A 48-year-old woman with a complex medical history comes to the clinic due to a change in her body habitus. She says her legs are "like sticks" while her "belly is getting bigger." The patient also feels increasingly fatigued but does not have excessive daytime somnolence. She has been homeless for much of the last 5 years but has been living in a residential care facility for the last 12 months. On physical examination, she is distractible and has an inappropriate affect but is cooperative. Neurologic and mental status examination is otherwise normal. There is loss of adipose tissue from the extremities and face, with a noticeable increase in abdominal girth. Which of the following types of medications is most likely to be responsible for this patient's symptoms?

Question

A 48-year-old woman with a complex medical history comes to the clinic due to a change in her body habitus.  She says her legs are "like sticks" while her "belly is getting bigger."  The patient also feels increasingly fatigued but does not have excessive daytime somnolence.  She has been homeless for much of the last 5 years but has been living in a residential care facility for the last 12 months.  On physical examination, she is distractible and has an inappropriate affect but is cooperative.  Neurologic and mental status examination is otherwise normal.  There is loss of adipose tissue from the extremities and face, with a noticeable increase in abdominal girth.  Which of the following types of medications is most likely to be responsible for this patient's symptoms?

Quizplus · Accepted Answer

This patient has redistribution of fat from the extremities to the trunk. Medication-induced body fat redistribution (sometimes called lipoatrophy or lipodystrophy) is a common adverse effect of highly-active antiretroviral therapy (HAART) and can be considered a product of 2 independent processes: wasting of fat from the face and extremities and deposition of fat in the trunk and viscera. Lipoatrophy refers to loss of subcutaneous fat, especially from the face, extremities, and buttocks. It is primarily seen in patients taking nucleoside reverse transcriptase inhibitors (mainly stavudine and zidovudine) and is also associated with protease inhibitor use. Central fat deposition also occurs in some patients and causes increased abdominal girth and a buffalo hump (dorsocervical fat accumulation) that is similar to Cushing syndrome. Central fat deposition may be seen with any HIV treatment regimen and may be a result of treating HIV rather than a specific medication adverse effect. Both syndromes have been associated with metabolic abnormalities including insulin resistance, hypertriglyceridemia, and reduced HDL cholesterol levels. (Choice B) HMG-CoA reductase inhibitors (statins) are associated with myalgias and an increase in hepatic transaminase levels. They do not cause fat redistribution. (Choice C) Thiazide diuretics (eg, chlorthalidone, hydrochlorothiazide) can cause hyperglycemia and hypertriglyceridemia and may have a small effect on fat distribution. However, these effects have not been seen with loop diuretics (eg, furosemide). (Choice D) Unlike glucocorticoids, nonsteroidal antiinflammatory drugs (NSAIDs) do not significantly alter tissue lipid metabolism or cause fat redistribution. (Choice E) Proton pump inhibitors (PPIs) are used to reduce gastric acid secretion in patients with peptic ulcer and gastroesophageal reflux. PPIs can cause hypomagnesemia and increased risk of osteoporosis. (Choice F) Selective serotonin reuptake inhibitors are indicated for treatment of depression and chronic anxiety. They can cause weight gain in a subset of patients but have not been linked to fat redistribution. (Choice G) Thyroperoxidase inhibitors (eg, methimazole, propylthiouracil) are used to treat hyperthyroidism. Common side effects include bone marrow suppression (eg, anemia, agranulocytosis). Educational objective: Highly-active antiretroviral therapy (HAART) for HIV is commonly associated with body fat redistribution. Subcutaneous lipoatrophy involving the face and extremities is associated with nucleoside reverse transcriptase inhibitors (especially stavudine and zidovudine) and protease inhibitors. Central fat accumulation in the trunk and viscera can occur with any HAART regimen. __________ References: Systematic review of antiretroviral-associated lipodystrophy: lipoatrophy, but not central fat gain, is an antiretroviral adverse drug reaction. (http://www.ncbi.nlm.nih.gov/pubmed/23723990) Prevalence of, evolution of, and risk factors for fat atrophy and fat deposition in a cohort of HIV-infected men and women. (http://www.ncbi.nlm.nih.gov/pubmed/15909274)

A 48-Year-Old Woman with a Complex Medical History Comes to the Clinic