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Screening for and Managing Dyslipidemia in People With HIV

April 20, 2017

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Abstract: Guidelines recommend measuring lipids when HIV-positive people enter care, before antiretroviral therapy, and regularly after therapy begins. Recent data indicate success with lifestyle changes that can improve lipids and lower cardiovascular risk, including simple dietary steps and an effective online smoking cessation program for people with HIV. When to start drug therapy for dyslipidemia depends on both lipid levels and coronary heart disease risk. Among people with HIV, the main lipid disorder is high triglycerides with low high-density lipoprotein cholesterol (HDL-C). Triglycerides above 500 mg/dL should generally be addressed before abnormal cholesterol levels. Statins aim to lower low-density lipoprotein cholesterol (LDL-C) and may have anti-inflammatory benefits in people with HIV. Research confirms that statins lower cardiovascular event risk in the general population. Atorvastatin and rosuvastatin are preferred high-intensity statins. Pitavastatin has a good pharmacokinetic profile, even with HIV protease inhibitors, but it ranks as a low- or moderate-intensity statin. Fibrates, niacin, and omega-3 fatty acids have roles for some dyslipidemic people with HIV. Fibrates and omega-3 fatty acids are the preferred agents for isolated high triglycerides. Treatment of dyslipidemia may not attain atherogenic cholesterol goals in all patients, but there are incremental benefits in lowering non-HDL-C and LDL-C toward target levels.


HIV care guidelines recommend close lipid monitoring in people with HIV. Department of Health and Human Services (DHHS) HIV treatment guidelines for adults and adolescents recommend regular fasting lipid measures:1

  • First patient visit
  • When starting or changing antiretroviral therapy (ART)
  • Every 6 months if the last measures had an abnormal result
  • Every 12 months if the last measures were normal

Other HIV guidelines suggest some wrinkles to this plan. IDSA/HIVMA experts advise retesting lipids 1 to 3 months after starting ART.2 HRSA HIV guidelines suggest monitoring as often as every 4 to 6 weeks in people with dyslipidemia, until the low-density lipoprotein cholesterol (LDL-C) goal is met, then every 4 to 6 months.3 However, dyslipidemia in many people with HIV entails high triglycerides and low high-density lipoprotein cholesterol (HDL-C) rather than high LDL-C. And a portion of HIV-positive people who do have high LDL-C never reach their target with therapy.


Managing Dyslipidemia With HIV: Where to Start

When planning how to treat dyslipidemia in people with HIV, DHHS guidelines1 recommend consulting current National Lipid Association (NLA) advice.4 That's a logical place to start -- and a logical place to continue, now that part 2 of the NLA tract offers a special section on people with HIV.5

NLA guidance on starting antilipid drug therapy in the general population combines two variables: (1) level of LDL-C or non-HDL-C, and (2) an atherosclerotic cardiovascular disease (ASCVD) risk score.4 (See Table 1 footnote for ASCVD risk factors.) Based on this detailed advice, HRSA HIV guidelines offer a simplified scheme suggesting when to start lifestyle interventions and when to consider drug therapy (Table 1).3 In people with high triglycerides -- a frequent lipid problem in people with HIV -- HRSA recommends drug therapy to get triglycerides below 500 mg/dL to prevent pancreatitis, then focusing on LDL-C (Table 2).


