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Treatment of dyslipidemias in HIV-infected individuals

[print pdf 107kb] Updated 1/11/06

  1. Baseline Labs
  2. Determine number of risk factors for CHD
  3. For pts with ≥ 2 RF estimate 10-year risk of MI
  4. Lipid goals and treatment decisions
  5. Drug therapy
  6. Antiretroviral therapy associated with dyslipidemias
  7. References

I. Baseline Labs

Obtain fasting (9-12 hours) lipid profile prior to starting ARVs, within 3-6 months of starting new regimen, and yearly unless abnormalities are detected or therapeutic interventions are initiated. On average, non-fasting labs falsely elevate TG by 20-30 and falsely lower LDL by 4- 6. Lipid levels may need to be repeated after fasting for more accurate measurements.

II. Determine number of risk factors for CHD (diabetes is a CHD risk equivalent) and refer to Nutrition/Smoking Cessation

  • Cigarette smoking
  • BP ≥ 140/90 mmHg or on antihypertensive medication
  • HDL < 40 mg/dL (HDL ≥ 60 mg/dL is a "negative" risk factor; removes one risk factor from the total count)
  • Family history of premature CHD (< 55 years in 1st degree male relatives; < 65 years in female 1st degree relatives)
  • Age: men ≥ 45; women ≥ 55

III. For pts with ≥ 2 RF estimate 10-year risk of MI or cardiac death - see table on back or online calculator at http://hin.nhlbi.nih.gov/atpiii/calculator.asp

IV. Lipid goals and treatment decisions (Any pt at high or moderately high risk who has lifestyle-related risk factors is a candidate for Therapeutic Lifestyle Changes (TLC) regardless of LDL level)

Risk category LDL mg/dL
Goal
Initiate TLC
Consider drug therapy
High risk CHD or CHD risk equivalents*§ <100
optional goal
< 70**
≤ 100 ≥ 100
(<100 consider drug options)
Moderately high risk 2+ risk factors(10-yr risk 10% to 20%) < 130
optional goal <100
>130 ≤ 130
100-129: consider drug options
Moderate risk 2+ risk factors (10 yr risk < 10%) <130 ≥ 130 ≥ 160
Lower risk 0-1 risk factor <160 >160 >190
160-189: LDL-lowering drug optional

*CHD risk equivalents: PAD, abdominal aortic aneurysm, symptomatic carotid stenosis, diabetes, and 2+ risk factors with 10-year risk for CHD >20%
** Very high risk pts: existing CVD + multiple RF (esp diabetes), severe & poorly controlled single RF (ie. cont. smoking) or metabolic syndrome; pts with recent ACS are also considered high risk
§ If a high-risk person has high TG or low HDL-cholesterol, may consider adding a fibrate or nicotinic acid with an LDL-lowering drug. When TG >200, non-HDL- cholesterol is a secondary target of therapy, with a goal of 30 higher than the identified LDL goal.

Therapeutic Lifestyle Changes (TLC) Features:

  • TLC Diet: Saturated fat <7% of calories, cholesterol <200 mg/day, consider increased viscous (soluble) fiber (10-25 g/day) and plant stanols/sterols
  • Weight Management
  • Increased physical activity

V. Drug therapy

Elevated LDL only STATIN (pravastatin 40mg QD, atorvastatin 10mg QD or rosuvastatin 5mg QD); All have potential for drug-drug interactions with ARV but less likely than simvastatin or lovastatin
If inadequate response to full dose of statin, (in HIV PI containing regimens: pravastatin max dose 80 mg, atorvastatin max dose 40 mg or rosuvastatin max dose 20mg) may consider adding Niaspan (0.5g QHS for 1 month, then increase by 0.5g monthly up to 1.5-2g QHS) or add a fibrate (gemfibrozil 600mg BID or fenofibrate 160mg QD)
Elevated LDL with TGs 200-500 mg/dL STATIN (pravastatin, atorvastatin or rosuvastatin); alternatives: 1st fibrate, 2nd Niaspan; may consider combining statin with a fibrate or Niaspan if inadequate response to full dose of statin
TGs > 500 mg/dL FIBRATE (gemfibrozil or fenofibrate); alternatives: Niaspan or fish oil (1-2g TID with meals); may consider combining fibrate with niacin or fish oil if inadequate response

Effects of drugs on lipids

LDL HDL TG
Atorvastatin ↓ 38-54% ↑ 0.1-5.5% ↓ 13-25%
Pravastatin ↓ 19-43% ↑ 3-6% ↓ 3-10%
Gemfibrozil ↓↑ 10% ↑ 10-20% ↓ 60%
Fenofibrate ↓↑ 10% ↑ 10-20% ↓ 30-60%
Niacin ↓ 5-25% ↑ 15-35% ↓ 20-50%
Fish oil ↓ 30-60%

Monitoring Labs

When using a statin, obtain LFTs at baseline and at 12 weeks following both the initiation of therapy and dose elevation. Check every 6 months thereafter.

Repeat lipid panel every 6 weeks after the initiation of therapy until LDL goal achieved, then every 4-6 months.

VI. Antiretroviral therapy associated with dyslipidemias

In one study, Protease inhibitor based regimens were associated with fasting TG inc of 50%, TC and LCL inc 10% and no change in HDL-cholesterol compared to non-PI based regimens. Atazanavir has a more favorable effect on all lipid parameters. Stavudine has been variably associated with increases in fasting TG, TC and LDL. Nevirapine has superior lipid profile to efavirenz.

VII. References:

Cannon CP, Intensive versus moderate lipid lowering after acute coronary syndromes, NEJM 2004; 350:1495-504

Heart Protection Study Collaborative Group, MRC/BHF Heart Protective Study of cholesterol lowering with simvastatin, Lancet 2002; 360:7-22.

NCEP Report: Implications of Recent Clinical Trials for the National Cholesterol Education Program Adult Treatment Panel III Guidelines Circulation 2004;110:227-239 or http://www.nhlbi.nih.gov/guidelines/cholesterol/

Guidelines for the Evaluation and Management of Dyslipidemia in Human Immunodeficiency Virus (HIV)- Infected Adults Receiving Antiretroviral Therapy: Recommendations of the HIV Medicine Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trials Group CID 2003;37: 613-627.

Estimates of 10-year Risk for Men and Women

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