This article provides a nice overview of HIV-associated wasting.
The paper makes a number of strong points. In particular, it focuses
on anorexia and decreased oral intake as key to wasting. In this
vein, both the discussion by Von Roenn and Knopf and Tables 1
and 2 offer a very valuable review of the multiple reasons why
HIV-infected patients may eat less. Given the many medications
that we often need to use in these patients, the text discussion
about the ways in which medications can result in decreased oral
intake, reinforced by Table 2, is particularly useful.
Another strong point of this paper is its description of the various
agents that have been evaluated as therapies for anorexia and/or
wasting. The authors provide a useful review of trials with a
variety of agents, including more obscure agents, such as cyproheptadine
and hydrazide, which are often mentioned as possible therapies
without much further information.
I would also echo the authors' comments about the clinical significance
of wasting, the frequent stepwise and sporadic weight loss, and
the multifactorial nature of wasting.
Importance of Other Factors Besides Oral Intake
For all these virtues of the paper, however, I am concerned about
the authors' conclusion that "oral intake is the primary
determinant of HIV-related weight loss." Although the authors
quote several studies supporting this hypothesis, other studies
argue against it, finding instead that other factors play greater
roles in causing weight loss and wasting [1-8]. In these studies,
weight loss occurred in HIV-infected patients despite caloric
intakes above their calculated requirements. Furthermore, caloric
intake did not correlate well with weight loss.
In the beginning of their review, the authors briefly mention
a variety of possible causes of wasting. However, it is important
for readers to note that each of these causes may play a significant
role in individual patients. In particular, endocrine dysfunction,
alterations in metabolism, and malabsorption may be the most important
cause of weight loss in a particular patient . The frequency
of malabsorption has been well established in the literature on
HIV infection, while the causes of this malabsorption may be as
numerous as the causes of decreased oral intake [9, 10].
This brings up another issue that Von Roenn and Knopf again mention
only briefly; ie, the need to try to identify reversible causes
of decreased intake and/or weight loss as the first step in treatment.
This point cannot be overemphasized. Very frequently, the drugs
that we give our patients may result in their loss of appetite
or diarrhea. In a large number of other patients, we may be able
to find a treatable pathogen; treatment to eradicate this pathogen
may result in the patient being able to regain weight without
a specific weight gain-inducing medication. There is documentation
of the success of this approach in treating cytomegaloviral colitis,
for example .
HIV as a Cause of Wasting
Finally, clinicians need to consider that HIV is more than a passive
bystander in the wasting suffered by these patients. Effective
antiretroviral therapy may result in significant improvement in
appetite, weight, and strength even without specific appetite
stimulants or anabolic agents.
Above all, fatalism should have no role in the clinician's approach
to HIV- associated weight loss and wasting. Moreover, the knowledge
being gained about the treatment of HIV-associated wasting may
prove invaluable in the treatment of similar problems associated
with other progressive or chronic diseases.
1. Bruera E: Is the pharmacological treatment of cancer cachexia
possible? Support Care
Cancer 1(6):298-304, 1993.
2. Macallan DC, Noble C, Baldwin C, et al: Energy expenditure
and wasting in human immunodeficiency virus infection. N Engl
J Med 333:83-88, 1995.
3. Grunfeld C, Pang M, Shimizu L, et al: Resting energy expenditure,
caloric intake, and short-term weight change in human immunodeficiency
virus infection and the acquired immunodeficiency syndrome. Am
J Clin Nutr 55:455-460, 1992.
4. Dworkin BM, Wormser GP, Axelrod F, et al: Dietary intake in
patient with acquired immunodeficiency syndrome (AIDS), patients
with AIDS-related complex and serologically positive human immunodeficiency
virus patients: Correlations with nutritional status. J Parenter
Enteral Nutr 14:605-609, 1990.
5. Sharkey SJ, Sharkey KA, Sutherland LR, et al: Nutritional status
and food intake in human immunodeficiency virus infection. J
Acquir Immune Defic Syndr 5:1090-1098, 1992.
6. Hommees MJ, Romijn JA, Godfried MH, et al: Increased resting
energy expenditure in human immunodeficiency virus-infected men.
Metabolism 39:1186-1190, 1990.
7. Zadra JN, Voight R, Hoggs RS, et al: Analysis of nutritional
intake in a cohort of homosexual men [abstract WS-B34-3]. Proceedings
of the 9th International Conference on AIDS, June 6-11, 1993.
International AIDS Society, Berlin.
8. Coodley GO, Loveless MO, Merrille TM: The HIV wasting syndrome:
A review. J Acquir Immune Defic Syndr 7:681-694, 1994.
9. Kotler DP, Gaetz HP, Lange M, et al: Enteropathy associated
with the acquired immunodeficiency syndrome. Ann Intern Med
10. Ehrenpreis ED, Ganger DR, Kochvar GT, et al: D-xylose malabsorption:
Characteristic finding in patients with the AIDS wasting syndrome
and chronic diarrhea. J Acquir Immune Defic
Syndr 3:1047-1050, 1992.
11. Kotler DP, Tierney AR, Altillio D, et al: Body mass depletion
during gancyclovir treatment of cytomegalovirus infections in
patient in acquired immunodeficiency syndrome. Arch Intern
Med 149:901-905, 1989.