications:• Advair• Kaletra (lopinavir/ritonavir)/• Truvada (tenofovir/emtricitabine)• Atorvastatin• Megestrol• MS Contin (controlled release morphine)What endocrine issues is she at risk for?
CASE STUDYMultiple medical issues
44 yo latina female with AIDSCD4 450, VL undetectable, nadir CD4 45Physical exam:• BMI 37• Uses a wheelchair for mobility• S/P total hysterectomy• Scattered wheezes throughout lung fields and bilateral rales at
both lung basesWhat endocrine issues is she at risk for?
CASE STUDYMultiple medical issues
Summary: Endocrine issues
• Untreated HIV: glandular infiltration and/or inflammation and metabolic changes
• Treated HIV: antiretroviral toxicity and/or inflammation and metabolic changes
• Endocrine abnormalities may be multi-factorial• Traditional risk factors for endocrine and
metabolic abnormalities also affect those with HIV
