A Multimodal, Evidence‐Based Approach to Achieve Lipid Targets in the Treatment of Antiretroviral‐Associated Dyslipidemia: Case Report and Review of the Literature

Abstract

Metabolic abnormalities associated with the treatment of human immunodeficiency virus (HIV) infection are well-recognized problems that increase cardiovascular risk. As a result of the complexity of treating both HIV- and antiretroviral-related comorbidities, strategies that improve adverse drug events while maintaining viral control are in critical need. Although guidelines have somewhat helped in the general approach and in first-line strategies for managing dyslipidemia in patients receiving antiretrovirals, a paucity of data exist to guide clinicians in treating patients whose conditions are refractory to first-line options or who are at substantial risk for cardiovascular events. Further complicating the choice of lipid-lowering strategy is the lack of randomized controlled data from the HIV-affected population and a concern about clinically significant drug-drug interactions. We describe an HIV-infected patient with efavirenz-associated dyslipidemia at very high cardiovascular risk who had not achieved his primary or secondary lipid goals despite 2 years of treatment in a lipid specialty clinic. Lipid control was accomplished in 10 weeks with a targeted, stepwise approach of switching efavirenz to nevirapine, followed by rosuvastatin 20 mg/day, which was sustained for at least 10 months. Of most importance, this outcome was achieved without any clinically significant alteration in virologic or immunologic control. This case report highlights the potential for a pharmacist-guided, multistep approach that addresses HIV-related dyslipidemia and incorporates the pharmacokinetic literature to guide lipid-lowering therapy and promote the attainment of goals based on current standards of care.

Lipid Management in Human Immunodeficiency Virus

“…This change should be done in consultation with the provider who is managing the patients' ART. 118,119 Monitoring and Follow-up According to the European guidelines, recommendations for follow-up after beginning therapy "stem from consensus rather than evidencebased guidelines" and that "response to therapy can be assessed at 6-8 weeks from initiation or dose increases for statins, but response to fibrates and lifestyle may take longer." 48 For most patients, maximum LDL and triglyceride lowering is evident by 6 weeks after starting therapy.…”

Hyperlipidemia in Primary Care

“…This might be related to drug interactions, noncompliance secondary to high pill burden, or the disease process itself [119]. Referral to an expert in treating lipid disorders is generally recommended in HIV-infected patients with refractory lipid disorders [5].…”

“…In fact, given its inductive CYP3A4 capabilities, efavirenz may decrease the efficacy of some statins [35]. Unfortunately, there is limited data on drug-drug interactions with NNRTIs and statins [5], including rosuvastatin [119]. It should be noted, however, that the only interaction predicted between rosuvastatin and NNRTIs is a potential reduction in potency of rosuvastatin due to inductive capabilities of the NNRTIs [119].…”

“…Unfortunately, there is limited data on drug-drug interactions with NNRTIs and statins [5], including rosuvastatin [119]. It should be noted, however, that the only interaction predicted between rosuvastatin and NNRTIs is a potential reduction in potency of rosuvastatin due to inductive capabilities of the NNRTIs [119]. (c) Statins and NRTIs: The NRTIs are metabolized via glucuronidation and phosphorylation and not via the CYP system, and as a result, have no effect on the metabolism of statins.…”

“…Simvastatin and lovastatin should be avoided in patients taking PIs or delavirdine, while atorvastatin and rosuvastatin should be used with caution in reduced dosages to avoid rhabdomyolysis [5,35]. Unfortunately, pravastatin and fluvastatin are low potency statins for secondary prevention of CV events, while atorvastatin and rosuvastatin are proven to be superior [119].…”