Managing dyslipidemia in HIV/AIDS patients: challenges and solutions

Figures & data

Table 1 Summary of some studies showing association between HIV and CVD

Type of study	Description of the study	Main outcome	Reference
Prospective observational study: Data Collection on Adverse Events of Anti-HIV Drugs (DAD Study)	Investigation of the impact of diabetes and preexisting CHD on the development of a new CHD episode among 33,347 HIV-infected individuals	The rate of CHD episodes was 7.52 times higher in those with preexisting CHD than in those without preexisting CHD, but it was only 2.41 times higher in those with preexisting DM compared with those without DM.	^Citation22
Prospective observational study	Data from the DAD Study	Increase in prevalence of metabolic syndrome from 19.4% in 2000–2001 to 41.6% in 2006–2007.	^Citation23
Cohort study	Health care system-based cohort study using a large data registry with 3,851 HIV and 1,044,589 non-HIV patients	Acute myocardial infarction rates were increased in HIV versus non-HIV patients, particularly among women. The HIV cohort had significantly higher proportions of hypertension, diabetes, and dyslipidemia than the non-HIV cohort.	^Citation24
Prospective observational study	Data from 23,437 patients infected with the human immunodeficiency virus	The incidence of myocardial infarction increased from 1.53 per 1,000 person-years in those not exposed to protease inhibitors to 6.01 per 1,000 person-years in those exposed to protease inhibitors for more than 6 years. The relative rate of myocardial infarction per year of protease-inhibitor exposure was 1.16, whereas the relative rate per year of exposure to nonnucleoside reverse-transcriptase inhibitors was 1.05. Increased exposure to protease inhibitors is associated with an increased risk of myocardial infarction, which is partly explained by dyslipidemia.	^Citation25

Abbreviations: HIV, human immunodeficiency virus; CVD, cardiovascular disease; CHD, coronary heart disease; DM, diabetes mellitus.

Table 2 Summary of the effect of different statins and other lipid-lowering medications

Lipid-lowering medication	Main recommendation	References
Simvastatin and lovastatin	The HIV Medicine Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trial Group recommended that simvastatin and lovastatin should not be given to patients taking PIs or delavirdine. This was also endorsed by the International AIDS Society USA Panel, which recommended that concomitant use of lovastatin or simvastatin with protease inhibitors or HAART is contraindicated.	^Citation74^–^Citation80
Atorvastatin	The HIV Medicine Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trial Group and International AIDS Society USA panel advised that atorvastatin is recommended as a first-line agent for high LDL-C, with a starting dose of atorvastatin 10 mg once daily. Caution is needed when combined with fenofibrate. In certain conditions, administration of atorvastatin (with clarithromycin and lopinavir/ritonavir, delavirdine) was associated with rhabdomyolysis.	^Citation15,Citation17,Citation81
Pravastatin	Pravastatin is recommended as first line in the management of HIV dyslipidemia. Interestingly, the combination therapy with fenofibrate and pravastatin for HIV-related dyslipidemia provides substantial improvements in lipid parameters and appears safe. The International AIDS Society USA panel recommended pravastatin and atorvastatin as first-line agents.	^Citation82^–^Citation85
Rosuvastatin	Rosuvastatin is not metabolized by CYP3A4 and is eliminated through feces. Interestingly, rosuvastatin 10 mg/day was more effective than pravastatin 40 mg/day on LDL-C and triglyceride levels in HIV-1-infected patients receiving a boosted protease inhibitor. Interestingly, rosuvastatin and atorvastatin are preferable to pravastatin, due to greater declines in total cholesterol, LDL-C, and non-HDL-C.	^Citation86^–^Citation91
Fluvastatin	The recommendations of the HIV Association of the Infectious Disease Society of America and Adult AIDS Clinical Trials Group, were that fluvastatin was a reasonable alternative to atorvastatin and pravastatin for patients on protease inhibitors.	^Citation78,Citation92,Citation93
Ezetimibe	Ezetimibe as monotherapy is an effective and safe lipid-lowering medication in HIV dyslipidemia, and also can be used in those with poor response to statin. In addition, the combination of statin and ezetimibe is also effective and safe lipid lowering medication in HIV-dyslipidaemia.	^Citation94^–^Citation99
Fenofibrate	Fenofibrate is a generally safe and useful agent for the treatment of mixed dyslipidemia and hypertriglyceridemia in people with HIV infection. The combination of pravastatin, fish oil, and niacin with fenofibrate appears to be safe and effective.	^Citation85,Citation100^–^Citation107
Niacin	In two studies, niacin was effective and safe in improving lipid profile in HIV patients.	^Citation108^–^Citation110

Abbreviations: PIs, protease inhibitors; HAART, highly active antiretroviral therapy; LDL-C, low-density lipid cholesterol; HIV, human immunodeficiency virus; CYP3A4, cytochrome P450 3A4; HDL-C, high-density lipid cholesterol; AIDS, acquired immunodeficiency syndrome.

Figure 1 Illustration of different potential factors that lead hyperlipidemia with HIV and associated increase in risk of CVD.

Abbreviations: HIV, human immunodeficiency virus; CVD, cardiovascular disease; CKD, chronic kidney disease; NAFLD, nonalcoholic fatty liver disease.

Figure 2 Illustration showing possible summary of current guidelines for the management of HIV dyslipidemia. Aging populations will need special consideration with regard to adjustment for lipid-lowering medication.

Abbreviations: HIV, human immunodeficiency virus; TFT, thyroid-function test; CK, creatine kinase; LFT, liver-function test; NAFLD, nonalcoholic fatty liver disease; US, ultrasonography; TG, triglyceride; TC, total cholesterol; LDL, low-density lipid; LH, luteinizing hormone; FSH, follicle-stimulating hormone.

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