Table 1. HRSA Guidelines on Managing High LDL-C With HIV3
Risk CategoryLDL-C GoalStart Therapeutic Lifestyle ChangesConsider Drug Therapy
Lower risk:
No CHD or CHD risk equivalents* and 0-1 risk factors†
<160 mg/dL (<4.1 mmol/L)LDL-C ≥160 mg/dL (>4.1 mmol/L)LDL-C ≥190 mg/dL (≥4.9 mmol/L); drug therapy optional at 160-189 mg/dL
Moderate risk:
No CHD or CHD risk equivalents and ≥2 risk factors and 10-y estimated risk <10%
<130 mg/dL (<3.4 mmol/L)LDL-C ≥130 mg/dL (≥3.4 mmol/L)LDL-C ≥160 mg/dL (≥4.1 mmol/L)
Moderately high risk:
No CHD or CHD risk equivalents and ≥2 risk factors and 10-y estimated risk 10-20%
<130 mg/dL (<3.4 mmol/L)
Optional goal <100 mg/dL
LDL-C ≥130 mg/dL (≥3.4 mmol/L)LDL-C ≥130 mg/dL (≥3.4 mmol/L)
High risk:
CHD or CHD risk equivalent
<100 mg/dL (<2.6 mmol/L)
Optional goal <70 mg/dL‡)
LDL-C ≥100 mg/dL (≥2.6 mmol/L)LDL-C ≥100 mg/dL (≥2.6 mmol/L)

CHD, coronary heart disease; LDL-C, low-density lipoprotein cholesterol.

* Risk equivalents are diabetes, peripheral vascular disease, symptomatic carotid artery disease, abdominal aortic aneurysm, transient ischemic attack, and ≥2 CHD risk factors with a 10-year CHD risk >20%.

† Risk factors are male sex; age ≥45 in men, ≥55 in women; current cigarette smoking; family history of CHD <55 years of age in male first-degree relative, <65 in female first-degree relative; blood pressure ≥140/90 mm Hg or blood pressure medication; HDL-C <40 mg/dL in men, <50 mg/dL in women.

‡ Goal preferred by many cardiologists for people with CHD or CHD risk equivalents.


Table 2. HRSA Guidelines on Managing High Triglycerides With HIV3
Risk CategoryTriglyceride LevelBegin Therapy
Normal triglycerides<150 mg/dL 
Borderline high triglycerides150-199 mg/dL* 
High triglycerides200-499 mg/dLStart therapeutic lifestyle changes; consider drug therapy for people with CHD, CHD equivalents,† or high risk
Very high triglycerides≥500 mg/dLStart therapeutic lifestyle changes; consider drug therapy

CHD, coronary heart disease.

* Some experts recommend lifestyle intervention in this range. See Myerson et al. in "Some worthy HIV lipid management reviews."

† Risk equivalents are diabetes, peripheral vascular disease, symptomatic carotid artery disease, abdominal aortic aneurysm, transient ischemic attack, and ≥2 CHD risk factors with a 10-year CHD risk >20%.


So much has been written -- and continues to be written -- about managing dyslipidemia in people with HIV that one could easily fill several issues of RITA dissecting it. Rather than attempting such a feat, this review will offer selected insights into lifestyle changes and treatment with statins and other medications, while pointing readers to current worthy reviews (see "Some Worthy HIV Lipid Management Reviews", below).


Some Worthy HIV Lipid Management Reviews

General Population

Jacobson TA, Ito MK, Maki KC, et al. National Lipid Association recommendations for patient-centered management of dyslipidemia: part 1 -- full report. J Clin Lipidol. 2015;9:129-169. www.lipidjournal.com/article/S1933-2874(15)00059-8/pdf

Jacobson TA, Maki KC, Orringer CE, et al. National Lipid Association recommendations for patientcentered management of dyslipidemia: part 2. J Clin Lipidol. 2015;9(6 Suppl):S1-122. www.lipidjournal.com/article/S1933-2874(15)00380-3/pdf

Includes section on HIV infection.


