- All PIs, especially RTV-boosted PIs; lower incidence reported with DRV/r and ATV with or without ritonavir
- As early as 2 weeks to months after beginning therapy
|10% to 20% in young children receiving LPV/RTV
20% to 50% of children receiving ART will have lipoprotein abnormalities.
|Advanced-stage HIV disease
High-fat, high-cholesterol diet
Lack of exercise
Family history of dyslipidemia or premature CVD
- Low-fat diet
- No smoking
Adolescents and Adults:
Children (Aged ≥2 Years) Without Lipid Abnormalities or Additional Risk Factors:
- Monitor 12-hour FLP, which includes TC, HDL-C, non-HDL-C, LDL-C, and TG, every 6–12 months. Obtain FLPs twice (>2 weeks—but ≤3 months—apart, average results) before initiating or changing lipid-lowering therapy.
Children with Lipid Abnormalities and/or Additional Risk Factors:
- Obtain non-fasting screening lipid profiles before initiating or changing therapy and then, if levels are stable, every 6–12 months. If TG or LDL-C is elevated, obtain fasting blood tests.
Children Receiving Lipid-Lowering Therapy with Statins or Fibrates:
- Obtain 12-hour FLP before initiating or changing therapy and every 6 months thereafter (more often if indicated).
- Obtain 12-hour FLP, LFTs, and CK at 4 and 8 weeks, and 3 months after starting lipid therapy.
- If minimal alterations in AST, ALT, and CK, monitor every 3–4 months in the first year and every 6 month thereafter (or as clinically indicated).
- Repeat FLPs 4 weeks after increasing doses of antihyper-lipidemic agents.
|Assessment of additional CVD risk factors should be done in all patients. HIV-infected patients are considered to be at moderate risk of CVD.a
Counsel lifestyle modification, dietary interventions (e.g., low-fat diet; low simple carbohydrate diet in case of ↑TG; exercise, smoking cessation) for adequate trial period (3–6 months).
Statin-related toxicities include liver enzyme elevation and myopathy, and risk may be increased by drug interactions with antiretroviral treatment.b Risks must be weighed against potential benefits
- Dyslipidemic children aged ≥10 years with LDL-C ≥250 mg/dL or TG levels ≥500 mg/dL and all children aged <10 years who require lipid-lowering treatment should be managed by a lipid specialist.
Consider switching to a new ART regimen less likely to cause lipid abnormalities.
Consider lipid-lowering therapy in consultation with a lipid specialist if 6-month trial of lifestyle modification fails.
No consensus exists as to what LDL-C should prompt treatment in children receiving ARV drugs. Drug therapy cut points recommended by NHLBI cardiovascular risk reduction guidelines for children aged ≥10 years: LDL–C ≥190 mg/dL, regardless of additional risks factors; LDL-C ≥160 mg/dL or LDL-C ≥130 mg/dL based on presence of additional risk factors and risk conditions.a
The minimal goal of therapy should be to achieve and maintain a LDL-C value below 130 mg/dL.
Initiate Drug Therapy Promptly in Patients with TG ≥500 mg/dL:
Fibrates (gemfibrozil and fenofibrate) and N-3 PUFAs derived from fish oils may be used as alternative agents for adults with ↑TG but are not approved for use in children. The long-term risks of lipid abnormalities in children receiving cART are unclear. However, persistent dyslipidemia in children may lead to premature CVD.
- Statins such as pravastatin, atorvastatin, or rosuvastatin.b Ezetimibe can be considered in addition to statins.c