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Wasting, anyone notice a risk factor?

  • 1.  Wasting, anyone notice a risk factor?

    Posted 06-11-2021 01:10
    I'm wondering if there is a known risk for developing cachexia such as being on a particular med or having a particular comorbidity.   Anyone?

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    Samuel Samalin
    Los Angeles CA
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  • 2.  RE: Wasting, anyone notice a risk factor?

    Posted 06-17-2021 13:12

    I found this quick read on mechanism, risk factors, and therapeutic strategies for Cachexia, anorexia, non malignant and malignant weight loss in Science Direct.
    Cachexia 

    https://www.sciencedirect.com/topics/neuroscience/cachexia

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    Henry Delu
    Los Angeles CA
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  • 3.  RE: Wasting, anyone notice a risk factor?

    Posted 06-17-2021 16:20
    Edited by Michael Harbour 06-17-2021 16:22
    Hi Samuel,
    There is no one mechanism or risk factor for HIV associated wasting (HIVAW).  Its cause can be multifactorial.  In 1987, the CDC definition of wasting was involuntary weight loss accompanied by chronic diarrhea, fever, and weakness for 30 days without an underlying cause.  ART changed the incidence of and prevalence of HIVAW, and now the definition evolved to be unintentional weight loss and loss of lean body mass.   The definition now includes:
    • 10% loss of body weight over 12-month period
    • 5% loss of body weight over 6-month period
    • BMI <20 kg/m2
    There is no specific ICD-10 code for HIVAW, so cachexia or weight loss is often co-listed with the HIV diagnosis.  It is an important condition to recognize because HIVAW is a predictor of mortality and morbidity in HIV patients.  It can occur despite adequate HIV viral control.  The multifactorial risk factors of HIVAW include the following:
    1.  Socioeconomic status and food insecurity
    2.  Mechanical factors such as difficulty swallowing
    3.  Poor appetite
    4.  Depression
    5.  Substance use and dependence
    6.  Diarrhea or malabsorption
    7.  Chronic infection and malignancy
    8.  Hormonal diseases like Hypogonadism or Hyperthyroidism
    9.  Metabolic changes and/or increased metabolic demand
    10.  Cytokine excess (IL-1, IL-6, TNF)

    Weight loss can also lead to frailty in the HIV elderly population as this is one of the defining criteria.  Again, this is another reason to quickly identify HIVAW.  In this era of telemedicine and virtual visits, diagnosing weight loss can be delayed as the physician may not "see" the patient and the patient may not bring it up.  Unfortunately, HIVAW is no longer discussed in the DHHS Guidelines or even the new edition of Fundamentals of HIV Medicine which makes searching for this information including treatment more challenging.  I recently presented an abstract on the prevalence of HIVAW in the Modern ART Era at the Miami Center for AIDS Research Conference in February 2021 and would be happy to get you a copy if you wish.

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    Michael Harbour, MD, MPH, FACP, AAHIVS
    Palo Alto CA
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  • 4.  RE: Wasting, anyone notice a risk factor?

    Posted 06-18-2021 18:49
    Thank you for this information. I wish I had known the updated definition of HIVAW before I recently completed disability paperwork for a patient with an upcoming hearing. He has lost weight including 10% of total body but not associated with diarrhea, and I was unaware this had been updated because you are correct that this information is hard to find and I did try to look it up when completing his paperwork. This can have a huge impact on our patients' ability to qualify for disability and have a better standard of living with dignity. In this case after an exhaustive workup to rule out malignancy I believe the weight loss is multi factorial related to poor dentition, exacerbated depression during Covid, a brief relapse with substance use disorder including self-stopping ART for about a month and drop in CD4 < 200 due to a history of poor immune reconstitution, as well as increased work of breathing from moderate COPD with poor control due to continued cigarette smoking and he goes everywhere on foot due to transportation difficulties. All of these conditions/circumstances intersect with his HIV.

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    Rachel Picone
    Lenox MA
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  • 5.  RE: Wasting, anyone notice a risk factor?

    Posted 06-18-2021 23:09
    Thank you for this precious information.  And please I would like a copy of the abstract.
    Sam Samalin, PA, AAHIVM

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    Samuel Samalin
    Los Angeles CA
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