Expert offers help for PI-related heart disease
Expert offers help for PI-related heart disease
Regimen switches may be advisable
[Editor’s note: The January issue of AIDS Alert included an article on the connection between highly active antiretroviral therapy (HAART) and heart disease. AIDS Alert asked Joseph J. Eron Jr., MD, an associate professor of medicine and director of Clinical Core at the University of North Carolina Center for AIDS Research in Chapel Hill, to comment on the recent findings that HAART and protease inhibitors (PIs) may increase the risk of heart disease in HIV patients and to offer a strategy for treating patients at risk for heart disease problems related to their antiretroviral therapy. Here are his comments.]
AIDS Alert: How concerned should clinicians be about the possibility of heart disease among HIV patients who are taking protease inhibitors, and what are some strategies for dealing with this problem?
Eron: This remains a very open question. Most PIs appear to raise cholesterol or triglycerides or both. There is much debate about the degree of change and whether total cholesterol rises are accompanied by HDL-C [high-density lipoprotein cholesterol] rises that might mitigate risk. Also, whether drug-induced rises in cholesterol have the same risk as high baseline cholesterol is not known, but it seems likely. I think clinicians should be paying very close attention to this problem, and we need to monitor research in this area that we may not have previously paid as much attention to. I think clinicians should be concerned about the long-term health effects on their patients, but this is not synonymous with abandoning therapy that raises cholesterol.
Strategies for addressing the problem include getting a full fasting lipid profile prior to initiating therapy and obtaining a careful risk factor history including family history and work to control other factors such as diet, exercise, blood pressure, smoking, etc. Clinicians need to make individual risk assessments for each of their patients. The more advanced the HIV disease or the more resistant a patient’s HIV is, the less important long-term lipid risks are. HIV clinicians should be very familiar with the most recent guidelines on management of increased lipids and know the risk of the lipid-lowering drugs.
AIDS Alert: When might a clinician need to swap a PI regimen with a non-PI regimen because of the heart disease risk?
Eron: I think a patient with known coronary disease or very high risk in whom there is evidence that his PI regimen resulted in an increase in lipids should be considered for a regimen switch. Diet, exercise, and lifestyle changes should be recommended; assistance given for cessation of smoking and good control of hypertension are equally if not more important. A switch strategy requires that there is a safe regimen to switch to. If a patient has failed multiple previous therapies and no easy switch regimen is available, then lipid-lowering agents used aggressively would most likely be a better alternative. They should also be part of the equation when trying to determine the best course of therapy, even when there is a switch option.
AIDS Alert: How big of a problem in the future do you think this relationship between PIs and heart disease/lipid problems will be?
Eron: This will depend on the data currently being collected in several studies and on the results of more basic research. I think there will be some relationship, but it will be manageable.
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