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Cheng HS, Tan WR, Low ZS, Marvalim C, Lee JYH, Tan NS. Exploration and Development of PPAR Modulators in Health and Disease: An Update of Clinical Evidence. Int J Mol Sci 2019; 20:E5055. [PMID: 31614690 PMCID: PMC6834327 DOI: 10.3390/ijms20205055] [Citation(s) in RCA: 125] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 10/10/2019] [Accepted: 10/10/2019] [Indexed: 12/20/2022] Open
Abstract
Peroxisome proliferator-activated receptors (PPARs) are nuclear receptors that govern the expression of genes responsible for energy metabolism, cellular development, and differentiation. Their crucial biological roles dictate the significance of PPAR-targeting synthetic ligands in medical research and drug discovery. Clinical implications of PPAR agonists span across a wide range of health conditions, including metabolic diseases, chronic inflammatory diseases, infections, autoimmune diseases, neurological and psychiatric disorders, and malignancies. In this review we aim to consolidate existing clinical evidence of PPAR modulators, highlighting their clinical prospects and challenges. Findings from clinical trials revealed that different agonists of the same PPAR subtype could present different safety profiles and clinical outcomes in a disease-dependent manner. Pemafibrate, due to its high selectivity, is likely to replace other PPARα agonists for dyslipidemia and cardiovascular diseases. PPARγ agonist pioglitazone showed tremendous promises in many non-metabolic disorders like chronic kidney disease, depression, inflammation, and autoimmune diseases. The clinical niche of PPARβ/δ agonists is less well-explored. Interestingly, dual- or pan-PPAR agonists, namely chiglitazar, saroglitazar, elafibranor, and lanifibranor, are gaining momentum with their optimistic outcomes in many diseases including type 2 diabetes, dyslipidemia, non-alcoholic fatty liver disease, and primary biliary cholangitis. Notably, the preclinical and clinical development for PPAR antagonists remains unacceptably deficient. We anticipate the future design of better PPAR modulators with minimal off-target effects, high selectivity, superior bioavailability, and pharmacokinetics. This will open new possibilities for PPAR ligands in medicine.
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Affiliation(s)
- Hong Sheng Cheng
- School of Biological Sciences, Nanyang Technological University Singapore, 60 Nanyang Drive, Singapore 637551, Singapore.
| | - Wei Ren Tan
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Singapore 308232, Singapore.
| | - Zun Siong Low
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Singapore 308232, Singapore.
| | - Charlie Marvalim
- School of Biological Sciences, Nanyang Technological University Singapore, 60 Nanyang Drive, Singapore 637551, Singapore.
| | - Justin Yin Hao Lee
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Singapore 308232, Singapore.
| | - Nguan Soon Tan
- School of Biological Sciences, Nanyang Technological University Singapore, 60 Nanyang Drive, Singapore 637551, Singapore.
- Lee Kong Chian School of Medicine, Nanyang Technological University Singapore, 11 Mandalay Road, Singapore 308232, Singapore.
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Abstract
HIV-infected individuals are at an increased risk of cardiovascular disease (CVD) and other HIV-related co-morbidities. This is due in part to dyslipidemia associated with antiretroviral therapy and increased inflammation and immune activation from chronic HIV infection. Statins not only have potent lipid-lowering properties but are also anti-inflammatory and immunomodulators. Studies suggest that statin therapy in the HIV-infected population may decrease the risk of CVD and other non-AIDS-defining co-morbidities. This review summarizes the recent literature on statin use in the HIV setting.
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Affiliation(s)
- Allison Ross Eckard
- Departments of Pediatrics and Medicine, Divisions of Infectious Diseases, Medical University of South Carolina, 135 Rutledge Ave, MSC 752, Charleston, SC, 29425, USA,
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Calza L, Colangeli V, Manfredi R, Bon I, Re MC, Viale P. Clinical management of dyslipidaemia associated with combination antiretroviral therapy in HIV-infected patients. J Antimicrob Chemother 2016; 71:1451-65. [PMID: 26846208 DOI: 10.1093/jac/dkv494] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The introduction of potent combination antiretroviral therapy (cART) has had a remarkable impact on the natural history of HIV infection, leading to a dramatic decline in the mortality rate and a considerable increase in the life expectancy of HIV-positive people. However, cART use is frequently associated with several metabolic complications, mostly represented by lipid metabolism alterations, which are reported very frequently among persons treated with antiretroviral agents. In particular, hyperlipidaemia occurs in up to 70%-80% of HIV-positive subjects receiving cART and is mainly associated with specific antiretroviral drugs belonging to three classes of antiretroviral agents: NRTIs, NNRTIs and PIs. The potential long-term consequences of cART-associated dyslipidaemia are not completely understood, but an increased risk of premature coronary heart disease has been reported in HIV-infected patients on cART, so prompt correction of lipid metabolism abnormalities is mandatory in this population. Dietary changes, regular aerobic exercise and switching to a different antiretroviral regimen associated with a more favourable metabolic profile are the first steps in clinical management, but lipid-lowering therapy with fibrates or statins is often required. In this case, the choice of hypolipidaemic drugs should take into account the potential pharmacokinetic interactions with many antiretroviral agents.
