Benefits and Risks of Statin Therapy in the HIV-Infected Population

Abstract

Statins remain the preferred agents for reducing risk for CVD among HIV-infected populations based on guidance extrapolated from general population (HIV-uninfected) cholesterol treatment guidelines across different settings globally. However, HIV-infected patients are consistently under prescribed statin therapy when compared to their HIV-uninfected counterparts. The most commonly studied statins in clinical care and small randomized and cohort studies have been rosuvastatin and atorvastatin. Both agents are preferred for their potent lipid-lowering effects and their favorable or neutral pleotropic effects on chronic inflammation, renal function, and hepatic steatosis among others. However, growing experience with the newer glucuronidated pitavastatin suggests that this agent has virtually no adverse drug interactions with ART or effects on glucose metabolism-all marked additional benefits when compared with rosuvastatin and atorvastatin while maintaining comparable anti-lipid effects. Pitavastatin is therefore the statin of choice for the ongoing largest trial (6500 participants) to test the benefits of statin therapy among HIV-infected adults. Statins are underutilized in the prevention of CVD in HIV-infected populations based on criteria in established cholesterol guidelines. There is a potential role for statin therapy for HIV-infected patients who do not meet guideline criteria which will be further delineated through ongoing clinical trials.

Radionuclide imaging of inflammation in atherosclerotic vascular disease among people living with HIV infection: current practice and future perspective

“…1). Our finding, as well as findings by others, has stimulated interest in evaluating various anti-inflammatory agents such as statins and methotrexate for primary prevention of CVD among PLWH (Mosepele et al 2018;Hsue et al 2018).…”

Lipid Abnormalities in Persons Living With HIV Infection

“…Simvastatin and lovastatin are contraindicated with PIs because of drugedrug interactions. Studies indicate that statins are underused in the setting of HIV, 59,62,63 perhaps because HIV specialists might not have the expertise to manage CV risk, and because cardiologists do not have expertise in HIV or appreciation of CV risk in this unique population.…”

“…58 Although not available in Canada, pitavastatin is theoretically a good choice for individuals living with HIV, because at higher doses its LDLeC-lowering effect is moderate, and because its metabolism is via glucuronidation, drugedrug interactions are avoided. 59 In a randomized, double-blind comparison study in 252 subjects with HIV, pitavastatin 4 mg/d reduced LDL-C by 31% and pravastatin 40 mg/d reduced LDL-C by 21%, with similar low rates of adverse events in the 2 treatment groups. 60 Levels of soluble CD14, oxidized LDL-C, and lipoproteinassociated phospholipase 2 were significantly lower in the pitavastatin group compared with the pravastatin group.…”

“…16,51 Several studies indicate that statins are underused in the setting of HIV. 59,62,63 In individuals living with HIV who do not tolerate statins, ezetimibe is a safe option, albeit with limited LDLeClowering efficacy. 64 Ezetimibe could be considered as add-on therapy for very high-risk individuals with HIV who do not achieve satisfactory LDL-C lowering with statins.…”

Outcomes of coronary artery bypass grafting in patients with human immunodeficiency virus infection

“…Data on muscle toxicity in PLHIV is inconclusive to date, with some studies reporting increased muscle toxicity among HIV‐infected adults, 22 while more recent studies did not detect this association 23 . Taken together, the benefits of statin therapy in PLHIV appear to outweigh toxicities of statin therapy 18 …”