Download Endocrine System and HIV

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/
Endocrine issues
with & without HIV treatment
Brown, TT. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.
HPA Axis
CRH
http://www.uchospitals.edu/
HPA Axis
CRH
ACTH
http://www.uchospitals.edu/
HPA Axis
CRH
ACTH
http://www.uchospitals.edu/
Cortisol
Adrenal issues
with & without HIV treatment
With antiretrovirals
• Iatrogenic adrenal
suppression
– Steroid/ antiretroviral
interactions
Without antiretrovirals
• Direct infiltration
– Opportunistic infection
– Malignancy
– HIV
• Medications
– Ketoconazole
– Megestrol
Brown, TT. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.
Signs and symptoms of AI
Symptoms
Signs
Labs
reference
Orthostatic symptoms
Salt craving
Fatigue, Weakness
Nausea, vomiting, diarrhea
Hyperpigmentation
Hypotension
Hyperkalemia
Hyponatremia
Hypoglycemia
CASE STUDY
Adrenal 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 STUDY
Adrenal 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 room
B. Potassium of 3.2 mEq/l
C. Diarrhea every day since discharge
D. Glucose of 56 mg/dl
CASE STUDY
Adrenal Insufficiency
All are possible causes of his adrenal
insufficiency, except:
A. Cryptococcal meningitis
B. Treatment of cryptococcal meningitis with
fluconazole
C. Self-treatment of a rash with hydrocortisone
1% topical cream for a week
D. Mass lesion in the brain
ACTH Stimulation test for AI
CRH
ACTH
http://www.uchospitals.edu/
Cortisol
Treatment of AI
• Daily glucocorticoid replacement
• Consider mineralcorticoid replacement
• Increase glucocorticoids for surgery and illness
Brown, T. The PRN Notebook; Volume 12, December 2007.
HPG Axis
GnRH
http://www.uchospitals.edu/
HPG Axis
GnRH
LH
FSH
http://www.uchospitals.edu/
HPG Axis
Female
GnRH
LH
FSH
Testosterone
Estrogen
http://www.uchospitals.edu/
HPG Axis
Male
GnRH
LH
FSH
Testosterone
(Estrogen)
http://www.uchospitals.edu/
Hypogonadism
with & without HIV treatment
With antiretrovirals
• Medications/drugs
–
–
–
–
Opiates
Marijuana
Alcohol
Anabolic steroids
• Inflammation
• Age
Without antiretrovirals
• Direct infiltration
– Opportunistic infection
– HIV
• Medications/drugs
– Opiates
– Megestrol
• Inflammation
• Wasting/malnutrition
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.
Signs and symptoms
male hypogonadism
Symptoms
Signs
Diagnostics
 Libido
Depression
Low energy
Poor concentration
 Face & body hair
 Muscle bulk & strength
Testicular atrophy
Gynecomastia
 Testosterone
 Bone mineral density
Bhasin S. et al, J Clin Endocrinol Metab 2010;95(6):2536.
Testing for male hypogonadism
Total testosterone
Primary or secondary?
Look for reversible causes
Treatment for hypogonadism
Testosterone replacement therapy
• Low libido and/or hypogonadal symptoms
• Low bone mineral density
• Low body mass/ weight loss on HIV treatment
Monitoring
• Hemoglobin/hematocrit
• Liver function
• Prostate specific antigen
www.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
IGF-1/GH Axis
GHRH
GHIH
GH
Muscle
Liver
http://www.uchospitals.edu/
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.
Lipid metabolism issues
with & without HIV treatment
With antiretrovirals
• Antiretrovirals
– High triglycerides
– High LDL
Without antiretrovirals
• Inflammation
– High triglycerides
– Low HDL
Brown, TT. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.
Pancreatic hormones
Glucose metabolism issues
with & without HIV treatment
With antiretrovirals
• Antiretrovirals
• Inflammation
Without antiretrovirals
• ? HIV/ inflammation
• Medications
– Pentamidine
Brown, TT. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.
Feeney ER. . Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.
Screen for lipid and glucose
metabolism abnormality
Metabolic • Fasting blood glucose On ART:
assessment • Fasting lipid profile
• before start
• 3-6 months
• annually
No ART:
• baseline
• annually
www.hivguidelines.org
CASE STUDY
Diabetes
44 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 STUDY
Diabetes
PE:
• BMI 25
• Scaling lesions between toes and on sides
of feet, no exudate, no erythema, nontender
CASE STUDY
Diabetes
Medication reconciliation indicates he has started
HIV treatment with his HIV specialist
What class of antiretrovirals do you suspect:
A. Integrase inhibitors
B. NRTIs
C. Protease inhibitors
D. NNRTIs
CASE STUDY
Diabetes
What are your treatment options?
A. Stop the antiretrovirals
B. Continue the antiretrovirals and start
antidiabetic agent(s)
C. Call the HIV specialist
D. Send the patient to the emergency room
Are there other options?
Bone metabolism issues
with & without HIV treatment
With antiretrovirals
• Antiretrovirals
– Acceleration of bone
turnover with ARV
initiation
– ARV-specific effects on
bone
Without antiretrovirals
• HIV
• Inflammation
Brown, TT. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13.
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 age
Check for secondary causes
• Vitamin D deficiency
• Hyperparathyroidism
• Hypogonadism
• Adrenal insufficiency
Aberg JA, et al. CID. (2013).
Cotter AG, et al. Best Pract Res Clin Endocrin Metab. 2011. Jun 25 (3):403-13
CASE STUDY
Multiple medical issues
44 yo latina female with AIDS
CD4 450, VL undetectable, nadir CD4 45
Medications:
• Advair
• Kaletra (lopinavir/ritonavir)/
• Truvada (tenofovir/emtricitabine)
• Atorvastatin
• Megestrol
• MS Contin (controlled release morphine)
What endocrine issues is she at risk for?
CASE STUDY
Multiple medical issues
44 yo latina female with AIDS
CD4 450, VL undetectable, nadir CD4 45
Physical exam:
• BMI 37
• Uses a wheelchair for mobility
• S/P total hysterectomy
• Scattered wheezes throughout lung fields and bilateral rales at
both lung bases
What endocrine issues is she at risk for?
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 multifactorial
• Traditional risk factors for endocrine and
metabolic abnormalities also affect those with
HIV
Questions?
[email protected]