New US HIV lipid guidelines favour lifestyle changes over drug therapy as first line

A modified low-fat diet, aerobic and resistance exercise and stopping smoking should be the first-line option for treatment of high cholesterol and triglycerides, according to the new guidelines from the HIV Medicine Association of the Infectious Diseases Society of America and the Adult AIDS Clinical Trials Group. Updated guidelines for the Evaluation and Management of Dyslipidemia in HIV-Infected Adults on HAART are published in the September 1^st issue of Clinical Infectious Diseases.

The Guidelines review the latest information on the prevalence and incidence of both high LDL cholesterol and high triglycerides and their relationship with cardiovascular disease in people with HIV on HAART, and recommend that under certain circumstances drug therapy to reduce the cardiovascular risks associated with dyslipidaemias should take place (see below).

However, because of extensive drug-drug interactions between many of the lipid-lowering therapies and limited clinical trial evidence on the usefulness of these therapies in people with HIV on HAART, the recommendations prioritise lifestyle changes over drug treatment, except when there is an urgent need to intervene (for example if coronary heart disease is already present or when LDL cholesterol is above 220 mg/dL[5.7 mmol/L]).

The Guidelines recommend a consultation with a dietician in order to assess diet and lose weight, if indicated. Reduced fat intake is recommended, and when high triglycerides are an issue, saturated fats should replaced with monosaturated fat or omega-3 polyunsaturated fats (e.g. fish oils).

Additionally, aerobic and resistance exercise (e.g. weight training) are recommended, along with stopping smoking. Hyperglycaemia due to diabetes should also be treated aggressively with insulin sensitisers such as metformin and thiazolidenediones (e.g. rosiglitazone), as appropriate.

If lifestyle interventions are not successful in treating high cholesterol and triglycerides, then the following recommendations are made for drug therapy:

Elevated LDL cholesterol or non-HDL cholesterol with a triglyceride level of 200-500 mg/dL [2.26-5.65 mmol/L]

• Recommended: pravastatin (20-40 mg/daily) or atorvastatin (10 mg/daily)
• Alternatives: fluvostatin (20-40 mg/daily), gemfibrozil (600 mg/twice daily) or micronised fenofibrate (54-160 mg/daily)

Elevated LDL cholesterol or non-HDL cholesterol with a triglyceride level above 500 mg/dL [5.65 mmol/L]

• Recommended: gemfibrozil (600 mg/twice daily, 30 minutes before meals)

  or micronised fenofibrate (54-160 mg/daily)

• Alternatives: fish oils or niacin

When statin therapy has not reduced elevated LDL cholesterol, the Guidelines note that adding either a fibrate or niacin is a possible approach, but due to the risk of myopathy, statin-fibrate therapy should be used with great caution. If statins and fibrates are to be used together, the Guidelines recommend pravastatin or fluvostatin in combination with either gemfibrozil or micronised fenofibrate. Additionally, since niacin treatment is associated with an increased risk of insulin resistance, regular fasting glucose levels should be taken.

When fibrate therapy has not reduced elevated triglycerides, the Guidelines suggest adding a fish oil supplement or niacin. Adding statin therapy is not recommended.

Due to drug-drug interactions, the use of simvastatin and lovastatin in people on PI- or delavirdine-containing HAART is not recommended, but atorvastatin can be used with caution. Pravastatin appears to be safe with PIs, but may need to be increased when taken along with ritonavir-containing regimens. Fluvastatin does not appear to have any PI-related drug-drug interactions. Any of the statins are probably safe in efavirenz or nevirapine-containing regimens. Fibrates may be reduced in ritonavir-containing regimens, but otherwise no interactions are known at this time.

A full review of these guidelines, along with diet and exercise recommendations will appear in the October issue of AIDS Treatment Update.