Statin Therapy for 1 Year Linked to Gains in Bone Density With HIV

What the Results Mean for You

This well-planned trial of rosuvastatin versus placebo in people with HIV found that 48 weeks of statin therapy increased hip and trochanter bone mineral density, while bone density fell at those sites in HIV-positive people taking placebo (a dummy pill). Clinicians prescribe statins to lower dangerously high cholesterol. The relatively small gains in bone mineral density seen with rosuvastatin in this trial do not support use of statins for bone health alone. But the study suggests that HIV-positive people taking a statin to lower cholesterol could get the added benefit of small gains in bone mineral density -- which is better than the continuing loss of bone density seen among people not taking statin.

The trial also showed that people taking rosuvastatin for 48 weeks gained total lean mass and leg lean mass. Fat mass also increased slightly but not significantly in people taking rosuvastatin. These findings suggest that statins may contribute to improved body composition in people with HIV.

Falling bone mineral density is a well-recognized problem in people with HIV infection. Bone density drops with age, and people responding well to antiretroviral therapy are now living as long or almost as long as people in the general population. HIV-positive people also have high rates of other risk factors for osteopenia and osteoporosis:

• Smoking
• Hepatitis C virus infection
• Low weight
• Physical inactivity
• Diet low in calcium

People with low bone density run a higher risk of fractures (broken bones), and several studies of HIV groups found higher fracture rates in people with HIV than in those without HIV.^8-11 Therefore, finding ways to slow or reverse bone loss has become a priority in people with HIV. Combined analysis of eight studies in the general population found that statins protect against fractures.¹² But statins did not lower fracture rates in a separate study of people with HIV¹³ or in a placebo-controlled trial including almost 18,000 men over 50 and women over 60 in the general population.¹⁴ The researchers who conducted the rosuvastatin study observed that larger and longer studies are needed to tell whether statin therapy helps people with HIV avoid fractures.

Statins can cause muscle pain in a few people. One person in this study stopped rosuvastatin because of muscle pain that required hospital admission; 2 people assigned to placebo dropped out of the study because of muscle pain.

US HIV care guidelines recommend statin therapy for HIV-positive adults with (1) high LDL cholesterol (at or above 190 mg/dL) or (2) high LDL cholesterol plus triglycerides between 200 and 500 mg/dL.¹⁵ Guidelines for bone health in people with HIV say providers should use FRAX (without DXA) to assess fracture risk in (1) all HIV-positive men 40 to 49 years old, and (2) all HIV-positive premenopausal women at least 40 years old.¹⁶ These guidelines recommend DXA scans for HIV-positive men 50 and older, postmenopausal women, people who have had a fragility fracture, people taking glucocorticoids (steroid hormones), and people with a high risk of falls.

References

1. Erlandson KM, Jiang Y, Debanne SM, McComsey GA. Effects of randomized rosuvastatin compared with placebo on bone and body composition among HIV-infected adults. AIDS. 2015;29:175-182.
2. Islam FM, Wu J, Jansson J, Wilson DP. Relative risk of cardiovascular disease among people living with HIV: a systematic review and meta-analysis. HIV Med. 2012;13:453-468.
3. Lo J, Lu MT, Ihenachor EJ, et al. Effects of statin therapy on coronary artery plaque volume and high-risk plaque morphology in HIV-infected patients with subclinical atherosclerosis: a randomised, double-blind, placebo-controlled trial. Lancet HIV. 2015;2:e52-e63.
4. Eckard AR, Jiang Y, Debanne SM, Funderburg NT, McComsey GA. Effect of 24 weeks of statin therapy on systemic and vascular inflammation in HIV-infected subjects receiving antiretroviral therapy. J Infect Dis. 2014;209:1156-1164.
5. Funderburg NT, Jiang Y, Debanne SM, et al. Rosuvastatin treatment reduces markers of monocyte activation in HIV-infected subjects on antiretroviral therapy. Clin Infect Dis. 2014;58:588-595.
6. Erlandson KM, O'Riordan M, Labbato D, McComsey GA. Relationships between inflammation, immune activation, and bone health among HIV-infected adults on stable antiretroviral therapy. J Acquir Immune Defic Syndr. 2014;65:290-298.
7. Longenecker CT, Funderburg NT, Jiang Y, et al. Markers of inflammation and CD8 T-cell activation, but not monocyte activation, are associated with subclinical carotid artery disease in HIV-infected individuals. HIV Med. 2013;14:385-390.
8. Prieto-Alhambra D, Güerri-Fernández R, De Vries F, et al. HIV infection and its association with an excess risk of clinical fractures: a nationwide case-control study. J Acquir Immune Defic Syndr. 2014;66:90-95.
9. Hansen AB, Gerstoft J, Kronborg G, et al. Incidence of low and high-energy fractures in persons with and without HIV infection: a Danish population-based cohort study. AIDS. 2012;26:285-293.
10. Peters BS, Perry M, Wierzbicki AS, et al. A cross-sectional randomised study of fracture risk in people with HIV infection in the PROBONO 1 study. PLoS One. 2013;8:e78048.
11. Womack JA, Goulet JL, Gibert C, et al. Increased risk of fragility fractures among HIV infected compared to uninfected male veterans. PLoS One. 2011;6:e17217.
12. Bauer DC, Mundy GR, Jamal SA, et al. Use of statins and fracture: results of 4 prospective studies and cumulative meta-analysis of observational studies and controlled trials. Arch Intern Med. 2004;164:146-152.
13. Overton ET, Kitch D, Benson CA, et al. Effect of statin therapy in reducing the risk of serious non-AIDS-defining events and nonaccidental death. Clin Infect Dis. 2013;56:1471-1479.
14. Peña JM, Aspberg S, MacFadyen J, Glynn RJ, Solomon DH, Ridker PM. Statin therapy and risk of fracture: results from the JUPITER randomized clinical trial. JAMA Intern Med. 2015;175:171-177.
15. US Department of Health and Human Services Health Resources and Services Administration. Guide for HIV/AIDS Clinical Care. April 2014.
16. Brown TT, Hoy J, Borderi M, et al. Recommendations for evaluation and management of bone disease in HIV. Clin Infect Dis. Published online January 21, 2015.