The treatment of
hyperlipidemia in patients infected with HIV is discussed.
Hyperlipidemia is common in HIV-infected patients receiving antiretroviral
therapy, especially
protease inhibitors and
stavudine. The recommendations of the National
Cholesterol Education Program (NCEP) may not entirely apply to HIV-infected patients. The pathogenesis of
hyperlipidemia in these patients may make them refractory to traditional
pharmacotherapy, and NCEP's emphasis on diet and exercise may be unrealistic. Other factors that may complicate treatment of
hyperlipidemia include metabolism of many antiretroviral drugs by the
cytochrome P-450 isoenzyme system,
polypharmacy, and drug-food interactions. A patient's cardiac risk should first be assessed. Nonpharmacologic measures, such as a
low-fat diet,
weight reduction, and exercise, should be considered.
Drug therapy is indicated for patients with
familial combined hyperlipidemia that is associated with
atherogenesis and for patients with
triglyceride concentrations exceeding 1000 mg/dL.
Drug therapy for
hyperlipidemia involves
niacin and
statins, in addition to
fibric acid derivatives and
probucol. Switching among
antiretroviral agents when one is found to cause
hyperlipidemia should be done cautiously because of the risk for viral rebound and
disease progression. NCEP guidelines recommend monitoring
low-density-lipoprotein cholesterol levels four to six weeks after the start of
lipid-lowering
therapy and then at three months; more frequent monitoring may be necessary in HIV-infected patients. The treatment of
hyperlipidemia in HIV-infected patients is complicated by their need for antiretroviral drugs, which can themselves contribute to
lipid disorders.