older, wiser & stronger - aging successfully with hiv
TRANSCRIPT
Older, Wiser, and Stronger
Nelson Vergel
Program for Wellness Restoration (PoWeR)ExcelMale.com
DiscountedLabs.comAuthor, Built to Survive
Testosterone: A Man’s Guide
To Get Copies of These Slides:Email
This information (and any accompanying printed material) is not intended to replace the attention or advice of a physician or other health care professional.
Anyone who wishes to embark on any dietary, drug, exercise, or other lifestyle change intended to prevent or treat a specific disease or condition should first consult with and seek clearance from a qualified health care professional.
Resources
ExcelMale.comDefyHIV.comPoWeRUSA.orgDiscountedLabs.comYahoo group: Subscribe by sending an
email to [email protected]
Facebook Group: PozhealthSubscribe to Nelson’s Aging with HIV
Newsletter: http://bit.do/HIVAging
The success of ART
Source: UNAIDS, gap report. Adapted from Lohse et al, 2007; Hoog et al. 2008; May et al, 2011; Hogg et al. 2013
Expected survival of a 20-year-old person living with HIV in a high income country
Era before ART Era of ART
Top Lessons I Have Learned From Aging with HIV
Life sucks sometimes. But nothing lasts. Mindfulness is the strongest muscle I have to overcome adversity.
My survival skills and resilience are useful for others who may not be HIV+. We are all anti- stigma activists. Created my ExcelMale.com platform and told my story. Share your resilience skills!
Not all tests are part of standard of care. The squeaky wheel gets the grease. Anoscopies, DEXA, hormone tests, cardiovascular tests, STI tests, etc, are sometimes difficult to access for non-privileged and are also missed in standard of care.
Being afraid of getting off disability took a lot of my energy. We can all reinvent ourselves and jump in!
Main Lessons I Have LearnedLife is short. I learned how to value my time
and focus.I have learned to be the cookie guy at my
doctor’s office.Learning to have compassion for myself took
a lot of effort but it saved me from going crazy through cancer, multi-drug resistant HIV, multi-drug resistant H-Pylori, back surgeries, IBS, depression and autoimmune nerve disease. What does not kill you makes you stronger.
I never allow the “I will do it tomorrow” voice to take over unless physically impaired.
Long Term HIV Survivors:Are We Facilitators of
Vicarious Resilience?
Every Aging HIV+ Person and Their Physician Needs to Read This Document!
http://www.aahivm.org/hivandagingforum
HIV Aging - Access and Coverage IssuesDEXA scanLipodystrophy therapiesHormone testing and replacementHigh resolution anoscopiesMental health counselingBack to work retraining. Disability counselingNo-stigma retirement facilities Little funding for patient educationCentralized online support group Formulary restrictions/ lack of copay assistance info for
polypharmacyPolypharmacy interactions
ROAH1: 1000 HIV+ NYC Residents Age 50 and Older
Average Number of ComorbiditiesROAH1: 1000 HIV+ NYC Residents Age 50 and Older
Elderly 70+ROAH
00.5
11.5
22.5
33.5
44.5
5
1.1
3.3
Average Age= 55 Years
Brennan et al., 2009 n=1000 NYC HIV+ Over 50
Need for Caregiving: PLWHA 50+ in the U.S.
Cur-rently Need Care19%
Needed Care in
Past19%
Have Not
Needed Care62%
Brennan, M., Karpiak, S. E., London, A. S., & Seidel, L., (2010). A Needs Assessment of Older GMHC Clients Living with HIV. http://www.acria.org/files/GMHCFinal.pdf
•Average Age= 55.5 Years
•Average Number Comorbid Conditions = 3.4
•46% reported difficulty with at least one Instrumental activities of daily living- ADL
•22% reported difficulty with at least one Personal ADL
The Problem:Fragile Social Networks!
• The social networks of older adults living with HIV are fragile – lack of family involvement and reliance on friends, many who are also HIV+
• Fragile social networks result from:– Stigma
• Self-Protective Withdrawal (Emlet, 2006)
• Rejection due to stigmatized behaviors (e.g., drug use, homophobia) (Flowers et al., 2006; Lichtenstein et al., 2002; Mayers & Svartberg, 2001; Trzynka & Erlen, 2004)
– MSM are much less likely to have partner/spouse/children to rely on in times of need
Proportion Living Alone: ROAH vs. Community-Dwelling NYC Elderly
NYC Elderly 65+
ROAH
0% 10% 20% 30% 40% 50% 60% 70% 80%
39%
70%
1 Brennan, M., Karpiak, S. E., Shippy, R. A., & Cantor, M. H. (2009). Older adults with HIV: An in-depth examination of an emerging population. New York: Nova Science Publishers.
