Management of dyslipidemia in patients with HIV disease

The epidemiological, etiopathogenetic, laboratory and clinical features of serum lipid abnormalities occurring in the course of HIV disease are still poorly understood (especially when the supporting role of single antiretroviral compounds is considered), while limited literature data are to date available regarding the management of HIV-related dyslipidemia, as well as the efficacy and safety of dietary-exercise programs, and that of selected hypolipidemic agents. At this time, a careful monitoring of serum lipid profile is needed during combination antiretroviral therapy including protease inhibitors, in order to suggest a diet and hypolipidemic treatment when applicable, and to prevent clinical sequelae related to long-term dyslipidemia. The selection of an appropriate hypolipidemic agent is difficult, since no controlled studies are available in this field, and possibly increased risks of pharmacologic interactions, toxicity and impaired patient's adherence should be taken into consideration. Waiting for specific guidelines for the treatment of hypertriglyceridemia and hypercholesterolemia in the setting of HIV infection, all available literature reports dealing with the management of HIV-associated hyperlipidemia are briefly discussed, on the basis of personal clinical experience.

Is acute appendicitis another inflammatory condition associated with highly active antiretroviral therapy (HAART)?

OBJECTIVE

To report the occurrence of acute appendicitis as a possible manifestation of the immune restoration inflammatory syndrome (IRIS) following the commencement of highly active antiretroviral therapy (HAART) in HIV patients.

DESIGN

Case-note review of HIV patients on HAART with acute appendicitis.

METHODS

Review of HIV markers, antiretroviral therapy and abdominal ultrasound results of four HIV patients with acute appendicitis and the histopathology reports on the appendix in two of the patients.

RESULTS

From a population of approximately 350 HIV patients on HAART, we found four patients who developed acute appendicitis within 6 months of commencing or changing HAART.

CONCLUSION

Acute appendicitis occurring in HIV patients on HAART may represent a variant of IRIS. Further immunohistopathological and epidemiological evaluation will be needed to define this relationship fully.

Metabolic and anthropometric consequences of interruption of highly active antiretroviral therapy

BACKGROUND

HAART has been associated with metabolic abnormalities (hyperlipidemia, insulin resistance, alterations in cortisol metabolism) and fat redistribution.

SETTING

A prospective study of 26 Caucasian men (median age 43.5 years) with HIV-1 viral loads < 500 copies/ml for 12 months while on highly active antiretroviral therapy (HAART) who interrupted treatment for a median of 7.0 weeks (range 4.9-10.3 weeks). Seventeen (65.4%) patients reported at least one fat redistribution symptom at baseline.

METHOD

Serum lipids, glucose and insulin levels during an oral glucose tolerance test, 24-h urinary free cortisol and 17-hydroxycorticosteroids, and anthropometric parameters were measured before HAART cessation and prior to its reinstitution.

RESULTS

When baseline values were compared with those obtained after HAART interruption (means +/- SD), there was a significant decrease in total cholesterol (194+/-47.3 versus 159+/-29.3 mg/dl; P < 0.0001), low density lipoprotein (LDL) cholesterol (114+/-32.6 versus 96+/-24.7 mg/dl; P = 0.0013), triglycerides (261+/-244.3 versus 185+/-165.4 mg/dl; P = 0.008), and 24-hour urinary 17-hydroxycorticosteroids (15+/-7.9 versus 5+/-2.5 mg/24 h, P < 0.0001) and a significant increase in 24-hour urinary free cortisol (45+/-34.1 versus 62+/-32.2 microg/24 h; P = 0.016). There were no significant changes in glucose or insulin levels or in anthropometric measurements.

CONCLUSIONS

A relatively brief interruption of HAART resulted in significant improvements in total cholesterol, LDL cholesterol, and triglyceride levels. No changes were observed in insulin resistance profiles or anthropometric measurements, perhaps because of the brief duration of HAART interruption. These results suggest that hyperlipidemia and alterations in corticosteroid metabolism in the setting of HAART are a direct drug effect that reverses with drug withdrawal. However, glucose metabolism and fat redistribution do not change over the short term.

Infections of the liver in HIV-infected patients

The liver is a common site of pathology in HIV-infected patients. In patients with controlled HIV and minimal immunosuppression, infection with hepatitis viruses is common owing to the risk factors of sexual transmission or parenteral drug use. In patients with AIDS, the liver is a common site of lymphohematogenous dissemination of several infectious pathogens. A thorough diagnostic approach leads to a diagnosis of most hepatobiliary processes. The therapeutic nihilism that has surrounded hepatic disease, including viral hepatitis, is unwarranted, because treatment of the underlying HIV and the hepatic process may improve the quality of life and longevity of these patients.

