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Dyslipidemia and HIV

for Health Care Providers

Dyslipidemia

Note: Some medications mentioned in this chapter may not be available on the VHA National Formulary. Consult VA pharmacists for alternatives.

Key Points

  • Dyslipidemia is a well-described risk factor for CV disease, and occurs in a high proportion of patients with HIV infection.
  • Both HIV infection itself and ARV medications may cause lipid abnormalities.
  • Other risk factors for CV disease are common in HIV-infected populations:
    • Other metabolic abnormalities (eg, insulin resistance and diabetes, which may be caused or exacerbated by ARV medications)
    • Hypertension
    • Smoking
    • Inactivity
  • Patients should be treated for dyslipidemia based on their lipid levels and other risk factors for CV disease.
  • LDL cholesterol is the primary target for lipid-lowering therapy.
  • Some lipid-lowering medications are contraindicated for use with ARV medications, and others require dosage adjustment.

Background

  • Dyslipidemia is an important risk factor for CV disease, and occurs in a high proportion of people with HIV infection. As advances in ART extend the life spans of people with HIV infection, it is likely that morbidity and mortality from CV disease will increase. It is important to identify patients' CV risk factors and to reduce those that are modifiable.
  • CV risk is associated with:
    • Elevated LDL and TC
    • Low HDL
    • Elevated TG

Of these, elevated LDL is most closely linked to CV risk, and usually is the primary target of therapeutic interventions.

  • Dyslipidemia is associated both with HIV infection itself and with ARV medications. Accumulating data suggest that both HIV infection and certain ARV medications may increase the risk of CV disease, independent of their effects on lipids.
  • Patients with untreated HIV infection commonly show:
    • ↓ TC
    • ↓ LDL cholesterol
    • ↓ HDL cholesterol
    • ↓ TG
  • Patients treated with ARV medications commonly show:
    • ↑ TC, LDL, and TG levels
    • Low HDL
  • Dyslipidemia among patients taking ARV medications probably is related to multiple factors, including:
    • Individual patient characteristics
    • HIV infection itself
    • ARV medications
  • Certain agents in each of the 3 major classes of ARVs may cause lipid abnormalities.
    • PIs: may markedly ↑ TC, LDL, and TG levels (particularly RTV and RTV-boosted PIs; unboosted ATV does not typically affect lipids)
    • NNRTIs: effects are more variable, particularly with EFV; NVP and ETR are less likely to cause abnormalities. NNRTIs may ↑ TC, LDL, and TG
    • NRTIs: d4T may ↑ TC and TG
    • Fusion inhibitors, CCR5 antagonists, integrase inhibitors: not associated with dyslipidemia
  • For patients with CHD or CHD risk equivalents (see below), if possible, select ARV regimen to minimize the risk of dyslipidemia.

Veterans with HIV*

Dyslipidemia: 38%

Ischemic heart disease: 11%

Hypertension: 45%

Diabetes, Type 2: 15%

Tobacco use: 38%

*Veterans in the VA HIV Clinical Case Registry in care in 2007 who had an ICD-9 code corresponding to these conditions

Screening

  • Check fasting lipids before starting ART.
  • Check fasting lipids 1-3 months after starting or changing ARVs.
    • If normal: screen at least once per year
    • If abnormal: monitor closely until LDL goal is achieved

Evaluation

Note: The following recommendations are based on National Cholesterol Education Program (NCEP) guidelinesLink will take you outside the VA website. for the evaluation and management of dyslipidemia. These are widely used, but have not been validated in HIV-infected patients.

History

The need for lipid management is based on lipid levels and on risk factors for coronary artery disease events. In the history, focus on factors that suggest CHD, CHD equivalents, or CV risk.

  • CHD risk equivalent: considered equal in risk to known CHD
  • CHD risk factor: a condition associated with greater risk of serious cardiac events
CHDCHD Risk EquivalentsCHD Risk Factors
  • History of MI
  • Unstable angina
  • Stable angina
  • CHD procedures
  • Evidence of clinically significant myocardial ischemia
  • Diabetes mellitus
  • Peripheral vascular disease
  • Carotid artery disease
  • Abdominal aortic aneurysm
  • Transient ischemic attacks
  • 2 or more CHD risk factors with a 10-year risk of CHD >20% (see the 10-year cardiac event risk calculatorLink will take you outside the VA website.)
  • Male sex
  • Cigarette smoking
  • Hypertension (systolic blood pressure ≥140 mmHg or taking antihypertensive medication)
  • HDL <40 mg/dL (if HDL is ≥60 mg/dL, subtract 1 risk factor)
  • Patient age ≥45 (men) or ≥55 (women)
  • Family history of premature CHD in first-degree relatives aged <55 (men) or <65 (women)

