General Patient Management Protocol

Address Issues Concurrently

Treatment of all patients with HIV-associated wasting should begin with the clinician implementing five general patient management interventions. In some cases, once these situations are corrected, body cell mass may be restored. Many of these interventions are designed to address the underlying conditions that may contribute to a patient's wasting. All five of these interventions must be addressed concurrently and not in a step-wise fashion.

1. Control viral load and maximize immune competence

As a general standard-of-care, the clinician needs to make certain the patient is maintaining good virologic control on their existing antiretroviral regimen. Optimally, this means the patient should have plasma HIV RNA <50 copies/mL. In addition, the clinician needs to identify any HIV-associated morphologic or metabolic abnormalities. This means distinguishing fat redistribution syndrome from true HIV-related wasting. Adjustments to antiretroviral regimens may be required in order to maintain virologic control and adequate adherence, as well as to minimize the incidence of complications. It is important to remember, however, that an effective HAART regimen may not adequately correct the continued loss of body cell mass in patients with HIV-related wasting.

2. Correct any immediate causes of HIV-related wasting

The clinician also needs to make certain that the patient receives appropriate treatment and interventions for any immediate causes of wasting. Such causes include various opportunistic infections, HIV-related malignancies, diarrhea, and gastrointestinal infections.

3. Address any psychosocial issues or lifestyle-associated situations

A patient with HIV-associated wasting needs to be treated for any underlying psychiatric disorders, such as anxiety or depression. In addition, the clinician needs to address possible lifestyle-associated situations that may interfere with adequate nutritional intake or treatment regimens. For example, the patient may need financial assistance in the form of food stamps or other interventions in order to purchase healthy food. Other patients with transportation difficulties may need assistance in the form of Meals-on-Wheels programs or weekly grocery store deliveries.

4. Improve nutritional intake

HIV-associated wasting may be due, in part, to a patient's poor nutritional intake. Taking appropriate action to improve a patient's intake of food and calories is a critical first step to ensure the success of subsequent therapeutic interventions. This is where the expert consultation of a registered dietitian is invaluable. Improving nutritional intake may take one of several forms, including the following:

› Ensuring that caloric intake is adequate to meet the high metabolic demands of HIV infection;
› Prescribing high-protein, low-fat diets;
› Maximizing the intake of high-calorie, nutrient-dense foods;
› Increasing vitamin supplementation (e.g., A, E, B6, B12, zinc); and
› Providing nutritional supplementation (e.g., oral food supplements, glutamine, enteral nutrition, total parenteral nutrition)

5. Treat anorexia

Various appetite stimulants may be used to increase appetite in patients who have inadequate caloric intake.22,32-36 Such agents typically increase a patient's weight in the form of increased fat, with limited gains in lean body mass. The clinician should not rely on appetite stimulants as the only intervention in patients with HIV-related wasting.