(Last updated: March 5, 2015; last reviewed: March 5, 2015)
|Adverse Effects||Associated ARVs||Onset/ Clinical Manifestations||Estimated Frequency||Risk Factors||Prevention/ Monitoring||Management|
|10% to 20% in young children receiving LPV/RTV
20% to 50% of children receiving cART will have lipoprotein abnormalities.
|Advanced-stage HIV disease
High-fat, high-cholesterol diet
Lack of exercise
Family history of dyslipidemia or premature CVD
Adolescents and Adults:
|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 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).
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.
Some experts suggest treatment in children receiving ARV drugs at cut points recommended by NHLBI cardiovascular risk reduction guidelines for children aged ≥10 years: LDL-C ≥190 mg/dL, regardless of additional risk factors; LDL-C ≥160 mg/dL or LDL-C ≥130 mg/dL based on presence of additional risk factors and risk conditions.b
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:
Statins such as pravastatin, atorvastatin, or rosuvastatin.c Ezetimibe can be considered in addition to statins.d Statin-related toxicities include liver enzyme elevation and myopathy, and risk may be increased by drug interactions with cART, particularly PIs.c Risks must be weighed against potential benefits.
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.
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.
b Refer to NHLBI guidelines at http://www.nhlbi.nih.gov/guidelines/cvd_ped/summary.htm#chap9.
c The risks of new treatment-related toxicities and virologic failure that could occur with changes in therapy must be weighed against the potential risk of drug interactions and toxicities associated with the use of lipid-lowering agents.
d Statins (HMG-CoA reductase inhibitors) are contraindicated in pregnancy (potentially teratogenic) and should not be used in patients who may become pregnant. Multiple drug interactions exist between ARV drugs and statins (exception pravastatin, which is not dependent on CYP3A4 for metabolism). Pravastatin, atorvastatin, rosuvastatin (Crestor®), fluvastatin, and ezetimibe (Zetia®) are approved for use in children aged ≥10 years.
Key to Acronyms: ALT = alanine aminotransferase; ART = antiretroviral therapy; ARV = antiretroviral; AST = aspartate aminotransferase; ATV = atazanavir; cART = combination antiretroviral therapy; 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