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In addition, consider the factors below:

History
  • Factors that contribute to dyslipidemia:
    • Obesity, chronic liver disease, alcohol consumption, high-fat or high-carbohydrate diet, genetic disorders of lipid metabolism, chronic kidney disease, and prothrombotic or proinflammatory states
  • Factors that contribute to hypertriglyceridemia:
    • Genetic disorders, obesity, diabetes, alcohol consumption, hypothyroidism, nephritic syndrome, chronic kidney disease
  • Causes of secondary dyslipidemia, including diabetes, hypothyroidism, nephrotic syndrome, liver diseases
  • Family history of obesity, diabetes, and lipid abnormalities
  • Medications
    • ARVs, especially those known to increase cholesterol or TG levels (eg, RTV and RTV-boosted PIs, EFV, d4T)
    • Other medications that may cause lipid abnormalities (eg, corticosteroids, anabolic steroids, progestins, beta-blockers, thiazide diuretics, quetiapine)
Physical examination
  • Blood pressure
  • Weight, height, and waist circumference (for patients of European descent, abnormal is >40 inches [men] or >35 inches [women])
  • Obtain BMI: normally available in the Vitals section of the CPRS Cover Sheet; otherwise BMI = weight (kg)/height (m2); see BMI calculatorLink will take you outside the VA website..
    • Underweight: BMI <18.5
    • Normal weight: 18.5-24.9
    • Overweight: 25-29.9
    • Obese: ≥30
  • Cardiovascular examination: murmurs, gallops
  • Stigmata of hyperlipidemia and hypertriglyceridemia: xanthelasma and tendon xanthomas, which are associated with extremely elevated LDL levels; eruptive xanthomas and hepatomegaly, which may be present in the setting of extremely elevated TG levels (chylomicronemia)
Laboratory evaluation
  • Fasting (8- to 12-hour fast) lipid panel: measured TC, LDL, HDL, and TG levels; calculated non-HDL, and TC/HDL ratio
  • Fasting glucose

Assessment Tools

Determine whether intervention is needed according to the patient's lipid values and CHD risks, following these 3 steps. Note that for most patients, LDL is the main indicator of need for lipid-lowering therapy.

  • Determine CHD risks (above).
  • Determine risk category, LDL goal, and LDL threshold for treatment using Table 1.
    • The NCEP also recommends estimating the patient's 10-year risk of MI using the assessment toolLink will take you outside the VA website. derived from the Framingham Heart Study . Note that this tool does not estimate lifetime risk of MI, which for many patients is substantially higher than their 10-year risk. Intervention to treat lipid abnormalities may be warranted even in patients with a low 10-year risk, to prevent CV events later in life.
  • Assess TG risk level using Table 2; determine whether TG-lowering treatment is needed.
Table 1. LDL Cholesterol Goals and Thresholds for Treatment
Risk CategoryLDL Goal*LDL Threshold to Initiate Therapeutic Lifestyle ChangesConsider Drug Therapy
* Non-HDL cholesterol target levels are 30 mg/dL higher than corresponding LDL cholesterol levels.
Adapted from National Cholesterol Education Program (NCEP), National Heart, Lung, and Blood Institute, National Institutes of Health. Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)Link will take you outside the VA website.. NIH Publication No. 02-5215. September 2002.
Lower risk:

No CHD or CHD equivalents and 0-1 risk factor

<160 mg/dL≥160 mg/dL≥190 mg/dL (at 160-189 mg/dL, drug therapy optional)
Moderate risk:

No CHD or CHD equivalents; ≥2 risk factors and 10-year estimated risk <10%

<130 mg/dL≥130 mg/dL≥160 mg/dL
Moderately high risk:

No CHD or CHD equivalents; ≥2 risk factors and 10-year estimated risk 10-20%

<130 mg/dL (optional goal: <100 mg/dL)≥130 mg/dL≥130 mg/dL
High risk:

CHD or CHD equivalent

<100 mg/dL (optional goal: <70 mg/dL)≥100 mg/dL≥100 mg/dL

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Other issues:

  • Consider drug therapy to decrease LDL (or non-HDL) if TC is >240 mg/dL or HDL cholesterol is <35 mg/dL.
  • If TG is >400 mg/dL, the LDL cholesterol calculation is unreliable. Use non-HDL cholesterol as a surrogate target of therapy (non-HDL = TC - HDL); the non-HDL goal is 30 mg/dL higher than the LDL goal.
  • If TG is 200-500 mg/dL, LDL is the primary target of initial therapy (see Table 1 for LDL intervention levels); if TG is ≥500 mg/dL, TG may be the initial target of therapy (see below).

