Researchers at Makerere University, Kampala and the pharmocology group at Liverpool University reported a significant interaction between high fat meals and ritonavir as a booster in lopinavir/r (Kaletra).

Three meal conditions were studied in an open-label, three part, cross over study in 12 HIV positive people (6 men, 6 women) using lopinavir/r (2 x 400/100 mg tablets) as second-line therapy. Median (IQR) age and weight of patients was 48 (44 – 49) years and 62 (59-68) kgs.

Intensive PK sampling after a moderate (20 g fat) and high (36 g) fat meal (on Day 1 and 8 respectively) were compared to fasted state on Day 15.

Compared to the fasting, administration with a high fat meal resulted in 29% lower ritonavir AUC (geometric mean ratio 0.71; 90%CI 0.61-0.84) and 29% lower Cmax (GM 0.71; 90%CI 0.60-0.84) while C12 increased non-significantly by 12% (GM 1.12 (90%CI 0.94-1.33).

Reference:

Lamorde M et al. – Steady-state exposure of ritonavir is reduced by a high fat meal in Ugandan patients receiving lopinavir plus ritonavir co-formulated tablets. 13th EACS, 12–15 October 2011, Belgrade. Abstract PE6.6/1 (BPD1/1).

The 1 April 2003 issue of the journal Clinical Infectious Diseases (Volume 36, Supplement 2) reports on the current management of nutrition in HIV infection. Drawing on the work of more than 50 authorities in the field, the supplement looks at:

• General nutrition management in HIV-positive patients
• An assessment of nutritional status, body composition, and HIV-associated morphologic changes
• Weight loss and wasting
• Lipid abnormalities
• Body habitus changes related to lipodystrophy
• Insulin and carbohydrate dysregulation
• Lactic acidemia
• Emerging bone problems, and
• Food and water safety

In an introduction to the supplement John G Bartlett of Johns Hopkins University, writes that the science and strategies for management of HIV infection move with a velocity that is unparalleled by any other important disease in the history of medicine. Nutritional issues have moved at the same or an even quicker pace. Most of the issues addressed in the supplement are complications that arise from the medical developments and are among the most challenging concerns we face.

Bartlett concludes his introduction: “Relevance is placed in perspective by the observation that modern management of HIV infection now requires substantial expertise in dealing with nutritional issues and access to this expertise, despite the fact that there have been virtually no guidelines that specifically target the nutritional care of the HIV-infected population. This report on the nutrition management and concerns of HIV infection is consequently welcomed as timely, authoritative, and greatly needed.”

Judith Nerad and colleagues at the, John H. Stroger Hospital, Chicago, write that nutritional management is integral to the care of all patients infected with HIV. HIV infection results in complicated nutritional issues for patients, and there is growing evidence that nutritional interventions influence health outcomes in HIV-infected patients. The authors define levels of nutritional care, and discuss when patients should be referred to dietitians with nutritional and HIV expertise.

Tamsin A Knox of Tufts University School of Medicine, Boston, and colleagues argue that nutritional status should be assessed at regular intervals as part of the management of HIV infection. The simplest approach to assessment is serial weight measurement. A comprehensive nutritional assessment includes:

1. anthropometric measurements of body composition;
2. biochemical measurements of serum protein, micronutrients, and metabolic parameters;
3. clinical assessment of altered nutritional requirements and social or psychological issues that may preclude adequate intake; and
4. measurement of dietary intake.

Techniques for measuring body composition of fat and lean body mass include anthropometry and bioelectric impedance analysis. Other techniques, including dual X-ray absorptiometry (DXA), hydrodensitometry, total body potassium measurement, and cross-sectional computed tomography or magnetic resonance imaging are available in research centres. Anthropometry, including waist-hip ratios, regional DXA, and cross-sectional imaging, is best for detecting morphologic changes associated with fat redistribution syndrome. Nutritional assessment and intervention in children with HIV can help to prevent stunted growth and development.

Steven Grinspoon and Kathleen Mulligan, for the Department of Health and Human Services Working Group on the Prevention and Treatment of Wasting and Weight Loss, outline the problems and dangers of weight loss and muscle wasting. Wasting, particularly loss of metabolically active lean tissue, has been associated with increased mortality, accelerated disease progression, loss of muscle protein mass, and impairment of strength and functional status. Factors that may contribute to wasting include inadequate intake, malabsorptive disorders, metabolic alterations, hypogonadism, and excessive cytokine production. Evidence now demonstrates that nutritional counselling and support, appetite stimulants, progressive resistance training, and anabolic hormones can reverse weight loss and increase lean body mass. Despite a growing body of evidence on the importance of nutritional intervention to prevent wasting in adults, maintain growth velocity in children, and promote restoration of weight and lean body mass in stable, low-weight patients, no therapeutic guidelines currently exist for the management of weight loss and wasting in HIV-infected patients. The authors recommend principles and guidelines for assessment and management of weight loss and wasting in patients with HIV/AIDS.

The supplement is available at:
http://www.journals.uchicago.edu/toc/cid/2003/36/S2