Hyperlipidemia

Lisa A. Spacek, M.D., Ph.D.
Hyperlipidemia is a topic covered in the Johns Hopkins HIV Guide.

To view the entire topic, please or .

Official website of the Johns Hopkins Antibiotic (ABX), HIV, Diabetes, and Psychiatry Guides, powered by Unbound Medicine. Johns Hopkins Guide App for iOS, iPhone, iPad, and Android included. Explore these free sample topics:

-- The first section of this topic is shown below --

CLINICAL

  • HIV infection and immune activation are associated with increased mortality and non-AIDS morbidity, including cardiovascular events, despite suppressive ART.[5][1]
    • Diabetes, hypertension, stroke, and cardiovascular disease are closely associated with metabolic syndrome and linked to long-term inflammation.
    • Uncontrolled HIV is associated with increased cardiovascular disease (CVD) and acute MI.[11][8]
  • 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

-- To view the remaining sections of this topic, please or --

CLINICAL

  • HIV infection and immune activation are associated with increased mortality and non-AIDS morbidity, including cardiovascular events, despite suppressive ART.[5][1]
    • Diabetes, hypertension, stroke, and cardiovascular disease are closely associated with metabolic syndrome and linked to long-term inflammation.
    • Uncontrolled HIV is associated with increased cardiovascular disease (CVD) and acute MI.[11][8]
  • 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

There's more to see -- the rest of this topic is available only to subscribers.

Last updated: March 5, 2022