(Last updated: March 1, 2016; last reviewed: March 1, 2016)
|Adverse Effects||Associated ARVs||Onset/Clinical Manifestations||Estimated Frequency||Risk Factors||Prevention/Monitoring||Management|
Reported frequency varies with specific ARV regimen, duration of ART and specific laboratory parameters used to diagnose lipid abnormalities.
10% to 20% in young children receiving LPV/RTV.
40% to 75% of older children and adolescents with prolonged ART history will have lipid abnormalities.
In studies of treatment naive adults, 38% and 32% receiving EVG/COBI/FTC/TAF developed abnormal fasting TC and LDL-C (respectively) after 48 weeks compared with 21% and 20% receiving EVG/COBI/FTC/TDF, difference mainly attributable to TAF.
In 48 adolescents treated with EVG/COBI/FTC/TAF median change from baseline to weeks 24 and 36 were 26 mg/dl and 36 mg/dl, respectively for fasting TC, and 10 mg/dl and 17 mg/dl, respectively for direct LDL-C.
|Advanced-stage HIV disease
High-fat, high-cholesterol diet
Lack of exercise
Family history of dyslipidemia or premature CVD
Children (Aged ≥2 Years) without Lipid Abnormalities or Additional Risk Factors:
Children with Lipid Abnormalities and/or Additional Risk Factors:
Children Receiving Lipid-Lowering Therapy with Statins or Fibrates:
Assessment of additional CVD risk factors should be done in all patients. HIV-infected patients are considered to be at moderate risk of CVD.b
Counsel on lifestyle modification, dietary interventions (e.g., a diet low in saturated fat, cholesterol, and refined sugars particularly in case of ↑TG, elimination of trans fat, physical activity, smoking cessation) for an adequate trial period (3–6 months). Consider consultation with dietician.
If receiving d4T, it should be discontinued. If receiving PI-based ART, consider switching to a new PI-sparing ART regimen or PI-based regimen containing boosted ATV or DRV, which are less likely to cause lipid abnormalities.
Consider lipid-lowering therapy in consultation with a lipid specialist if ≥6-month trial of lifestyle modification fails.
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 Fasting 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 ART are unclear. However, persistent dyslipidemia in children may lead to premature CVD.
a Given the burden of collecting fasting blood samples, some practitioners routinely measure cholesterol and triglycerides from non-fasting blood samples and follow up abnormal values with a test done in the fasted state.
Key to Acronyms: ALT = alanine aminotransferase; ART = antiretroviral therapy; ARV = antiretroviral; AST = aspartate aminotransferase; ATV = atazanavir; CK = creatine kinase; CVD = cardiovascular disease; CYP3A4 = cytochrome P450 3A4; d4T = stavudine; DRV = darunavir; DRV/r = ritonavir-boosted darunavir; EFV = efavirenz; ETR = etravirine; FLP = fasting lipid profile; HDL-C = high-density lipoprotein cholesterol; LDL-C = low-density lipoprotein cholesterol; LFT = liver function test; LPV = lopinavir; NHLBI = National Heart, Lung, and Blood Institute; NNRTI = non-nucleoside reverse transcriptase inhibitor; NRTI = nucleoside reverse transcriptase inhibitor; NVP = nevirapine; PI = protease inhibitor; PUFA = polyunsaturated fatty acid; RPV = rilpivirine; RTV = ritonavir; TC = total cholesterol; TG = triglyceride