Hyperlipidemia
CLINICAL
- HIV infection and immune activation are associated with increased mortality and non-AIDS morbidity, including cardiovascular events, despite suppressive ART.[5][1]
- Dyslipidemia is 3-4 times more prevalent in those living with HIV.
- HIV-related disorders of lipid metabolism lead to lower total cholesterol, higher triglycerides, lower HDL, and lower LDL.[7]
- ART with viral suppression combined with lipid-lowering therapy may improve inflammation and atherogenic dyslipidemia.
- Lipid profile and risk factor assessment drives initiation of statins for primary prevention of atherosclerotic and cardiovascular disease.
- Lipid effects are associated with ART.
- Longitudinal studies of the effect of ART on lipid levels are limited to combination therapy, as single agents are not used to treat HIV.
- INSTIs: EVG/COBI/TDF/FTC → ↑TG, ↑LDL, ↑HDL. DTG > RAL → ↑TG[10]
- NNRTIs: EFV → ↑TG, ↑LDL, ↑HDL. Next-generation NNRTIs, RPV or DOR are switch options that do not contribute to dyslipidemia.
- NRTIs: ZDV > ABC→ ↑LDL and ↑TG. TDF has lipid-lowering effect. ABC associated with MI in D:A:D and some other observational studies, but other studies have not found an association. DHHS and IAS-USA guidelines recommend avoiding ABC in patients with high CVD risk.
- PIs: all boosted PIs → ↑LDL, ↑TG, ↑HDL. ATV/r and DRV/r preferred over FPV/r and LPV/r.
- Statin therapy lowers LDL and reduces inflammation, immune activation, and oxidative stress.[7]
- Statins are dosed as high, moderate, and low intensity. Table 3 in the AHA cholesterol guidelines lists statins with dose by intensity.[2]
- ART drug interactions with statins vary according to ART class. Hepatic enzyme, cytochrome P450, metabolizes atorvastatin, lovastatin, and simvastatin.
- REPRIEVE trial (Randomized Trial to Prevent Vascular Events in HIV) examines primary prevention of CVD using pitavastatin therapy.[6] Accessed 2/28/2022 at https://clinicaltrials.gov/ct2/show/NCT02344290
- HIV drug interactions checker includes lipid lowering agents as drug class. Accessed 2/28/2022 at https://www.hiv-druginteractions.org/checker
- Statins are dosed as high, moderate, and low intensity. Table 3 in the AHA cholesterol guidelines lists statins with dose by intensity.[2]
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Last updated: March 5, 2022
Citation
Spacek, Lisa A. "Hyperlipidemia." Johns Hopkins HIV Guide, 2022. Johns Hopkins Guides, www.hopkinsguides.com/hopkins/view/Johns_Hopkins_HIV_Guide/545099/all/Hyperlipidemia.
Spacek LA. Hyperlipidemia. Johns Hopkins HIV Guide. 2022. https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_HIV_Guide/545099/all/Hyperlipidemia. Accessed December 6, 2023.
Spacek, L. A. (2022). Hyperlipidemia. In Johns Hopkins HIV Guide https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_HIV_Guide/545099/all/Hyperlipidemia
Spacek LA. Hyperlipidemia [Internet]. In: Johns Hopkins HIV Guide. ; 2022. [cited 2023 December 06]. Available from: https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_HIV_Guide/545099/all/Hyperlipidemia.
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