Hypertriglyceridemia is associated with CAD risk, but it is unclear whether it is an independent risk factor; hence indications for treatment are less certain than those for cholesterol abnormalities.

Table 2. Classification of Triglyceride Levels
Risk CategoryTriglyceride MeasurementInitiate Therapy
Adapted from National Cholesterol Education Program (NCEP), National Heart, Lung, and Blood Institute, National Institutes of Health. Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III)Link will take you outside the VA website.. NIH Publication No. 02-5215. September 2002.
Normal<150 mg/dL
Borderline High150-199 mg/dL
High200-499 mg/dL
  • TLC
  • Consider drug therapy for those with CHD, CHD equivalents, high risk of CHD
Very High≥500 mg/dL
  • Low-fat diet (<15% of caloric intake); pharmacologic therapy probably will be required
  • Consider drug therapy
  • If severe (>1,000 mg/dL), treat to decrease risk of pancreatitis

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Management

The primary goal of lipid-lowering therapy for most patients is to lower LDL to target levels. The potential benefits of lipid-lowering therapy for HIV-infected patients should be balanced against drug toxicities, as well as the risk of CV mortality relative to HIV-associated mortality.

  • If the TG level is very high, it may have to be reduced before LDL is treated directly (see below).
  • Low HDL is not usually a primary target of therapy; data are conflicting as to whether raising HDL confers CV benefits.

A multimodal approach to treatment is important:

  • Lifestyle modification
  • Lipid-modifying medication
  • Changes in ARV medication (or other exacerbating medication), if possible
  • Management of associated conditions (eg, diabetes)

See Table 1 for LDL levels at which either TLC or drug therapy should be initiated, and for the target goals for LDL cholesterol.

Lifestyle Modification

Lifestyle modification is fundamental to the management of dyslipidemia and should be initiated in all patients with dyslipidemia. Behavioral changes may be difficult for patients, but can yield significant results in improving lipid values and reducing CHD risk.

Encourage patients to:

  • Reduce dietary cholesterol and saturated fat (all patients)
  • If overweight, lose weight
  • Maintain or increase aerobic exercise (all patients)
  • Reduce alcohol consumption (especially for those with high TGs)
  • Stop smoking, and reduce other CHD risk factors

Medication

See Table 3 and Characteristics of Lipid-Lowering Medications, below, for information about lipid-lowering medications. Therapies should be intensified or augmented until lipid targets are met.

Table 3. Suggested Drug Treatments for Lipid Abnormalities
Lipid AbnormalityFirst ChoiceSecond ChoiceComments
* See PBM Criteria for Use for Ezetimibe.
Isolated high LDL, non-HDL cholesterolStatin
  • Niacin (time-release formulation)
  • Fibrate (reserve for patients intolerant of other agents who have high LDL, low HDL)
  • Ezetimibe (third choice)*
Be aware of possible statin-ARV interactions (see below and Lipid-Lowering Medications); use pravastatin, fluvastatin, rosuvastatin, or atorvastatin for most patients taking PIs

Patients taking PIs may have increased risk of myopathy

Start with low statin dosages

If incomplete response to statin, consider:

  • Increasing statin dosage
  • Switching to more potent statin (rosuvastatin or atorvastatin)
  • Adding niacin (time-release formulation)
  • Adding ezetimibe
  • Bile acid sequestrants in general should be avoided unless there are no other options; may interfere with absorption of ARVs and other medications
Ezetimibe should used as monotherapy only for patients unable to tolerate statins who do not respond to other agents

Avoid combining statin and fibrate: increased risk of myopathy

Triple therapy with statins, niacin, and ezetimibe is not recommended
Isolated high TGN-3 fatty acid

Niacin (time-release formulation)

Fibrate

Fibrates are most effective in lowering TG

If response is inadequate, add second agent

Atorvastatin may lower TG (as well as LDL)

High LDL + high TGStatin + N-3 fatty acid or niacin (time-release formulation)Fibrate Dual therapy likely to be most effective

Could start with single agent (eg, niacin) and add second agent if response is inadequate

Avoid combination of statin and fibrate: increased risk of myopathy

Isolated low HDLNiacin (time-release formulation)Fibrate Initiate CV exercise

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Characteristics of Lipid-Lowering Medications

Statins (HMG-CoA reductase inhibitors): Decrease TC, LDL, and non-HDL cholesterol levels; atorvastatin also decreases TG levels. There is substantial evidence that statins reduce CV events. First-line treatment for most patients with hypercholesterolemia or combined hypercholesterolemia + hypertriglyceridemia (see Table 3).

