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Dyslipidemia – Treatment Overview

Treatment Overview

Prevention

In patients with pre-existing cardiovascular risk factors, ARV drugs with more favorable lipid profiles should be chosen as initial therapy.1 However, HIV itself should be treated first, with consideration for underlying comorbidities.1


Lifestyle modification

  • Interventions should routinely be offered for modifiable cardiovascular risk factors, including:2

A table describing lifestyle modifications for people living with HIV has been developed by the European AIDS Clinical Association (EACS).3

Recommended dietary modifications in patients with dyslipidemia

Patients with elevated triglycerides should avoid / limit foods that are high in simple or refined sugars4 Patients with elevated triglycerides should avoid / limit foods that are high in simple or refined sugars4
Alcohol Animal fats
High-sugar beverages or snacks (inc. fruit juices) Whole milk
High-sugar cereals Cheese
Honey / Syrups Butter, Lard
Jams / Preserves Egg yolk
Sweets and non sugar-free gums Coconut and Palm oils
Ice cream, frozen yogurt, gelato Shellfish
Biscuts, cakes, pies and cereals bars Poultry served with skin
Highly refined breads, cereals, rice or pastas  

Treatment for dyslipidemia

  • Guidelines recommend that lifestyle modifications should be attempted first as these may improve dyslipidemia.2,3 
  • If lifestyle modifications are not effective, changes to ARV therapy should be considered first,2,3 then lipid-lowering medication in high-risk patients.3
  • Clinicians will need to carefully consider:2
    • the risks of new treatment-related toxicities and the possibility of virological relapse when switching ARV drugs
    • the risks of potential drug interactions and new treatment-related toxicities from lipid-lowering agents that are added to existing regimens
       
  • The NCEP ATP III Guidelines (page IV-1) recommend adjusting the intensity of risk reduction therapy (lipid-lowering medication) according to the patient’s risk of having an adverse coronary event.6
  • Additional information is available on drug therapy for dyslipidemia.
     

Treament Goals3

Target* Total cholesterol LDL-c†
Optimal, mmol/L (mg/dL) ≤4 (155) ≤2 (80)
Standard, mmol/L (mg/dL) ≤5 (190) ≤3 (115)

*Target levels are to be used as guidance and are not definitive.
†In case LDL-c cannot be calculated because of high triglyceride levels, the non-HDL-c (total cholesterol minus HDL-c) target should be used, which is 0.8 mmol/L (30 mg/dL) higher than the corresponding LDL-c target. 
HDL-c = high-density lipoprotein cholesterol , LDL-c = low-density lipoprotein cholesterol.



For more information please also refer to the ESC/EAS guidelines for the management of dyslipidemias.7

Drug-drug interactions are particularly important when treating HIV-infected patients who are already receiving treatment. Please refer to the HIV drug interactions website and the drug-drug interactions section of myHIVclinic.


 

References

  1. Tungsiripat M, Aberg JA. Dyslipidemia in HIV patients. Cleve Clin J Med. 2005;72:1113–1120.
  2. Dubé MP, Stein JH, Aberg JA, et al. Guidelines for the Evaluation and Management of Dyslipidemia in Human Immunodeficiency Virus (HIV)–Infected Adults Receiving Antiretroviral Therapy: Recommendations of the HIV Medicine Association of the Infectious Disease Society of America and the Adult AIDS Clinical Trials Group. Clin Infect Dis. 2003;37:613–627.
  3. European AIDS Clinical Society (EACS) Guidelines for the Prevention and Management of Non-infectious Co-morbidities in HIV. Version 5–4. Accessed 5 August 2011
  4. Cleveland Clinic. How food affects triglycerides. 2011. Accessed 23 August 2011.
  5. Cleveland Clinic. How to lower your cholesterol. 2009. Accessed 23 August 2011.
  6. National Institutes of Health, National Heart, Lung and Blood Institute. Third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III]). Accessed 05 August 2011.
  7. The Task Force for the management of dyslipidemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). ESC/EAS Guidelines for the Management of Dyslipidemias. Eur Heart J. 2011;32:1769–1818.