The purpose of this article is to educate nurse practitioners about wasting syndrome in HIV patients, a problem that can benefit from nurse practitioner intervention. After reading this article, the nurse practitioner should be able to:
As access to medical care takes on different forms and venues, nurse practitioners are providing primary care to patients with increasingly complex conditions. Patients with wasting syndrome are among the growing patient populations that can benefit from nurse practitioner services.
HIV wasting syndrome is defined as the unintended, involuntary loss of more than 10% of body weight that is associated with intermittent or constant fever and chronic diarrhea or fatigue for more than 30 days in the absence of a defined cause other than HIV infection. A persistent symptom is major muscle wasting. A variety of factors impact this syndrome, which is multifactorial in its etiology and impact on health and prognosis. HIV wasting syndrome also has a financial impact on the patient, the health care setting and the general population.
Experts believe that HIV wasting syndrome originates or coexists with malnutrition. Whether malnutrition is the cause or an effect of HIV wasting syndrome, correction of malnutrition is key to prevention of the wasting. Once wasting has begun, achieving adequate nutritional intake is essential to management of the syndrome. The malnutrition of wasting syndrome apparently is fueled by starvation or altered metabolic processes. Starvation may occur as a result of decreased food intake due to nausea or vomiting, anorexia, diarrhea or malabsorption. The altered metabolic state that coincides with other syndrome factors contributes to and perpetuates wasting.1 Examples of these altered processes are:
routine follow-up with office visits to primary care provider as well as other team members (dietitians, social workers).
Nutrition is another cornerstone of wasting syndrome prevention. Over-the-counter nutritional supplement preparations are available at health stores, grocery stores and pharmacies. Choices include liquid preparations such as Carnation Instant Breakfast, Ensure, Advera and others. These should be recommended after a formal nutritional consult and follow-up. They may be used prior to wasting to augment presumed changes that occur with an altered metabolic state, infection and diet.
Regularly scheduled patient evaluations are crucial to identifying risk factors and symptoms that precede wasting syndrome. Appropriate intervals are every 3 months until the patient's CD4 cell counts drop below 200. Once the CD4 counts dip below 200, monitor the patient every 2 months, and even more frequently as risk factors increase. Appropriate monitoring parameters are listed in Table 1.
Management of Wasting Syndrome
The management of established wasting syndrome in HIV/AIDS is based on your initial assessment findings. Management principles and treatment modalities for wasting syndrome are listed in Table 2.
Once wasting begins, improved nutrition takes priority as a treatment goal. Management of wasting syndrome consists of identifying the cause of malnutrition and treating that cause-for example, nausea or vomiting, anorexia, diarrhea or depression. If you suspect the patient has altered metabolic processes, screen for malabsorption, increased caloric and protein needs (resulting from secondary infections), hypogonadism, insulin resistance, increased HIV viral load and lowered CD4 cell counts.
When evaluating malnutrition and diarrhea, two tests are specific for malabsorption: the D-xylose test, which measures the ability to absorb sugars in the small intestine, and the 24-hour stool test for fecal fat (Sudan stain), which evaluates the level of steatorrhea.2
Treatment of Malnutrition
Nausea and vomiting are influenced by HIV infection, gastroesophageal reflux disease (GERD) and medication side effects. Target your treatment at reducing symptoms and eradicating the causative agent. Medications used to treat nausea include, but are not limited to, promethazine HCl (Phenergan) and H2 blocking agents (Tagamet, Zantac, Pepcid, etc.). A bland diet can also help manage nausea, as can treatment for esophageal candidiasis (Diflucan) or Helicobacter pylori infection (proton pump inhibitors, antimicrobials).
Diarrhea and malabsorption may occur as a result of HIV infection, secondary infection (cryptosporidium, cytomegalovirus [CMV], Candida, etc.) or as side effects to medication. Treatment should be aimed at identifying the cause and then suppressing or eradicating it. Sometimes, the only effective treatment method is antidiarrheal medication (Lomotil, Immodium and bulking agents).
Depression can affect appetite, food choices, will to live and judgment. Clinical depression can be a sequelae of HIV infection and impact nutrition, or can be directly related and exacerbated by poor nutrition in HIV infection. The Beck Depression Inventory Scale is a standard parameter to gauge a patient's level of depression. Management consists of counseling and, in many cases, treatment with antidepressant therapy. Carefully consider your choice of antidepressant therapy because some have interactions with newer antiretroviral combinations.