HIV-Specific

Myerson M, Malvestutto C, Aberg JA. Management of lipid disorders in patients living with HIV. J Clin Pharmacol. 2015;55:957-974. http://onlinelibrary.wiley.com/doi/10.1002/jcph.473/epdf

Eckard AR, McComsey GA. The role of statins in the setting of HIV infection. Curr HIV/AIDS Rep. 2015;12:305-312. www.ncbi.nlm.nih.gov/pmc/articles/PMC4860807/pdf/nihms780235.pdf

da Cunha J, Maselli LM, Stern AC, Spada C, Bydlowski SP. Impact of antiretroviral therapy on lipid metabolism of human immunodeficiency virus-infected patients: Old and new drugs. World J Virol. 2015;4:56-77. www.wjgnet.com/2220-3249/full/v4/i2/56.htm


Changing Lifestyles to Change Lives

More than a few clinicians cringe at entreaties to start lipid management with lifestyle modifications. It's so much easier to start a statin -- but also much riskier to put a patient on a potentially lifelong therapy that carries its own risks and interacts with antiretrovirals and many other drugs. Getting people to exercise, adopt a healthy diet, and quit smoking can be tough, but statistics show it can be done.

  • Quitting smoking has a huge HIV cardio impact.
    Smoking lowers HDL-C6 and heightens the cardiovascular risk conferred by dyslipidemia. Analysis of 29,515 HIV-positive North Americans determined that if these people never smoked, they would avert 38% of lifetime myocardial infarctions.7
  • Many smokers quit for good.
    In the United States smokers make up 42% of the HIV population but only 21% of the general population.8 Yet this 419,945-person analysis counted lots of quitters in the HIV contingent: 1 in 5 had stopped smoking. And the general U.S. population now has more former smokers than current smokers.9
  • Effective online quitting tool for HIV smokers.
    An 8-session online interactive program designed for people with HIV, Positively Smoke Free,10 is already helping HIV-positive people quit.11
  • Quick-and-easy dietary do-list.
    For clinicians who work with a good dietician, referring HIV-positive people with bad diets or poor weight control makes lots of sense. But for providers without a savvy diet planner at their elbow, quick-and-easy eating pointers could help. And a bounty of such tips just arrived from a big analysis by the U.S. National Health and Nutrition Examination Surveys (NHANES) (Figure 1).12 A comparative risk assessment model incorporating data on population demographics and dietary habits figured that the biggest fractions of diet-related cardiometabolic deaths could be traced to too much sodium, too few nuts/seeds, too many processed meats, not enough seafood omega-3 fats, too few vegetables, too few fruits, and too many sugar-sweetened drinks.


Impact of Dietary Factors on Cardiometabolic Death

Figure 1. Impact of Dietary Factors on Cardiometabolic Death

Figure 1. Analysis of the National Health and Nutrition Examination Surveys (NHANES) determined that seven dietary factors accounted for similar proportions of all cardiometabolic deaths in the general U.S. population.12


  • Saturated fat intake is triglyceride culprit in HIV group.
    A comparison of 356 people with HIV and metabolic problems (55% men, 44% nonwhite) and 162 HIV-negative community-dwelling individuals found significantly greater intake of total fat, saturated fat, cholesterol, and calories from saturated fat and trans fat in the HIV group.13 Saturated fat intake correlated positively with triglycerides, which were 8.7 mg/dL higher with every additional gram of saturated fat. Total fat intake was inversely associated with triglyceride level.
  • Quarterly dietary follow-up prevents dyslipidemia with ART.
    A National Cholesterol Education Program diet with follow-up every 3 months maintained total cholesterol and LDL-C while lowering triglycerides in a small open-label randomized trial of people starting ART in Brazil.14 After 1 year of follow-up, 21% of people in the diet group compared with 68% in the control group, which got general dietary counseling without follow-up,15 had a lipid profile indicating dyslipidemia (P < 0.001). Fat intake fell in the diet group but not in the control group.
  • How much exercise has a lipid impact?
    The National Lipid Association recommends 150 minutes of moderate to higher intensity aerobic activity weekly to lower triglycerides and sometimes raise HDL-C.5 Boosting that level to 200 to 300 minutes per week can improve triglycerides, HDL-C, and LDL-C while trimming body fat and weight.
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Dyslipidemia With HIV: High Prevalence, Multiple Risks
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This article was provided by The Center for AIDS Information & Advocacy. It is a part of the publication Research Initiative/Treatment Action!. Visit CFA's website to find out more about their activities and publications.
 

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