Androgenic anabolic steroids and other therapies for HIV-related wasting

Wasting is a syndrome of progressive weight loss seen most frequently in human immunodeficiency virus (HIV)-related disease, although it has also been reported in cirrhosis, pulmonary disease, burns, and chronic renal failure. Wasting is closely related to cachexia in that lean body mass inexorably declines accompanied by a negative nitrogen balance. Neither condition responds well to nutritional support, in contrast to starvation in which the process is rapidly reversed upon restoration of protein-calorie intake. The etiology of wasting remains uncertain and is the result of several complex mechanisms. The relationship between resting energy expenditure and total energy expenditure has recently been clarified. Previous data were contradictory, mostly because clinical studies were conducted at different timepoints during the natural history of the disease. The role of specific cytokines, de novo lipogenesis, and hypogonadism have also received considerable attention. More accurate techniques to measure body composition have been developed. Specific therapies are also being explored and show promise. Megestrol acetate works as an appetite stimulant but leads primarily to increases in total body fat rather than lean body mass. Although recombinant growth hormone is anabolic and improves fat-free mass and weight, it is expensive and may not improve quality of life. Androgenic anabolic steroids in conjunction with progressive resistance exercise and physiologic doses of testosterone now offer considerable benefit in improving lean body mass and other important parameters in eugonadal men with HIV-wasting. However, the role for this therapy in HIV-seropositive women, children, and eugonadal men remains to be determined.