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A Randomized Controlled Trial

Colleen Hadigan, MD; Colleen Corcoran, NP; Nesli Basgoz, MD; Benjamin Davis, MD; Paul Sax, MD; Steven Grinspoon, MD

JAMA. 2000;284:472-477.

Context  A syndrome of lipodystrophy, characterized by fat redistribution and insulin resistance, has been estimated to affect the majority of human immunodeficiency virus (HIV)–infected individuals who are treated with combination antiretroviral therapy. There are no proven therapies for the metabolic disturbances associated with HIV lipodystrophy syndrome.

Objective  To determine the safety and efficacy of metformin therapy in HIV-infected patients with fat redistribution and abnormal glucose homeostasis.

Design and Setting  Randomized, double-blind, placebo-controlled pilot study conducted in a university hospital between December 1998 and January 2000.

Patients  Twenty-six HIV-infected, nondiabetic patients with fat redistribution and abnormal oral glucose tolerance test (OGTT) results, hyperinsulinemia, or both.

Interventions  Patients were randomly assigned to receive metformin, 500 mg twice daily (n = 14), or identical placebo (n = 12), for 3 months.

Main Outcome Measures  Insulin area under the curve (AUC), calculated 120 minutes following a 75-g OGTT at baseline vs at 3-month follow-up and compared between treatment groups.

Results  Patients treated with metformin demonstrated significant reductions in mean (SEM) insulin AUC 120 minutes after OGTT (-2930 [912] vs -414 [432] µIU/mL [-20349 {6334} vs -2875 {3000} pmol/L]; P = .01), weight (-1.3 [0.6] vs 1.1 [0.4] kg; P = .005), and diastolic blood pressure (-5 [4] vs 5 [2] mm Hg; P = .009) vs controls, respectively. Metformin therapy was associated with a decrease in visceral abdominal fat (VAT; -1115 [819] vs 1191 [699] mm²; P = .08) and a proportional reduction in subcutaneous abdominal fat (SAT); the VAT-SAT ratio was unchanged in metformin-treated vs placebo-treated patients. No increase in lactate or liver transaminase levels was observed with metformin treatment. Mild diarrhea was the most common adverse effect of metformin. No patient discontinued therapy because of adverse effects.

Conclusions  This study suggests that a relatively low dosage of metformin reduces insulin resistance and related cardiovascular risk parameters in HIV-infected patients with lipodystrophy.

Author Affiliations: Neuroendocrine Unit (Drs Hadigan and Grinspoon and Ms Corcoran) and Infectious Disease Unit (Drs Basgoz and Davis), Massachusetts General Hospital, and the Combined Program in Pediatric Gastroenterology and Nutrition (Dr Hadigan) and Division of Infectious Diseases, Brigham and Women's Hospital (Dr Sax), Harvard Medical School, Boston.

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