Polypharmacy Interactions
% on Non-ART Medication by AgeSwiss Cohort N = 8575
<50 >65 p -value
Anti-Hyper not ACE 5.6 31.3 <0.001
ACE Inhibitors 11.1 32.9 <0.001
Lipid-Lower 12.7 41.8 <0.001
Oral Anti-diabetics 2.1 9.1 <0.001
Insulin 1.4 5.8 <0.001
Anti-platelet 5.8 28.9 <0.001
Anti-depressant 10 7.8 0.659
Hasse et al., ..Swiss HIV Cohort, 2011 CID53:1130-1139
Nelson’s Pill Box
hiv-druginteractions.org
Treatment Considerations for Older Patients with Comorbidities
Slide credit: clinicaloptions.com
Key Interactions: Integrase Inhibitor-Containing ART Regimens Consider www.hiv-druginteractions.org to assist with
identifying potential interactions for all regimens
References in slidenotes.
Regimen Key Drug–Drug Interaction Considerations
All[1-8] Use caution with/avoid polyvalent cation-containing antacids
DTG/3TC/ABC[1]
DTG + FTC/TDF or FTC/TAF[2-4]
Avoid dofetilide (antiarrhythmic) Dose adjust metformin (diabetes medication)
EVG/COBI/FTC/TDF[5]
EVG/COBI/FTC/TAF[6]
Avoid lovastatin, simvastatin (lipid-lowering agents), salmeterol (asthma/COPD medication)
Dose adjust metformin Use caution with hormonal contraceptives
RAL + FTC/TAF or FTC/TAF[7,8] No notable comedications to avoid for RAL aside from aluminum/magnesium antacids
Slide credit: clinicaloptions.com
Key Interactions: Boosted PI- or NNRTI-Containing ART Regimens
References in slidenotes.
Regimen Key Drug–Drug Interactions
ATV/RTV + FTC/TDF or FTC/TAF[1,3-6]
DRV/RTV + FTC/TDF or FTC/TAF[2,3-6]
Avoid lovastatin, simvastatin, atorvastatin*(lipid-lowering agents), simeprevir, elbasvir/grazoprevir (HCV agents), salmeterol (asthma/COPD medication)
Use caution with/avoid specific antiarrhythmics (eg, amiodarone)
Avoid PPIs (eg, omeprazole) with ATV Use caution with/avoid specific glucocorticoids (eg,
budesonide, fluticasone) Use caution with hormonal contraceptives
RPV/FTC/TDF[7]
RPV/FTC/TAF[8]
Avoid PPIs (eg, omeprazole, pantoprazole), dexamethasone
*ATV/RTV only.
Poor CD4 T Cell Recovery Despite HIV Suppression Linked to Increased Morbidity and Mortality
These patients are called “immunological non-responders” (INRs).
As yet, there is no universally accepted definition of INRs (e.g. persistently
below 200, 250 or 350 cells despite 3+ years of HIV suppression).
Depending on the definition, estimates of the proportion of people starting ART
who can be categorized as INRs are typically around 5-20%.
In studies conducted to date, the most consistently reported risk factors for this
outcome are low CD4 T cell counts at the time of ART initiation and older
age.
Several published studies have also reported that INRs have a greater risk of
morbidity and mortality compared to HIV-positive individuals with more
robust CD4 T cell gains.
Immunotherapy in HIV infection: Past and Current Challenges
IL- 2 IL-2 was extensively studied in several phase II and two large phase
III studies. Results from these studies showed that IL-2 significantly increases CD4 counts in the long term. However, this biological effect did not translate into clinical benefit.
IL- 7 Cytheris had ambitious plans to conduct a phase III clinical endpoint
trial in INRs, but went out of business in 2015. The rights to pursue IL-7 as a therapy for HIV-related immune impairment are reportedly now being directed by a collaboration involving the French National Agency for Research on AIDS and Viral Hepatitis (ANRS) and Cognate BioServices. At best, this will certainly delay evaluation of the ability of IL-7 to reduce morbidity and mortality in INRs.
SB-728-T (ZFN-CCR5-gene modification) Research continues into the use of the Sangamo BioSciences
technology to genetically modify CD4+ T cells ex vivo. Like other small companies, Sangamo has not been able to move a product near FDA approval and has shown no interest in pursuing an INR indication after receiving letter from community members advocating for it.
Top Supplements for HIV+ People
Vitamin D (decrease in parathyroid hormone)Whey Protein (increased CD4 cells)Multivitamin (with selenium) (survival)Neuropathy:
Acetyl-L-CarnitineAlpha lipoic acid
SAMe (S-adenosyl-L-methionine) (mood, joint pain, endogenous glutathione)
Coenzyme Q-10 (heart protective. Muscle myopathy protective specially for statin users)
Frailty PreventionExerciseAdequate protein intakeTestosterone ReplacementThyroid ReplacementGrowth Hormone ReplacementCreatine monohydrateWhey proteinVitamin D supplementation + calcium intakeAnabolic agents (nandrolone and oxandrolone)Carnitine and Coenzyme Q10
Commonly Used Medications for Improved Quality of Life in Aging with HIV
Testosterone gels, injections, etc (mood, low libido, fatigue, etc) Thyroid medications (Cytomel, Synthroid, Armour) (fatigue, weight
gain) Modanifil (fatigue) Nandrolone decanoate (muscle loss) Oxandrolone (muscle loss, visceral fat?) Egrifta (abdominal fat) B-12 Injections (stamina?) Trimix (erectile function) PDE5 Inhibitors (erectile function) Testosterone and Thyroid formulations Zolpidem and other sleep aids. Losartan and other ACE and ARB blood pressure meds. PMMA (facial and buttock wasting) IV Nutrients (lack of data but some doctors prescribe them) Metformin (glucose control, abdominal fat?)
