Current pharmacotherapy for the treatment of dyslipidemia associated with HIV infection

ABSTRACT

Introduction: Cardiovascular disease is an important cause of morbidity and mortality in persons with human immunodeficiency virus (PWH). The risk of atherosclerotic cardiovascular disease (ASCVD) is higher in PWH compared to uninfected persons. Dyslipidemia is a critical link in the pathogenesis of ASCVD in PWH. Chronic inflammation associated with HIV infection may drive both dyslipidemia and ASCVD.

Areas covered: The authors review the evidence for using lipid-lowering therapy in PWH and includes an overview of the utility and complexity of using statins in PWH, in particular, drug interactions, safety, and efficacy. In addition, data covering alternate therapies like omega-3 fatty acids, fibrates, niacin, ezetimibe, and PCSK-9 inhibitors are reviewed.

Expert opinion: Dyslipidemia is a common problem in PWH. The risk of ASCVD is higher in PWH. Lipid-lowering therapy reduces the risk of ASCVD, but clinical endpoint trials are lacking in PWH. Statin therapy is the mainstay of primary prevention for ASCVD. The timing of when to initiate primary prevention with statins in PWH is unclear. Beyond statins, there are limited data that other lipid-lowering agents have utility in PWH. Ongoing trials like the REPRIEVE trial will inform the community about the optimal approach to lipid-lowering therapy in PWH.

KEYWORDS:

• Dyslipidemia
• HIV
• HMG-CoA reductase inhibitors
• statins
• PCSK-9 inhibitors

Article highlights

• Dyslipidemia is associated with HIV infection and many of the antiretroviral agents used to HIV.

• Dyslipidemia is an important risk factor associated with the development of cardiovascular disease that is 1.5-2.0 fold higher in persons with HIV compared to uninfected persons.

• HMG-CoA reductase inhibitors or Statins are effective in lowering cholesterol and low-density lipoprotein-cholesterol but have not been demonstrated to reduce cardiovascular events in randomized controlled trials of persons with HIV infection.

• Statins have a number of significant drug–drug interactions with antiretroviral agents.

• PCSK-9 inhibitors are a newer class of lipid-lowering agents that may have some value in treating dyslipidemia in persons with HIV infection though there is little-published information to date.

This box summarizes the key points contained in the article.

Declaration of interest

C Fichtenbaum has received research grant support via his institution from Janssen Pharmaceuticals, Merck & CO, ViiV Healthcare, Gilead Sciences, and Amgen Inc. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer Reviewers on this manuscript have no financial or other relationships to disclose.

Additional information

Funding

This manuscript is funded in part by support from the National Institute of Allergy and Infectious Diseases [grant no. AI-069501].