Predictive factors of hyperlipidemia in HIV-infected subjects receiving lopinavir/ritonavir

Effectors of Hyperlipidemia among HIV/AIDS patients with second-line antiretroviral therapy based on register data

OBJECTIVE

In this study, we aimed to determine the prevalence and effectors of hyperlipidemia among people living with HIV/AIDS (PLWHA) and taking second-line antiretroviral therapy (ART) using registry data in central China.

METHODS

We conducted a cross-sectional study and collected information of PLWHA on second-line ART during 2018 from two medical registries. Hyperlipidemia was defined according to the 2016 Chinese guidelines for the management of dyslipidemia in adults. Univariate and multivariate logistic regression analyses were performed to explore the influencing factors of hyperlipidemia. We calculated odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 2886 PLWHA taking second-line ART were included in this study, and 978 (33.9%) had hyperlipidemia. Female patients, those with hyperglycemia, and patients with CD4+ cell counts >500 cells/μL had a higher prevalence of hyperlipidemia with 37.0%, 49.0%, and 41.3%, respectively. Multivariate analysis showed that CD4+ cell count 350-500 cells/μL (OR=1.72, 95% CI: 1.26-2.38), CD4+ cell count >500 cells/μL (OR=2.49, 95% CI: 1.85-3.38), and FPG >6.2 mmol/L (OR=2.08, 95% CI:1.64-2.65) were risk factors for hyperlipidemia. Male sex (OR=0.72, 95% CI: 0.61-0.85) and Hb <110 g/L (OR=0.59, 95% CI: 0.45-0.76) were protective factors against hyperlipidemia.

CONCLUSIONS

PLWHA on second-line ART had a higher prevalence of hyperlipidemia. Gender, CD4+ cell count, FPG, and hemoglobin were influencing factors of hyperlipidemia.

Hyperlipidaemia in HIV-infected patients on lopinavir/ritonavir monotherapy in resource-limited settings

BACKGROUND

Cardiovascular disease (CVD) is an emerging concern for HIV-infected patients. Hyperlipidaemia is a risk factor for CVD and a complication of protease-inhibitor-based antiretroviral therapy, but little is known about its incidence and risk factors in treated patients in resource-limited settings (RLS).

METHODS

We conducted a secondary analysis of ACTG A5230 trial in which HIV-infected adults from India, Malawi, Tanzania, Thailand and South Africa, with virological relapse on first-line therapy were initiated on lopinavir/ritonavir (LPV/r) monotherapy. Hyperlipidaemia was a grade 2+ elevated fasting total cholesterol (FTC≥240 mg/dl) or fasting triglycerides (FTG≥500 mg/dl) or calculated low-density lipoprotein cholesterol (LDL≥160 mg/dl) based on measurements at weeks 12, 24, 48, 68 and 104. We evaluated factors potentially associated with quantitative lipid changes from baseline to week 12. These were age, sex, race, site and baseline body mass index, CD4⁺ T-cell count, HIV-1 RNA level and lipids.

RESULTS

106 participants without hyperlipidaemia at baseline started LPV/r; median age 39 years, 68% Black African, 55% female. The cumulative incidence of hyperlipidaemia at week 104 was 48% (95% CI 36, 58%). At week 12, there were significant mean increases from baseline in FTC (17 mg/dl, P<0.001) and FTG (104 mg/dl, P<0.001). In multivariable analysis, higher baseline FTC (P=0.044), FTG (P=0.025), Thai (P<0.001) or Indian sites (P=0.020) versus African sites were associated with increased risk of hyperlipidaemia.

CONCLUSIONS

In HIV-infected adults in RLS initiating LPV/r, hyperlipidaemia was common. Baseline lipid measurements and routine monitoring should be recommended in individuals starting LPV/r-based treatments with borderline high lipids.

Differences in genetic variants in lopinavir disposition among HIV-infected Bantu Africans

INTRODUCTION

Variability in lopinavir (LPV) plasma concentration among patients could be due to genetic polymorphisms. This study set to evaluate significance of variants in CYP3A4/5, SLCO1B1 and ABCC2 on LPV plasma concentration among African HIV-positive patients.

MATERIALS & METHODS

Eighty-six HIV-positive participants on ritonavir (LPV/r) were genetically characterized and LPV plasma concentration determined.

RESULTS & DISCUSSION

LPV plasma concentrations differed >188-fold (range 0.0206-38.6 µg/ml). Both CYP3A4*22 and SLCO1B1 rs4149056G (c.521C) were not observed in this cohort. CYP3A4*1B, CYP3A5*3, CYP3A5*6 and ABCC2 c.1249G>A which have been associated with LPV plasma concentration, showed no significant association.

CONCLUSION

These findings highlight the need to include African groups in genomics research to identify variants of pharmacogenomics significance.

