ID Week 2020: Updates in HIV - Episode 2
An expert physician reflects upon the notable adverse effect of weight gain seen in HIV care with integrase inhibitors and the implications of recent study results.
Moti Ramgopal, MD, FACP, FIDSA, CPI: Something impacting us in HIV care today is the weight gain we see with integrase inhibitors. When we look at patients with antiretroviral therapy [ART], the [adverse] effect of weight gain associated with integrase inhibitors is something we are addressing and looking at. The question for us is: what are the risk factors?
There are several studies looking at this. The one we’re going to look at is a retrospective study that was developed to evaluate the presence of integrase-associated weight gain in a diverse, urban HIV population, as well as risk factors of the metabolic implications with integrase-associated weight gain. This study demonstrated that female patients on an integrase strand inhibitor had greater weight gain than male patients, and nonwhite females had greater weight gain than white females. I think we need to recognize that nonwhite females are at higher risk of gaining weight, as well as female patients more than male patients.
Then the question is going to be, what are the metabolic implications of these patients, as well as their gain in weight? We’re also observing there is an increased risk of diabetes following initiation of ART therapy by these patients. If you’re recognizing this, the next question would be, how might this risk be mitigated? That risk is an ongoing discussion with providers today. Can we change the ART option? How do we identify these patients? What early intervention do we need to do with assessments, like abdominal circumference? There are many questions around this question.
Then, when do we start addressing the weight? What I tend to do—and this is very important—when you ask how you incorporate the potential for weight gain and evaluate appropriate treatment options for patients, the first thing I do is to have that discussion at the first visit. This is especially if you have a female patient, especially having nonwhite patients. As we’ve identified this in this study, as well as multiple other studies, we’ve seen this repetitively: female patients, African American patients, they’re at higher risk for weight gain, and associated with weight gain are also metabolic complications, such as diabetes.
This question needs to be addressed very early in the discussion with the patient, in the first visit, the second visit, third visit. “Are you gaining weight? How are you doing? Did your appetite change? Does this weight return to your normal weight?” There are multiple intervention strategies that need to be looked at from now. Then after having assessed your patient, you ask the question, “What is the right treatment option? Is this an integrase patient or not? Having now recognized that integrase is resulting in this weight gain, should we use a non-integrase regimen in these higher-risk patients?”