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hypercortisolism and lipodystrophy
May 9, 2001

I think many of us are frustrated by the slow pace of answers for the problem of lipodystrophy. Time and again we read that there are many questions and few answers. In particular, I'm frustrated by the apparent inattention paid to the theory (as elucidated by Dr. Donald Kottler et al several years ago), that increased cortisol levels are responsible. In several studies I've seen publicized on Medscape, increased cortisol (or inverted cortisol/DHEA ratio) is time and again seen in this syndrome, yet few seem to pay any attention to it in clinical practice. Dr. Kottler noted in a 1998 article that simply taking a fasting serum cortisol level was not sufficient "the only accurate way to measure cortisol is a 24 hour urine cortisol" test. The similiarity between lipodystrophy and Syndrome X (in those who survive other chronic conditions), and the fact that various lipodystrophy symptoms occur with no clear correlation to any particular drug, as well as the effect of increased cortisol on such parameters as insulin resistance and reduced immune functioning, would appear to warrant a major focus on this stress hormone in research and clincal practice. If patients with lipodystrophy indeed have high cortisol levels, can nothing be done to measure and reduce them, even if the research isn't final?

Response from Dr. Henry

The data is mixed on that but good groups have also reported little association between altered cortisol levels and the manifestations of lipidystrophy/HIV related metabolic disturbances. Another theory is that altered insulin function is a common thread. That theory will be put to the test with an ACTG study starting soon looking at metformin +/- a glitizide diabetes drug for treatment. I share your frustration but the answer probably is multi-factorial combining host elements (age, genetic predisposition) with viral/immune system elements (duration of infection and degree of immune reconstitution) and treatment factors. Like many things in medicine the story is often very complex and takes many efforts before things fall into place providing answers. I agree that it would be nice if we had more interest from our endocrine colleagues in studying the hormone status of our patients. KH

2 part question.
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