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The Role of Protease Inhibitors in the Pathogenesis of HIV-Associated Lipodystrophy: Cellular Mechanisms and Clinical Implications
1 Pharmaceutical Research and Development, Bristol-Myers Squibb Company, Princeton, New Jersey Correspondence: Oliver Flint, PhD, P.O. Box 5400, Princeton, NJ 08543 USA; e-mail:oliver.flint{at}bms.com. Metabolic complications associated with HIV infection and treatment frequently present as a relative lack of peripheral adipose tissue associated with dyslipidemia and insulin resistance. In this review we explain the connection between abnormalities of intermediary metabolism, observed either in vitro or in vivo, and this group of metabolic effects. We review molecular mechanisms by which the HIV protease inhibitor (PI) class of drugs may affect the normal stimulatory effect of insulin on glucose and fat storage. We then propose that both chronic inflammation from HIV infection and treatment with some drugs in this class trigger cellular homeostatic stress responses with adverse effects on intermediary metabolism. The physiologic outcome is such that total adipocyte storage capacity is decreased, and the remaining adipocytes resist further fat storage. The excess circulating and dietary lipid metabolites, normally "absorbed" by adipose tissue, are deposited ectopically in lean (muscle and liver) tissue, where they impair insulin action. This process leads to a pathologic cycle of lipotoxicity and lipoatrophy and a clinical phenotype of body fat distribution with elevated waist-to-hip ratio similar to the metabolic syndrome.
Key Words: protease inhibitors • lipodystrophy • dyslipidemia • insulin resistance • cardiovascular disease • mechanisms of toxicity • molecular pathology • clinical pathology • in vitro toxicology • endocrine system • pharmaceutical development/products Abbreviations: AIDS, acquired immunodeficiency syndrome • APV, amprenavir • ARV, antiretroviral • ATV, atazanavir • CV, cardiovascular • DEXA, dual-energy x-ray absorptiometry • FFA, free fatty acids • HAART, highly active antiretroviral therapy • HDL-C, high-density lipoprotein cholesterol • HIV, human immunodeficiency virus • IDV, indinavir • LDL, low-density lipoprotein • LPV, lopinavir • NRTI, nucleoside reverse transcriptase inhibitor • PI, protease inhibitor • RTV, ritonavir
This version was published on January
1, 2009 Toxicologic Pathology, Vol. 37, No. 1,
65-77 (2009) |
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