April 20, 2017
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
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.
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 Category||LDL-C Goal||Start Therapeutic Lifestyle Changes||Consider Drug Therapy|
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|
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)|
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 Category||Triglyceride Level||Begin Therapy|
|Normal triglycerides||<150 mg/dL|
|Borderline high triglycerides||150-199 mg/dL*|
|High triglycerides||200-499 mg/dL||Start therapeutic lifestyle changes; consider drug therapy for people with CHD, CHD equivalents,† or high risk|
|Very high triglycerides||≥500 mg/dL||Start 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|
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.
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
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.
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
|Dyslipidemia With HIV: High Prevalence, Multiple Risks|
|Some Keys to Dyslipidemia Care in People With HIV|
|Lipid Impact on HIV Heart Disease and Antiretroviral Impact on Lipids|
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