HAART tolerability: post-exposure prophylaxis in healthcare workers versus treatment in HIV-infected patients

The aim of our study is to compare the tolerability of zidovudine/lamivudine/indinavir when used in post-exposure prophylaxis (PEP) subjects and in HIV-infected patients. HIV-negative patients were enrolled as part of the surveillance protocol for professional exposure at the Luigi Sacco Hospital in Milan. HIV-positive patients were selected among all subjects undergoing treatment with zidovudine/lamivudine/indinavir from the CISAI cohort, an Italian cohort for the evaluation of adverse reactions to HAART. In both studies patients were followed prospectively and the severity of the reactions was evaluated using the AIDS Clinical Trial Group adverse experience grading scales. Up to September 1999, 37 HIV-seronegative subjects had undergone treatment with zidovudine/ lamivudine/indinavir. From a total of 1207 patients belonging to the CISAI cohort, 199 were identified as being treated with the same regimen. The frequency of adverse events in the PEP subjects was 70.3% compared to 11.1% for HIV-infected patients. In the first group, adverse events caused treatment interruption in 21 subjects (56.7%) versus 14 patients (7%) among the HIV-infected group. Only one case of a severe event (grade 3-4) was observed in the prophylaxis group against 12 in the treatment group. Our study shows that treatment interruption is eight times higher in HIV-negative subjects compared to HIV-seropositive patients, and that the incidence of adverse events is approximately six times higher, though such events, are for the most part, not severe.

Clinical features and risk factors of lactic acidosis following long-term antiretroviral therapy: 4 fatal cases

Our objective was to describe clinical features and predisposing factors attributed to lactic acidosis in 4 HIV-infected patients on long-term nucleoside reverse transcriptase inhibitor (NRTI) therapy. All patients had received at least 6-20 months of NRTI-containing antiretroviral therapy: all used stavudine (d4T), in one combined with lamivudine (3TC), in the other 3 with didanosine (ddI); in one hydroxyurea was added. In all, the initial symptoms were gastrointestinal (nausea and vomiting), followed by tachypnoea preceding the lactic acidosis; death followed 6-22 days after admission (liver failure and uncontrollable arrhythmias). Treatment with riboflavin was unsuccessful in one patient. The only definite risk factor in all cases was NRTI-induced mitochondrial toxicity; one patient was concomitantly treated for Kaposi's sarcoma (with bleomycin and vinblastine) and one just recovered from pneumococcal sepsis. None of the patients had a history of chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection. In all patients, some sort of toxicity to other previously used NRTIs had occurred earlier. Lactic acidosis occurred after months of NRTI therapy in patients who had already suffered other forms of NRTI toxicity. Concomitant diseases or comedication might have aggravated the mitochondrial toxicity of the NRTIs. Screening methods to detect mitochondrial toxicity are necessary, since lactic acidosis occurs rather unexpectedly, with a rapid, fatal course.

Surviving with HIV in the HAART era: emerging challenges

It is clear that metabolic disorders and cancers will continue to be important risks for HIV-infected individuals, especially in the long term. Patients must be aware of new potential risks and, when possible, take preventive measures. In this context, HIV becomes one major aspect of a patient's health, but not the entire focus. By concentrating on the changing aspects of HIV disease, researchers and physicians are keeping pace with a disease that always reveals new information not only about itself, but also on how the immune system functions.

Dietary intake, serum lipids, insulin resistance and body composition in the era of highly active antiretroviral therapy 'Diet FRS Study'

OBJECTIVES

To investigate (i) differences in dietary fat and energy intake between those reporting and those not reporting fat redistribution syndrome (FRS), and (ii) the relationship between dietary fat, total energy intake, serum biochemistry and the clinical characteristics of the syndrome.

DESIGN

A cross-sectional study.

SETTING

Outpatient service of a tertiary referral hospital, Sydney, Australia.

PATIENTS AND METHODS

Dietary intake, serum lipids and insulin resistance and body composition (fat-free mass, fat mass, waist-to-hip ratio; WHR) were determined in 100 HIV-positive patients whose FRS status was classified on the basis of self-report of body composition changes, verified by clinical examination.

RESULTS

There was no significant difference in total or saturated dietary fat intake when grouped by FRS status. There was no significant correlation between dietary saturated or total fat intake and the serum or body composition parameters measured. Total energy intake was higher in those patients reporting FRS (14575 versus 12283 kJ, P = 0.037) after adjustment for age, smoking and exercise status.

CONCLUSION

There appears to be no relationship between either dietary saturated or total fat intake and the serum or body composition parameters characteristic of FRS; however, the total energy intake was significantly higher in those with FRS. The nature of the relationship between total energy intake and FRS (cause or effect) warrants further investigation.