New Guidelines for Avoiding Heart Disease by Managing High Cholesterol, Triglycerides, or Related Problems in HIV

On September 1, 2003, the Infectious Disease Society of America (IDSA) released new guidelines for treating dyslipidemia (blood fat and some related disorders) in persons with HIV. These guidelines were prepared by a team of clinical scientists on the Cardiovascular Subcommittee of the AIDS Clinical Trials Group (ACTG), who updated preliminary recommendations published in 2000. These guidelines also reflect the updated cholesterol guidelines for the general public, which were published in 2001. The result is an authoritative (for 2003) and practical document filled with useful suggestions and advice. The new guidelines, 11 pages of text plus 147 references, were written mainly for physicians.

From the executive summary:

"We recommend that HIV-infected adults undergo evaluation and treatment on the basis of NCEP ATP III guidelines [National Cholesterol Education Project -- Adult Treatment Panel III] for dyslipidemia, with particular attention to potential drug interactions with antiretroviral agents and maintenance of virologic control of HIV infection. When drugs become necessary, we recommend as initial therapy pravastatin or atorvastatin for elevated low-density lipoprotein cholesterol levels and gemfibrozil or fenofibrate when triglyceride concentrations exceed 500 mg/dL."

Basically these guidelines apply the NCEP standards for reducing cardiovascular (heart and blood-vessel) disease risk for the general public, to people with HIV. There are a number of HIV-specific considerations, for example avoiding interactions of lipid-lowering drugs with antiretrovirals. Perhaps even more than in the general population, lifestyle changes such as diet and exercise (and of course quitting smoking) are recommended before lipid-lowering drugs, except in urgent cases.

The new guidelines review the following topics:

• Evidence that certain antiretrovirals cause more lipid problems than others;

• Possibilities of switching antiretrovirals;

• Studies of the risk of cardiovascular disease in persons with HIV, using the NCEP to help decide about lifestyle changes and lipid-lowering drugs;

• Therapeutic use of niacin to help correct cholesterol levels, or fish oils to reduce triglycerides, which may be tried in some cases;

• When to refer a patient to an expert in treating dyslipidemia in persons with HIV;

• Drug interactions, including certain lipid-lowering drugs to avoid because they can interact dangerously with antiretrovirals.

The guidelines were published in Clinical Infectious Diseases, September 1, pages 613-627. They are also available at the Web site of NATAP, the National AIDS Treatment Advocacy Project, www.natap.org/2003/sept/GuidelinesforDyslipidemia.pdf (PDF).

ISSN # 1052-4207

Copyright 2003 by John S. James. Permission granted for noncommercial reproduction, provided that our address and phone number are included if more than short quotations are used.