Dyslipidemia and its Treatment in HIV Infection

Abstract

HIV-infected patients have metabolic abnormalities that put them at increased risk of cardiovascular disease (CVD), including abnormalities associated with HIV infection itself, antiretroviral treatment, restoration to health, and body composition changes. The 2 major components of dyslipidemia in HIV-infected patients are hypertriglyceridemia and reduction in high-density lipoprotein (HDL) cholesterol (with likely altered function of HDL cholesterol); these abnormalities contribute to increased atherosclerotic risk. Adverse effects of antiretroviral drugs on lipids are not class specific but rather are associated with particular drugs. Thus, practitioners need to be cognizant of the risks of metabolic abnormalities posed by individual drugs. HIV infection increases CVD risk independent of the effects of traditional risk factors. The relative risk of CVD in HIV-infected patients has decreased in recent years with increasing use of lipid-lowering therapy. However, use of lipid-lowering therapy is complicated by numerous potential drug interactions with antiretroviral drugs that practitioners need to consider when prescribing lipid-lowering therapy. This article summarizes a presentation made by Carl Grunfeld, MD, PhD, at the International AIDS Society-USA continuing medical education program in Los Angeles in March 2010. The original presentation is available as a Webcast at www.iasusa.org.

Figure 1

Effects of protease inhibitors on lipid measures. A, Effects of ritonavir-boosted (/r) lopinavir and B, indinavir on levels of triglycerides (TG), very low-density lipoprotein cholesterol (VLDL-C), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and free fatty acids (FFA) in HIV-seronegative subjects. Based on data for lopinavir/r from Lee et al, AIDS, 2004, and for indinavir from Noor et al, AIDS, 2001. C, Effects on TG levels of ritonavir, indinavir, and nelfinavir in HIV-seropositive patients and of ritonavir, indinavir, and lopinavir/r in HIV-seronegative subjects. Based on data for HIV-seronegative patients from Periard et al, Circulation, 1999, and for HIV-seropositive subjects from Purnell et al, AIDS, 2000; Lee et al, AIDS, 2004; and Noor et al, AIDS, 2001. D, Effects on LDL-C levels of ritonavir, indinavir, and nelfinavir in HIV-seropositive patients and of ritonavir, indinavir, and lopinavir/r in HIV-seronegative subjects. Based on data for HIV-seronegative subjects from Periard et al, Circulation, 1999, and for HIV-seropositive subjects from Purnell et al, AIDS, 2000; Lee et al, AIDS, 2004; and Noor et al, AIDS, 2001