Appetite may be affected by secondary infections such as Candida esophagitis, H. pylori, CMV esophagitis, side effects to medication, depression and advanced HIV infection. Low circulating levels of testosterone and human growth hormone also may cause anorexia, as can insulin resistance.
Treatment is aimed at restoring appetite. Consider evaluation for gastrointestinal infection if the patient does not respond adequately to appetite-stimulating medications. Appetite stimulants include megastrol acetate (Megace), nandrolone (Deca-Durabolin) and dronabinol (Marinol). Consider anabolic steroids first, since this class of medications can enhance lean body mass and weight when augmented with exercise. Research shows that this treatment strategy is well-tolerated and can enhance quality-of-life indicators.
Metabolic changes, such as insulin resistance, depressed hormone levels, oxidative stress, osteopenia or osteoporosis, may occur in wasting syndrome as a cause of wasting or a direct result of the wasting syndrome. Either way, the alterations must be identified and appropriately treated. Evaluation criteria and treatment options are listed in Table 3.
Recombinant Human Growth Hormone
Wasting syndrome is a major cause of morbidity and mortality for the HIV/AIDS patient. Lean body mass, muscle strength and ability to perform activities of daily living (ADLs) are diminished as a result of wasting syndrome. These declines may be reversed with treatment of the syndrome using recombinant human growth hormone and progressive resistance exercise.3
Research suggests that any HIV/AIDS patient with wasting syndrome who continues to lose body cell mass (BCM) after appropriate factors have been evaluated and treated (i.e., antiretroviral therapy, opportunistic infection treatment, anorexia, malabsorption and hypogonadism) is a candidate for a 3-month trial of recombinant human growth hormone (rhGH[m]).4 For example, Serostim (rhGH) may be given by intramuscular injection at 6 mg per day.
Other treatments include thalidomide as a cytokine modulator, dosed at 100 mg/day. In clinical trials, bioimpedance analysis showed that subjects treated with thalidomide experienced significant increases in weight, more than 50% of which was fat-free mass.5
Testosterone therapy and progressive resistance training may help increase muscle mass and improve health status in eugonadal men and hypogonadal men with HIV/AIDS wasting syndrome, research shows.6-8 Another study documented sustained improvements in lean body mass in hypogonadal AIDS patients with wasting syndrome who received testosterone therapy for 1 year.9
In a separate study, researchers combined growth hormone with other anabolic agents and found that when given in combination therapy, these agents help HIV patients regain weight and lean body mass in the proper therapeutic circumstances.10 The criteria for treatment include the ability to monitor side effects, compliance with proper dosing and positive response to therapy after 3 months.
Limited studies have investigated the impact of these treatments on women with HIV/AIDS wasting syndrome. One study evaluated the effects of transdermal testosterone in women with AIDS wasting syndrome who also experienced low serum testosterone levels. Researchers documented a positive impact on weight gain and quality of life and good tolerance with low incidence of side effects in the group that received the lower dose of testosterone replacement therapy.11
Two studies investigated micronutrient administration to patients with wasting syndrome, one involving micronutrient supplementation with L-glutamine (Gln) alone and one involving supplementation with beta-hydroxy-beta-methylbutyrate (HMB), L-glutamine (Gln), and L-arginine (Arg). The study of Gln alone documented favorable increases in body weight, body cell mass and intracellular water.12 The study of a combination of micronutrients documented improvements in body weight, predominantly in lean body mass. The study also documented improvements in CD4 cell counts and reduced viral load in the treatment group.13 Further results have validated micronutrients' ability to improve depression in hypogonadal men with AIDS wasting syndrome.14
Insulin resistance was evaluated in HIV/AIDS patients with wasting syndrome who had lowered lean body mass and higher body mass index. Researchers found a correlation between insulin resistance and wasting syndrome with and without protease inhibitor use. Thus, treatment for hypogonadal men should be aimed at replacing physiologic androgen. This successfully improved insulin-sensitization in these treatment groups.15
There has been an explosion of clinical studies aimed at evaluating the management of wasting syndrome in men with HIV/AIDS. While the HIV/AIDS patient population is predominantly male, the percentage of affected women is increasing. More research needs to be aimed at how malabsorption and altered metabolic states are affected in the female patient with AIDS wasting syndrome. Until that need is met, perhaps we can extrapolate the advances documented in men for use in women.
Suzanne Woolard is a family nurse practitioner at Quadrangle Medical Specialists in Greenville, N.C. She has worked in HIV/AIDS clinical trial settings and treated HIV-positive patients.