Clinical Manual for Management of the HIV-Infected ... - myCME.com

4–8 | Clinical Manual for Management of the HIV-Infected Adult/2006
non-HDL cholesterol (TC minus HDL) can be used as
a surrogate target of therapy; the non-HDL goal is 30
mg/dL higher than the LDL goal. For these individuals,
dietary intervention is warranted, and drug therapy to
decrease LDL (or non-HDL) can be considered if TC
is >240 mg/dL or HDL cholesterol is 500 mg/dL, a low-fat diet (200 mg/dL
may need pharmacologic therapy.
Fibrates are the first-line drug option for isolated
hypertriglyceridemia and are an alternative
treatment for combined hypertriglyceridemia and
hypercholesterolemia. Fenofibrate or gemfibrozil reduce
TG levels effectively in patients on ARVs. Because they
are not metabolized by the cytochrome P450 hepatic
enzyme system, they do not have significant drug
interactions with ARVs. Fibrates are contraindicated in
patients with renal failure. Recommended dosages of
these agents are as follows:
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Fenofibrate: 50-200 mg orally daily
Gemfibrozil: 600 mg orally twice daily, 30 minutes
before meals
If a fibrate alone is inadequate in reducing TGs, several
options are possible. A statin (notably atorvastatin,
which acts on TGs as well as cholesterol) could be
added cautiously, although there is an increased risk
of skeletal muscle toxicity with concomitant use
of a fibrate and a statin. N-3 (omega-3) fatty acid
supplements, administered at 2 g 3 times a day, have
decreased TG levels in patients taking ART. Niacin
also decreases both TG and TC levels, although its
clinical utility is restricted because of associated insulin
resistance and flushing.
Switching Antiretroviral Therapy
In patients with CHD or CHD equivalents, ARV
medications should, if possible, be selected to minimize
the risk of hyperlipidemia. In patients with dyslipidemia
caused by ARV agents, data suggest that it may be
beneficial to discontinue the offending ARVs if
reasonable alternatives exist. Substituting atazanavir
or nevirapine in place of a lipogenic PI, or replacing
stavudine with abacavir or tenofovir, may improve the
lipid profile. Before making ARV substitutions, however,
consider carefully the possible effect of the substitution
on HIV virologic control and the potential adverse
effects of new ARVs. In some cases, antihyperlipidemic
agents may still be necessary after ARV substitution.