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Canadian Journal of Cardiology

Lipid Abnormalities in Persons Living With HIV Infection

  • David D. Waters
    Correspondence
    Corresponding author: Dr David D. Waters, Division of Cardiology, Room 5G1, Zuckerberg San Francisco General Hospital, 1001 Potrero Ave, San Francisco, California 94110, USA. Tel.: +1-415-420-6646.
    Affiliations
    Division of Cardiology, Zuckerberg San Francisco General Hospital, and Department of Medicine, University of California, San Francisco, California, USA
    Search for articles by this author
  • Priscilla Y. Hsue
    Affiliations
    Division of Cardiology, Zuckerberg San Francisco General Hospital, and Department of Medicine, University of California, San Francisco, California, USA
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Published:November 14, 2018DOI:https://doi.org/10.1016/j.cjca.2018.11.005

      Abstract

      Lipid abnormalities are prevalent among persons living with HIV infection and contribute to increasing the risk of cardiovascular events. Antiretroviral therapy (ART) is associated with lipid abnormalities, most commonly hypertriglyceridemia, but also increases in low-density lipoprotein cholesterol and total cholesterol. Different classes of ART, and different drugs within classes, have differing effects on lipid levels, but in general newer drugs have more favourable effects compared with older ones. Low-level inflammation and chronic immune activation act on lipids through a variety of mechanisms to make them more atherogenic. As a consequence, risk is higher than would be expected for any given cholesterol level. Clinical outcome trials of cholesterol-lowering therapies have not yet been completed in people living with HIV, so that treatment decisions depend on extrapolation from studies in uninfected populations. Traditional risk assessment tools underestimate cardiovascular risk in individuals with HIV. Statins are the mainstay of lipid-lowering drug treatment; however, drug–drug interactions with ART must be considered. Simvastatin and lovastatin are contraindicated in patients taking protease inhibitors, and the dose of atorvastatin and rosuvastatin should be limited to 40 mg and 10 mg/d with some ART combinations. Switching from older forms of ART to lipid-friendly newer ones is a useful strategy as long as virologic suppression is maintained, but adding a statin lowers low-density lipoprotein cholesterol more effectively. Studies indicate that lipid abnormalities are not treated as aggressively in individuals living with HIV as they are in uninfected people, making this an opportunity to improve care.

      Résumé

      Les anomalies lipidiques sont répandues chez les personnes qui vivent avec le VIH et contribuent à l’augmentation du risque d’événements cardiovasculaires. Le traitement antirétroviral (TARV) est associé aux anomalies lipidiques, plus fréquemment à l’hypertriglycéridémie, mais aussi à l’augmentation du cholestérol à lipoprotéines de basse densité et du cholestérol total. Les différentes classes de TARV et les différents médicaments parmi ces classes ont des effets distincts sur les taux de lipides, mais en général les nouveaux médicaments ont des effets plus favorables que les anciens médicaments. L’inflammation de faible degré et l’activation chronique du système immunitaire agissent sur les lipides par divers mécanismes pour les rendre plus athérogènes. Par conséquent, le risque est supérieur à ce que l’on s’attendrait pour tout taux de cholestérol donné. Les études sur les résultats cliniques des traitements hypocholestérolémiants chez les personnes atteintes du VIH n’étant pas encore achevées, les décisions en matière de traitement dépendent donc de l’extrapolation des résultats des études auprès des populations non infectées. Les outils traditionnels d’évaluation des risques sous-estiment les risques cardiovasculaires chez les individus infectés par le VIH. Les statines constituent le pilier du traitement par hypolipidémiants. Toutefois, les interactions médicamenteuses avec le TARV doivent être considérées. La simvastatine et la lovastatine sont contre-indiquées chez les patients qui prennent des inhibiteurs de protéase, et la dose respective d’atorvastatine et de rosuvastatine devrait être limitée à 40 mg et à 10 mg/j avec certaines combinaisons de TARV. Le passage des anciens TARV vers les nouveaux TARV dont les effets sur le profil lipidique sont favorables est une stratégie utile pourvu que la suppression virologique soit maintenue, mais l’utilisation supplémentaire d’une statine abaisse plus efficacement le cholestérol à lipoprotéines de faible densité. Les études montrent que les anomalies des lipides ne sont pas traitées aussi énergiquement chez les individus qui vivent avec le VIH qu’elles le sont chez les personnes non infectées et offrent une occasion d’amélioration des soins.
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