Hyperlipidemia is a topic covered in the Johns Hopkins HIV Guide.

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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 11/27/21 at https://clinicaltrials.gov/ct2/show/NCT02344290
    • HIV drug interactions checker includes lipid lowering agents as drug class. Accessed 11/21/21 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 11/27/21 at https://clinicaltrials.gov/ct2/show/NCT02344290
    • HIV drug interactions checker includes lipid lowering agents as drug class. Accessed 11/21/21 at https://www.hiv-druginteractions.org/checker

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Last updated: November 27, 2021