Drug therapies for HIV-related metabolic disorders

ABSTRACT

Introduction: Human immunodeficiency virus (HIV) has become a chronic disease often associated with dyslipidaemia and insulin resistance. Combination antiretroviral therapy (cART) may contribute to metabolic disturbances, eventually leading to increased cardiovascular disease (CVR) in this population.

Escalating interventions to decrease CVR include promoting a healthy lifestyle, such as quitting smoking, diet and regular exercise. If they do not achieve the goals, a change of cART should be considered, followed by or used concomitantly with the use of chemical therapies.

Areas covered: The aim of this article is to review the available drug therapies for the treatment of metabolic disorders in HIV-infected patients and to examine their safety and effectiveness in this population. A review of the literature was conducted, highlighting the most relevant articles.

Expert opinion: Switching strategies can be useful but its expected benefit is not high. Therefore, chemical intervention is often needed. Statins have been proven to reduce CVR in the general population and in HIV-infected patients. Simvastatin is contraindicated in patients treated with boosted PI due to interactions; atorvastatin is safe at submaximal dose and needs close monitoring, while pravastatin lacks lipid-lowering potency, and rosuvastatin and pitavastatin are safe. Ezetimibe and fibrates are also safe and effective in HIV-infected patients and can be used in combination with statins. The management of glucose homeostatic disorders in HIV-infected patients follows the same guidelines as in the general population. However, there are specific considerations with respect to the interactions of particular medications with cART. When drug therapy is needed, metformin is the first-line drug. Decisions regarding second- and third-line drugs should be carefully individualized.

KEYWORDS:

• Combination antiretroviral therapy
• metabolic complications
• cardiovascular risk
• statins
• fibrates
• ezetimibe
• metformin

Article highlights

• Statins have a higher lipid-lowering potential than antiretroviral drug switching

• Statin use decreases cardiovascular risk in HIV-infected patients

• Rosuvastatin and pitavastatin are the most powerdul statins and have a good safety profile.

• Ezetimibe is an alternative or adjuvant drug for the treatment of hypercholesterolaemia

• Fibrates are safe and useful to control HIV-associated hypertriglyceridemia

• Glucose homoeostatic disorders in HIV-infected patients should be managed as in the general population

• Potentially harmful interactions may arise when statins are used concomitantly with boosted protease inhibitors

This box summarizes key points contained in the article.

Declaration of interest

This work has been partially funded by Fondo de Investigaciones Sanitarias (PI11/00376, and PI13/0796 and PI14/00700), Instituto de Salud Carlos III, Ministerio de Sanidad, Politica Social e Igualdad (EC11-293), Programa de Suport als Grups de Recerca AGAUR (2009 SGR 1061), and Red de Investigación en SIDA (RIS RD012/0017/0014, RD12/0017/0005). Pere Domingo and Francesc Vidal are supported by grants from the Programa de Intensificación de Investigadores, Instituto de Salud Carlos III (INT13/232, INT15/00140, and INT15/00226). 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.