Cardiovascular risk and dyslipidemia among persons living with HIV: a review

Abstract

BackgroundAim of this review is to focus the attention on people living with HIV infection at risk of developing a cardiovascular event. What is or what would be the most suitable antiretroviral therapy? Which statin or fibrate to reduce the risk? How to influence behavior and lifestyles?DiscussionPrevention of cardiovascular disease (CVD) risk remains the first and essential step in a medical intervention on these patients. The lifestyle modification, including smoking cessation, increased physical activity, weight reduction, and the education on healthy dietary practices are the main instruments.Statins are the cornerstone for the treatment of hypercholesterolemia. They have been shown to slow the progression or promote regression of coronary plaque, and could also exert an anti-inflammatory and immunomodulatory effect. However the current guidelines for the use of these drugs in general population are dissimilar, with important differences between American and European ones. The debate between American and European guidelines is still open and, also considering the independent risk factor represented by HIV, specific guidelines are warranted.Ezetimibe reduces the intestinal absorption of cholesterol. It is effective alone or in combination with rosuvastatin. It does not modify plasmatic concentrations of antiretrovirals. A number of experimental new classes of drugs for the treatment of hypercholesterolemia are being studied.Fibrates represent the first choice for treatment of hypertriglyceridemia, however, the renal toxicity of fibrates and statins should be considered.Omega 3 fatty acids have a good safety profile, but their efficacy is limited. Another concern is the high dose needed. Other drugs are acipimox and tesamorelin.Current antiretroviral therapies are less toxic and more effective than regimens used in the early years. Lipodistrophy and dyslipidemia are the main causes of long-term toxicities. Not all antiretrovirals have similar toxicities. Protease Inhibitors may cause dyslipidemia and lipodystrophy, while integrase inhibitors have a minimal impact on lipids profile, and no evidence of lipodystrophy. There is still much to be written with the introduction of new drugs in clinical practice.ConclusionsCardiovascular risk among HIV infected patients, interventions on behavior and lifestyles, use of drugs to reduce the risk, and switch in antiretroviral therapy, remain nowadays major issues in the management of HIV-infected patients.

Benchmarks of Diabetes Care in Men Living With Treated HIV-Infection: A Tertiary Center Experience

“…Of note, non-nucleoside reverse transcriptase inhibitors efavirenz and nevirapine increase HDL while fusion inhibitors and integrase strand transfer inhibitors have neutral effects on the lipids demonstrating cART plays a large role in lipid metabolism and choice of therapy can effect target lipid outcomes (23). Treatment options for dyslipidaemia include changing cART to a more lipid-neutral regimen and using medical therapy (24). Statins are generally first line therapy due to their ability to reduce cardiovascular morbidity and mortality in primary and secondary prevention and ezetimibe can be used in statin-intolerant individuals or as add on therapy (23, 24).…”

“…Treatment options for dyslipidaemia include changing cART to a more lipid-neutral regimen and using medical therapy (24). Statins are generally first line therapy due to their ability to reduce cardiovascular morbidity and mortality in primary and secondary prevention and ezetimibe can be used in statin-intolerant individuals or as add on therapy (23, 24). For patients with isolated hypertriglyceridaemia, omega 3 fatty acid supplementation has been shown to be effective as shown in a meta-analysis including 20 randomized controlled studies ( n = 1,209 participants) that demonstrated individuals on supplements had triglyceride levels significantly decreased compared to controls (25).…”

“…For patients with isolated hypertriglyceridaemia, omega 3 fatty acid supplementation has been shown to be effective as shown in a meta-analysis including 20 randomized controlled studies ( n = 1,209 participants) that demonstrated individuals on supplements had triglyceride levels significantly decreased compared to controls (25). Fenofibrates and omega 3 fatty acid supplementation can be used alone or in combination, however care must be taken with fenofibrates if on statin therapy due to increased risk of skeletal toxicity (23, 24). Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are a novel class of drugs that block the activity of PCSK9, a proprotein convertase that has a role in breaking down LDL receptors in the liver (24, 26).…”

“…Fenofibrates and omega 3 fatty acid supplementation can be used alone or in combination, however care must be taken with fenofibrates if on statin therapy due to increased risk of skeletal toxicity (23, 24). Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors are a novel class of drugs that block the activity of PCSK9, a proprotein convertase that has a role in breaking down LDL receptors in the liver (24, 26). Mutations in the PCSK9 gene are responsible for familial hypercholesterolemia that is a result of reduced LDL receptors on hepatocytes and reduced ability to remove LDL cholesterol from plasma (26).…”

“…By reducing the breakdown of LDL receptors, they increase the clearance of LDL cholesterol with overall reduction in LDL cholesterol (24, 26). They were not available during the study period.…”