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Gail Berkenblit, M.D.,Ph.D. and Joseph Cofrancesco, Jr., M.D., M.P.H.
02-08-2008
- Epidemiology of hyperlipidemia in Zambia not well-defined.
- In Zambia, recommended baseline labs prior to starting ART include cholesterol and triglycerides, if available.
- In Zambia, consideration of cholesterol and triglyceride monitoring recommended after 6 months if on PI-containing regimen.
- If cholesterol and triglycerides normal on ART, can then be repeated on a yearly basis.
- Suggestions to reduce high blood cholesterol include reducing dietary fat intake, limiting saturated and trans-fat intake, increasing daily vegetable and fruit intake, and exercising regularly.
- Suggestions to reduce high triglycerides include limiting saturated triglycerides and trans-fat intake, reducing carbohydrate intake, increasing intake of whole grain cereals, fruits, and vegetables, and exercising regularly.
- WHO notes that routine monitoring of lipid levels not absolutely necessary in patients on ART.
- Most statins, fibrates, ezetimibe, and omega-2-acid ethyl esters not readily available in Zambia.
Zambia Information Author: Larry William Chang, MD, MPH
- PIs: most cause elevation in total cholesterol (TC), LDL and triglycerides (TG). Highest risk:RTV, TPV/r and LPV/r. Least or no risk: ATV and SQV. TC and LDL increase an average of 30 mg/dL on PIs. TGs may be severely elevated. Usually seen within 2-3 mos of starting PI.
- NRTIs: d4T highest risk for TG and LDL increase. Low or no risk with TDF and ABC. NNRTIs: EFV > NVP associated with TG, LDL increase. NNRTIs increase HDL. Increase in TG, TC and LDL less than for PIs.
- High LDL increases risk of coronary artery disease (CAD). Lipid elevation may be part of metabolic syndrome.
- Hx: evaluate for atherosclerotic disease (CAD, CVA, PVD), diabetes, and CAD risk factors.
- CAD risk factors: smoking; age (men >45, women >55) ; HTN; HDL <40 (subtract 1 risk factor if HDL >60); family history of premature CAD (male 1st degree relative <55, female 1st degree relative <65 ).
- PE: often unrevealing, though may detect vascular disease, xanthomas, xanthelasma, and, in severe hypertriglyceridemia, lipemia retinalis.
- TG >1000-2000: risk for pancreatitis.
- Obtain lipid profile after 8-12 hr fast:at baseline, before initiating or changing HAART, 3-6 mos afterwards; and annually if at target cholesterol.
- LDL goal:(1) high risk (CAD, non-coronary atherosclerotic disease, diabetes): LDL <100 . (Optional goal <70 for very high risk) (2) >2 risk factors: LDL <130. (Optional goal <100 for moderately high risk.) (3) 0-1 risk factor: LDL <160.
- TG goal: normal <150 , borderline 150-199 , high 200-499 , very high>500 .
- If cannot obtain fasting profile, use non-HDL cholesterol (total cholesterol - HDL = "non-HDL)." Targets for non-HDL = "LDL" target + 30.
- Counsel on risk factor modification: smoking, cocaine, diet, exercise.
- Treatment of hypercholesterolemia focuses on LDL reduction (based on NCEP guidelines (SeeTable).
- Refer to nutritionist for diet and weight management. Exercise program for elevated TG.
- Medical therapy indicated for fasting TG levels >500.
- Consider changing ART if diet, exercise and lipid-lowering therapy insufficient.
- Change to NNRTI or to PI with more favorable lipid profile (ATV or SQV may improve lipids). Substituting TDF or ABC for d4T or AZT may be beneficial.
- HMG-CoA reductase inhibitors (statins) most potent to lower LDL. Statin levels may be increased by PIs; start at low doses and cautiously increase. Pravastatin and rosuvastatin have least interactions with CYP3A4. Atorvastatin may be used cautiously, starting at low doses. Avoid lovastatin and simvastatin. See HMG-CoA reductase inhibitor module for detailed drug interactions with ART.
- Begin with pravastatin 20 mg (max 80 mg) qhs or atorvastatin 10 mg (max 80mg, but most do not exceed 40 mg with ART) qd. Rosuvastatin may be started at 5 mg PO (max 40 mg) qhs, but may be associated with greater risk of myositis.
- Fibric acids preferred for high TG. Start with gemfibrozil 600 mg PO bid or fenofibrate 48-145 mg PO qd.
- Avoid bile acid sequestrants (interfere with ART absorption).
- Niacin an option, but may worsen insulin resistance. Can cause flushing; patients may take aspirin 81 mg (if no contraindication) 1/2 hour before dose and gradually escalate dose.
- Ezetimibe (2nd line after statin) to lower LDL. Drug interactions not well-known. Usually used along with a statin to lower cholesterol.
| Drug | Recommendations/Comments |
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atorvastatin
| One of most effective lipid-lowering agents, but levels increased by PIs. Avoid high doses (>40 mg/d) in pts on PIs, monitor LFTs, and counsel pts about Sx of rhabodymyolysis, especially if used in combination with a fibrate. |
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pravastatin
| Less potent than other statins, but levels lowered by PIs: can be used at full dose. Causes less myositis. |
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fenofibrate
| Possibly more effective than gemfibrozil and can be dosed once a day with food. Possibly less likely than gemfibrozil to cause rhabdomyolysis when combined with statin. |
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gemfibrozil
| Effective at lowering TG, but requires bid dosing before meals. Increased risk of rhabdomyolysis when combined with statins. |
| ezetimibe | Can be used along with statin to further reduce LDL levels in difficult cases. |
| Omega-2-acid ethyl esters | (Omacor) A prescription purity/strength fish oil compound useful for lowering triglycerides. Also raises LDL slightly. |
- Repeat fasting lipid profile 6-12 wks after starting or changing lipid lowering therapy, then every 6 mos once stable.
- Check LFTs at baseline then 6-12 wks after initiation of therapy, then every 3-6 mos depending on pt's clinical situation
- Both statins and fibric acid cause rhabdomyolysis; combination with fenofibrate may have less risk than gemfibrozil. Routine CK monitoring not recommended in asymptomatic pts, but pts should report myalgias. Discontinue Rx temporarily if myositis occurs, then consider restarting at lower dose.
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