Many have significant drug interactions with PIs and NNRTIs; some combinations are contraindicated (see Lipid-Lowering Medications). Possible adverse effects include, GI disturbance, myopathy, rhabdomyolysis, liver toxicity (check LFTs 1 month after initiating, then every 3 months). Contraindicated in women who are pregnant or nursing; use caution in patients with active or chronic liver disease.

Recommended starting dosages of statins for patients taking PIs:

  • Pravastatin: 20 mg PO QD
  • Fluvastatin: 20 mg PO QD
  • Atorvastatin: 10 mg PO QD
  • Rosuvastatin: 5-10 mg PO QD

When given concomitantly, statins and fibrates increase the risk of rhabdomyolysis; in general, this combination should be avoided.

Fibrates: Decrease TG and increase HDL; modestly decrease LDL. Gemfibrozil has been shown to reduce risk of CV events (in HIV-uninfected individuals); fenofibrate has not. In one study, clofibrate was associated with increased risk of noncardiac mortality. An option for initial treatment of isolated hypertriglyceridemia and an alternative treatment for combined hypertriglyceridemia and hypercholesterolemia.

Not metabolized by the cytochrome P450 hepatic enzyme system; no significant drug interactions with ARVs (an exception is LPV/r, which reduces gemfibrozil levels). Contraindicated in severe renal or hepatic disease. Fibrates generally should not be used with statins because of increased risk of myositis. Other possible adverse effects: GI disturbance, gallstones, dizziness. Recommended dosages:

  • Fenofibrate: 50-200 mg PO QD
  • Gemfibrozil: 600 mg PO BID, 30 minutes before meals

N-3 (omega-3) polyunsaturated fatty acids: Decrease TG levels. May be effective as initial or adjunctive therapy. Limited data suggest CV benefit. Usual dosage 2-6 grams daily. Possible adverse effects: fishy taste, GI disturbance.

Niacin: Increases HDL, decreases both TC and TG. May be effective as adjunctive therapy, but may worsen insulin resistance. Other possible adverse effects include elevated serum transaminase levels, flushing (to decrease flushing, premedicate with aspirin; titrate dosage slowly, use time-release formulations [eg, Niaspan]). Contraindicated in chronic liver disease and severe gout; relatively contraindicated in diabetes, peptic ulcer disease, and hyperuricemia.

Bile acid sequestrants: Generally should be avoided unless no other options; may interfere with the absorption of other drugs (including ARVs), and may increase TG levels.

Ezetimibe: Has not been studied thoroughly in HIV-infected individuals, but appears to be effective in lowering TC and LDL. However, because of lack of data showing that ezetimibe decreases CV events, it should not generally be used as monotherapy. Usually used in combination with statins if LDL is not controlled adequately with a statin alone. Contraindicated in patients with liver disease.

Switching ARVs
  • For patients with CHD or CHD equivalents, try to select ARV medications associated with the lowest risk of dyslipidemia.
  • For patients with dyslipidemia caused by ARV agents, consider discontinuing lipogenic ARVs if safe and effective alternatives exist.
    • For example, substitute ATV, RAL, or NVP in place of a lipogenic PI or substitute an unboosted PI (eg, ATV or FPV) for an RTV-boosted PI.
    • Replace d4T with TDF, or perhaps ABC*.
  • Before making ARV substitutions, consider the possible effect on HIV virologic control and the potential adverse effects of new ARVs.
  • In some cases, antihyperlipidemic agents may still be necessary after ARV substitution.

* Data from the D:A:D observational study associated ABC with increased risk of MI; some other studies have not confirmed this association. See References.

Potential ARV Interactions

Interactions with ARVs: Most PIs inhibit the metabolism of most statins and can significantly increase serum statin levels, thus increasing the risk of toxicity, including rhabdomyolysis.

Some combinations are contraindicated. Of the statin drugs, pravastatin is the least affected by most PIs (DRV is an exception). Atorvastatin, if used, must be initiated cautiously and at a low dose. EFV can induce the metabolism of some statins, causing therapeutically significant decreases in their concentrations. See Lipid-Lowering Medications, for further information.

References