Official guidelines on managing HIV dislipidemia

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HIV/AIDS, November 30, 2003

Posted 12/08/2003

Bartlett, MD

Management of Dyslipidemia

New Guidelines for Management of Dyslipidemia From IDSA and the ACTG

Dube MP, Stein JH, Aberg JA, et al. Guidelines for the evaluation

and management of dyslipidemia in human immunodeficiency virus (HIV)-

infected adults receiving antiretroviral therapy: recommendations of

the HIV medicine association of the infectious disease society of

America and the adult AIDS clinical trials group. Clin Infect Dis.

2003;37:613-627.

Preliminary guidelines were previously published.[1] The present

document is the full report with updated information. The guidelines

for management are provided in Tables 1-4, which addTherapy

Nondrug therapy: Diet, smoking cessation, exercise, treatment of

high blood pressure and diabetes.

Sequencing: Initiate nondrug therapy first unless there are extreme

elevations (eg, LDL-C > 220 mg/dL and/or triglyceride > 2000 mg/dL

or > 1000 mg/dL and history of pancreatitis).

Switch therapy:

Protease inhibitor (PI) nevirapine (NVP) or abacavir (ABC):

Improves total cholesterol and triglycerides

PI efavirenz (EFV) is less effective

Stavudine (d4T) ABC is inconclusive

Comment: Many of the recommendations are based on the National

Cholesterol Education Program Expert Panel on Detection, Evaluation,

and Treatment of High Blood Cholesterol in Adults.[2] This

particularly applies to risk assessment, the goal for LDL-C levels,

and the approach to drug therapy. Factors that are somewhat unique

to persons with HIV infection are the influence of highly active

antiretroviral therapy (HAART) on lipids, the recommendations for

screening in patients receiving this therapy, several issues

regarding therapeutic intervention, and drug interactions between

statins and PIs. With regard to the recommended drugs, the statins

that are favored for concurrent use with PIs include pravastatin,

atorvastatin, and fluvastatin. Unfortunately, their recommendations

appear to have preceded the US Food and Drug Administration's

approval of rosuvastatin, which is of particular interest because of

potency and little effect on the cytochrome P450 metabolic pathway.

ress risk factors for coronary artery disease, the goals for LDL-

cholesterol (LDL-C), screening tests, therapy, and drug interactions.

Screening: Total cholesterol, HDL-cholesterol, and triglyceride

levels after 8 or more (preferably 12) hours' fasting at baseline,

at 3-6 months post therapy, and then annually.

The Value of Expert Advice With Genotypic Resistance Tests

Badri SM, Adeyemi OM, Max BE, Zagorski BM, Barker DE. How does

expert advice impact genotypic resistance testing in clinical

practice? Clin Infect Dis. 2003;37:708-713.

This is a report from the CORE Center, which is the largest

outpatient provider of HIV care in metropolitan Chicago with

approximately 3500 patients. The clinic is staffed by 16 physicians

trained in infectious diseases, 10 infectious disease fellows, 10

internists, 3 physician assistants, and 6 nurse practitioners. The

present trial addresses the issue of the value of expert

interpretation of genotypic resistance testing in the management of

HIV infection. Enrollment criteria included: (1) a HAART regimen

with at least 3 drugs; (2) viral load > 2000 copies/mL; and (3)

patient adherence to the current treatment. Physicians were required

to list previous therapy and previous adverse reactions on the

request slip. The results of genotypic analysis were supplied to 3

infectious disease physicians and 1 clinical pharmacist who

routinely reviewed resistance test results as well as the historical

information provided to make recommendations. Providers had the

option of accepting or rejecting recommendations of the expert

panel. The primary endpoint was the viral load and CD4+ cell count

at 24 weeks.

There were 74 patients enrolled in the study, including 50 for whom

the expert panel recommendations were accepted and 24 for whom the

expert panel recommendations were rejected. The median log decrease

in viral load for those patients receiving treatment based on expert

advice was 2.6 log10 copies/mL compared with 1.3 log10 copies/mL for

the group that did not use the information. These differences are

highly significant by statistical analysis. There was also a

statistically significant increase in the number that achieved viral

load of < 50 copies/mL. These results and the baseline values are

illustrated in Table 5.

The study authors concluded that viral load outcome is improved when

failing regimens are managed by substitutions selected on the basis

of expert interpretation of the genotypic resistance test.

Comment: The results of this test should not surprise those who have

experience with genotypic testing. Unfortunately, most centers do

not have the luxury of a 3-person panel to make such recommendation,

although many would agree that this is appropriate given the

magnitude of the benefit with it and the risk without it.

Factors Associated With Long-term Viral Suppression

Holmberg SD, Hamburger ME, Moorman AC, Wood KC, Palella FJ Jr.

Factors associated with maintenance of long-term plasma human

immunodeficiency virus RNA suppression. Clin Infect Dis. 2003;37:702-

707.

This is a report from the HIV Outpatient Study (HOPS) designed to

determine variables associated with long-term viral suppression by

retrospective analysis of records in a case-control study.

Participants included 286 patients who consistently had viral loads

< 50 copies/mL for at least 2 years. Factors that showed a

statistically significant association with viral suppression are

summarized in Table 6, which includes several drugs that also proved

to have a significant association with long-term viral suppression.

References for:

HIV/AIDS, November 30, 2003

[Medscape HIV/AIDS 9(2), 2003. © 2003 Medscape]

1 Dube MP, Sprecher D, Henry WK, et al. Preliminary guidelines for

the evaluation and management of dyslipidemia in adults infected

with human immunodeficiency virus and receiving antiretroviral

therapy: Recommendations of the Adult AIDS Clinical Trial Group

Cardiovascular Disease Focus Group. Clin Infect Dis. 2000;31:1216-

1224. Abstract

2 Expert Panel on Detection, Evaluation, and Treatment of High Blood

Cholesterol in Adults. Executive Summary of The Third Report of The

National Cholesterol Education Program (NCEP) Expert Panel on

Detection, Evaluation, And Treatment of High Blood Cholesterol In

Adults (Adult Treatment Panel III). JAMA. 2001;285:2486-2497.

Abstract

3 Goedert JJ, Duliege AM, Amos CI, Felton S, Biggar RJ. High risk of

HIV-1 infection for first-born twins. The International Registry of

HIV-exposed Twins. Lancet. 1991;338:1471-1475. Abstract

4 Duliege AM, Amos CI, Felton S, Biggar RJ, Goedert JJ. Birth order,

delivery route, and concordance in the transmission of human

immunodeficiency virus type 1 from mothers to twins. International

Registry of HIV-Exposed Twins. J Pediatr. 1995;126:625-632. Abstract

5 Biggar RJ, Miotti PG, Taha TE, et al. Perinatal intervention trial

in Africa: effect of a birth canal cleansing intervention to prevent

HIV transmission. Lancet. 1996;347:1647-1650. Abstract