Virologic and Immunologic Outcomes of the Second-Line Regimens of Antiretroviral Therapy Among HIV-Infected Patients in Thailand

Goal of the second-line therapy among HIV-1-infected patients is to re-establish virological suppression, although treatment options in resource-limited settings are limited. An observational cohort of patients with first-line antiretroviral therapy (ART) failure was conducted in a university hospital in Thailand. Of 95 patients, mean age 39 years, 65% were male. Median CD4 and HIV-1 RNA at second-line ART initiation were 158 cells/mm(3) and 4.1 copies/mL, respectively. Boosted protease inhibitor plus 2 nucleoside reverse transcriptase inhibitors (NRTIs), indicated by genotype results, was commonly used as second-line regimen. At 6, 12, 24, and 36 months of second-line ART, 67%, 62%, 84%, and 90% of patients achieved HIV-1 RNA <50 copies/mL; median CD4 were 258, 366, 444, and 522 cells/mm( 3), respectively. Good adherence, high baseline CD4, and early Centers for Centers for Disease Control and Prevention (CDC) staging were associated with virologic success (P < .05). Second-line ART based on the results of genotype testing yields the good virologic and immunologic outcomes in a resource-limited setting, and scaling-up of second-line ART is indicated.

Association of lopinavir concentrations with plasma lipid or glucose concentrations in HIV-infected South Africans: a cross sectional study

Background

Dyslipidaemia and dysglycaemia have been associated with exposure to ritonavir-boosted protease inhibitors. Lopinavir/ritonavir, the most commonly used protease inhibitor in resource-limited settings, often causes dyslipidaemia. There are contradictory data regarding the association between lopinavir concentrations and changes in lipids.

Aim

To investigate associations between plasma lopinavir concentrations and lipid and glucose concentrations in HIV-infected South African adults.

Methods

Participants stable on lopinavir-based antiretroviral therapy were enrolled into a cross-sectional study. After an overnight fast, total cholesterol, triglycerides, and lopinavir concentrations were measured and an oral glucose tolerance test was performed. Regression analyses were used to determine associations between plasma lopinavir concentrations and fasting and 2 hour plasma glucose, fasting cholesterol, and triglycerides concentrations.

Results

There were 84 participants (72 women) with a median age of 36 years. The median blood pressure, body mass index and waist: hip ratio were 108/72 mmHg, 26 kg/m² and 0.89 respectively. The median CD4 count was 478 cells/mm³. Median duration on lopinavir was 18.5 months. The median (interquartile range) lopinavir concentration was 8.0 (5.2 to 12.8) μg/mL. Regression analyses showed no significant association between lopinavir pre-dose concentrations and fasting cholesterol (β-coefficient −0.04 (95% CI −0.07 to 0.00)), triglycerides (β-coefficient −0.01 (95% CI −0.04 to 0.02)), fasting glucose (β-coefficient −0.01 (95% CI −0.04 to 0.02)), or 2-hour glucose concentrations (β-coefficient −0.02 (95% CI −0.09 to 0.06)). Lopinavir concentrations above the median were not associated with presence of dyslipidaemia or dysglycaemia.

Conclusions

There was no association between lopinavir plasma concentrations and plasma lipid and glucose concentrations.

Meta-analysis of once-daily and twice-daily lopinavir/ritonavir combined with NRTIs in HIV-1-infected, antiretroviral-naive patients

Aims: Several studies reported similar virologic responses for lopinavir/ritonavir (LPV/r) 800/200 mg once-daily (q.d.)-containing regimens or LPV/r 400/100 mg twice-daily (b.i.d.)-containing regimens in antiretroviral-naive patients. However, the virologic response in patients with baseline viral loads ≥100,000 copies/ml and gastrointestinal adverse events (AEs) sometimes favored b.i.d. dosing, whereas hypertriglyceridemia may be less frequent with q.d. dosing. This meta-analysis compared the efficacy and tolerability of these two dosing strategies. Materials & methods: Random effects meta-analysis models, in all patients and subgroups with baseline plasma HIV-1 RNA ≥100,000 copies/ml and CD4+ T-cell counts <200 cells/µl, assessed virologic efficacy (HIV-1 RNA <50 copies/ml and time to virologic failure) and prespecified AEs incidence between q.d. and b.i.d. dosing strategies. Descriptive analysis of the pharmacokinetic/pharmacodynamic relationship and resistance development was performed. Results: No difference was found between the two strategies in virologic efficacy, to virologic failure, or AEs in the overall or subgroup populations. Numerical but nonstatistically significant differences in discontinuations due to AEs (2.4%; 95% CI: -0.7–5.5; p = 0.132) favored b.i.d. over q.d. dosing in the overall population. Conclusion: Virologic efficacy, treatment durability and tolerability were similar between the two dosing strategies in the overall and subgroup populations. The LPV/r dosing strategy should be individualized according to patient need.