(binds testosterone)
Production and Regulationof Testosterone
T = testosteroneOnly 2% is free testosteroneand 98% is bound
Free T2%
SHBG-bound T60%
Albumin-bound T
38%
Adapted from Bagatell CJ, Bremner WJ. N Engl J Med. 1996;334:707-715.
GnRH
LH FSHTestosterone
Testosterone
Sperm
Hypothalamus
Pituitary
Testis
Adapted from Braunstein GD. In: Basic & Clinical Endocrinology. 5th ed. Stamford, Conn: Appleton & Lange; 1997:403-433.
How can one increase testosterone naturally?
Improve sleep quality and hygiene
Nutrition/Weight lossAvoiding environmental toxinsImprove glucose controlExerciseNote: There is no effective over the counter testosterone booster
FDA Approved Testosterone Replacement Products
Newest Testosterone Products
Long Acting
Injectable Testosterone Esters Approved in the U.S.
Compounded Products
Most Commonly Used TRT RegimensTestosterone Cypionate or Enanthate:
200 mg every two weeks100-200 mg very week50-75 mg twice per week
Testosterone Propionate:25-50 mg three times per week
Aveed (testosterone undecanoate)1000 mg every 10 weeks
Testopel pellets (14 pellets every 12 weeks)
Adjunctive: HCG 500IU twice per week to preserve testicular function and/or anastrazole (.5 mg/week) for high estradiol.
Most Men on Androgel and Testim Stop Using Them
Included were 15,435 hypogonadal men, from the Thomson Reuters MarketScan® Database, who had an initial topical testosterone prescription in 2009 and who were followed for 12 months.
What are the health risks associated with low testosterone?Higher Cardiovascular Risks/Mortality
Low FertilityCognitiveMuscoloskeletal (low of lean mass)Increased risk for Diabetes and metabolic syndrome
Quality of life related
TRT ContraindicationsAbsolute contraindications for TRT
include carcinoma of the prostate and the male breast. These cancers are androgen dependent for growth and proliferation.
TRT should be used with caution in older men with enlarged prostates and urinary symptoms, elevated hematocrit, and sleep-related breathing disorders. (PSA should be under 4)
What are the potential side effects of TRT and how can we prevent or manage them?
Polycythemia (20-50% of patients) Blood donations/therapeutic phlebotomy
Lipid changes (decreased HDL at higher TRT doses) Dose adjustment. NAC, Niacin?
Edema (men with comorbidities) Dose adjustment. Anastrazole?, Diuretics
Acne (age <40) Topical creams containing drying agents/antibiotics
Hair loss (age < 40) Topical lotions containing monoxinil, lotanaprost, finasteride, etc
Tachycardia (dose related- rare)Testicular atrophy and low fertility (over 50% of patients)
Human chorionic gonadotropin (HCG)Gynecomastia (rare)
Anastrazole High blood pressure
Weight loss, ACE, ARBsBPH (rare)- Cialis, FlomaxSleep apnea- weight loss, CPAP
TRT Patient Blood Test Monitoring Schedule Initial Blood Test – New Patient
Testosterone, Free & Total (If total T is under 150 ng/dL test for prolactin) PSA LH & FSH Lipids (LDL, HDL, triglycerides) Complete Blood Count ( CMP-white and red blood cells, platelets, etc) Comprehensive metabolic panel (CMP- electrolytes, liver and kidney function) TSH, free T3 (if high TSH, test for thyroid antibodies)
6 or 8 wk Follow up – 6 or 8 weeks after initial RX CBC CMP Testosterone, Free & Total Estradiol, sensitive test TSH
6 Month Follow up – 6 months after initial RX
Testosterone, Free & Total PSA LH & FSH Lipids CBC CMP Estradiol, sensitive test
Annual Blood Test – Same as 6 months
Lowest Cost Blood Tests Online:
LowDesire
Obesity
StressMedications
Alcohol&
Drugs
Heart Disease
Diabetes
Cholesterol
Prolactin
Surgery
Injury
Organ Failure
Low Testosterone
High BloodPressure
Sleep
Courtesy of Dr Turek
Causes of Erectile Dysfunction
When TRT is not enough to fix ED
Free download on ExcelMale.com
Free Download at PoWeRUSA.org
THANK YOU!
QUESTIONS?