Body mass index and nutritional intake in patients with HIV and chronic diarrhea: a secondary analysis

PURPOSE

The purpose of this study was to examine the differences in nutritional intake and body mass index (BMI) in HIV patients with chronic diarrhea via secondary analysis of patients' nutritional diaries. A secondary purpose was to evaluate the quality of diets against national dietary guidelines.

DATA SOURCES

Seventy-five ambulatory patients with HIV were included in this study. Patients were categorized using baseline BMI as normal weight (BMI 18.5-24.9 kg/m2), overweight (BMI 25.0-29.9 kg/m2), and obese (BMI >or=30.0 kg/m2). Seven-day nutritional diaries were used to estimate diet in terms of dietary fats, cholesterol, fiber, protein, and sugar. A one-way analysis of variance was conducted to evaluate the relationship between BMI and mean nutritional intake from fat, saturated fat, polyunsaturated fat, monounsaturated fat, cholesterol, fiber, and sugar.

CONCLUSIONS

39.7% and 13.3% of participants were overweight and obese, respectively. The mean intake of fat, saturated fat, and cholesterol was higher than the recommended levels by the National Cholesterol Education Program (NCEP), while the mean intake of monounsaturated fat, polyunsaturated fat, and fiber was below the NCEP guideline. Although the results were not statistically different between groups, grams of fiber intake were lowest for individuals with BMI >or=30.0 kg/m2.

IMPLICATIONS FOR PRACTICE

Advanced practice nurses should encourage increased physical activity and healthy diets at each visit for individuals living with HIV. The continued use of nutritional supplements to boost weight should also be reviewed at each visit to prevent the consumption of unnecessary calories.

Evaluation of sex differences of fosamprenavir (with and without ritonavir) in HIV-infected men and women

PURPOSE

Recent studies focusing on HIV-1-infected women have suggested the existence of sex-related differences in natural history, antiretroviral pharmacokinetics, efficacy, and tolerability. This article analyzes three pivotal trials of the protease inhibitor (PI) fosamprenavir (FPV) with a view to providing a better understanding of potential sex differences in efficacy and safety.

METHOD

A post hoc, descriptive analysis was performed on data from 700 subjects (26% women) in three trials of FPV to evaluate sex differences with regard to efficacy, rates of discontinuation, and treatment-related adverse events.

RESULTS

No major sex differences were found. Men and women had similarly good antiviral responses, with greater than 60% of treatment-naïve subjects achieving virologic suppression (<400 copies/mL) at 48 weeks. PI-experienced women in CONTEXT receiving once-daily FPV/r experienced the highest rates of discontinuations due to virologic failure (29% in women vs. 8% in men). Women generally had slightly lower rates of liver enzyme elevations and fewer abnormalities of total cholesterol and triglycerides.

CONCLUSION

The absence of major sex differences provides reassurance, but the small number of women in these trials limited the ability to draw conclusions. Future trials should be specifically powered to detect sex differences in safety and efficacy.

Cardiovascular risk and choice of HIV drug regimen

Since the introduction of combination antiretroviral therapy (cART), there have been many conflicting reports linking its use to the development of cardiovascular disease (CVD). Most antiretroviral drugs have been associated with the development of lipid abnormalities to some degree. However, whereas several large observational studies have reported a link between the use of cART (particularly protease inhibitors) and CVD, evidence linking specific antiretroviral drugs to CVD is limited. Much of the evidence linking cART to the development of dyslipidemia derives from randomized trials. However, given the relative infrequency of CVD in most HIV-positive populations, these may be inadequately powered to demonstrate a link with clinical events. In contrast, large observational studies have greater power to describe the development of clinical events but may be affected by bias. This review will describe the current literature linking cART to CVD as well as the limitations of some of the published studies.

Cholesterol levels in HIV-HCV infected patients treated with lopinavir/r: results from the SCOLTA project

BACKGROUND

It is not known whether antiretroviral therapy (ART) including lopinavir/r has a different effect on the lipid metabolism in HIV patients co-infected with HCV. This study investigated changes in lipid levels, comparing patients with HIV infection alone and those with HCV too, in the lopinavir/r cohort of the SCOLTA project.

METHODS

We analyzed the data for the lopinavir/r nationwide cohort from 25 Italian infectious disease departments, which comprises 743 HIV-infected patients followed prospectively, comparing subjects with HIV-HCV co-infection and those with single-infection.

RESULTS

At enrolment, co-infected patients had significantly lower mean cholesterol than HCV negative cases (162+/-43mg/dL vs. 185+/-52mg/dL, p=0.0009). Total and non-HDL cholesterol and triglycerides rose significantly from baseline in HIV single-infection patients, but not in those with co-infection. The patients with dual HIV-HCV infection, treated with an ART regimen including lopinavir/r, have only limited increases in total and non-HDL cholesterol and triglycerides.

CONCLUSIONS

Changes in serum lipids in co-infected patients differed significantly from those in patients without HCV. It remains to be seen whether this is associated with a lower risk of progression of atherosclerotic disease.