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Affiliation(s)
- Leonardo Calza
- Department of Medical and Surgical Sciences, Section of Infectious Diseases, S. Orsola-Malpighi Hospital, University of Bologna, via G. Massarenti n.11, 40138 Bologna, Italy
| | - Vincenzo Colangeli
- Department of Medical and Surgical Sciences, Section of Infectious Diseases, S. Orsola-Malpighi Hospital, University of Bologna, via G. Massarenti n.11, 40138 Bologna, Italy
| | - Roberto Manfredi
- Department of Medical and Surgical Sciences, Section of Infectious Diseases, S. Orsola-Malpighi Hospital, University of Bologna, via G. Massarenti n.11, 40138 Bologna, Italy
| | - Isabella Bon
- Department of Specialized, Diagnostic and Experimental Medicine, Section of Microbiology, S. Orsola-Malpighi Hospital, University of Bologna, via G. Massarenti n.11, 40138 Bologna, Italy
| | - Maria Carla Re
- Department of Specialized, Diagnostic and Experimental Medicine, Section of Microbiology, S. Orsola-Malpighi Hospital, University of Bologna, via G. Massarenti n.11, 40138 Bologna, Italy
| | - Pierluigi Viale
- Department of Medical and Surgical Sciences, Section of Infectious Diseases, S. Orsola-Malpighi Hospital, University of Bologna, via G. Massarenti n.11, 40138 Bologna, Italy
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Deshpande A, Toshniwal H, Joshi S, Jani RH. A Prospective, Multicentre, Open-Label Single-Arm Exploratory Study to Evaluate Efficacy and Safety of Saroglitazar on Hypertriglyceridemia in HIV Associated Lipodystrophy. PLoS One 2016; 11:e0146222. [PMID: 26789842 PMCID: PMC4720399 DOI: 10.1371/journal.pone.0146222] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Accepted: 12/14/2015] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE This study was designed to explore the efficacy and safety of saroglitazar 4 mg on hypertriglyceridemia in patients with HIV associated lipodystrophy. METHODS During this 12-week prospective, multi-centric, open-label, single arm exploratory study, 50 patients were enrolled to receive saroglitazar 4 mg orally once daily in the morning before breakfast. The primary efficacy endpoint was the percent change in triglyceride (TG) levels from baseline to Week 6 and Week 12. The secondary efficacy endpoints were assessment of low-density-lipoprotein (LDL), very-low-density-lipoprotein (VLDL), high-density-lipoprotein (HDL), non-HDL cholesterol, total cholesterol, apo-lipoprotein (Apo) A1, Apo B, and C-peptide and fasting insulin for HOMA beta and HOMA IR. Safety assessment was performed during the study. RESULTS Saroglitazar 4 mg significantly decreased the serum TG levels from baseline at Week 6 (percent change: -40.98; 95% CI: -50.82, -31.15) and Week 12 (percent change -45.11; 95% CI: -52.37, -37.86). Reduction in VLDL cholesterol (percent change: -46.33; 95% CI: -52.89, -39.76) and total cholesterol (percent change: 7.37; 95% CI: 1.96, 12.78) was observed at week 12 from baseline. Saroglitazar increased HDL cholesterol (percent change: 34.56, 95% CI: 22.22, 46.90), Apo A1 (percent change: 33.16; 95% CI: 18.69, 47.63) and Apo B (percent change: 10.55, 95% CI: 2.86, 18.25) levels at week 12 from baseline. Saroglitazar treatment led to increase in the C-peptide (percent change: 59.42, 95% CI: 48.78, 70.06), fasting insulin levels (percent change: 47.10; 95% CI: 38.63, 55.57), HOMA of beta cell function for C-peptide (percent change: 71.67; 95% CI: 39.09, 104.26) and HOMA of insulin resistance for C-peptide (percent change: 58.29, 95% CI: 46.74, 69.83) at week 12 from baseline. Saroglitazar treatment was safe and well tolerated in this study. CONCLUSION Overall, the observed changes in lipid profile after 12 weeks of saroglitazar treatment were in the direction of improvement in patients with HIV associated lipodystrophy. TRIAL REGISTRATION Clinical Trial Registry of India Phase II/CTRI/2010/091/000107.
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Affiliation(s)
- Alka Deshpande
- Grant Medical College & Sir J.J. Group of Hospitals, Mumbai, Maharashtra, India
| | | | - Shashank Joshi
- Joshi Clinic, 12, Golden Palace, Behind Union Bank of India, Turner Road, Bandra West, Mumbai, India
| | - Rajendrakumar H. Jani
- Clinical R & D, Cadila Healthcare Limited, Zydus Research Centre, Sarkhej-Bavla N.H. No. 8A, Moriaya, Ahmedabad, Gujarat, India
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Mehta N, Reilly M. Atherosclerotic Cardiovascular Disease Risk in the HAART-Treated HIV-1 Population. HIV CLINICAL TRIALS 2015; 6:5-24. [PMID: 15765307 DOI: 10.1310/ht0w-nx2n-u2bm-7luu] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Atherosclerotic cardiovascular disease (CVD), a leading cause of morbidity and mortality in the general population, is also an increasing cause for concern for HIV-infected patients. A number of risk factors for CVD are also associated with HIV disease and HIV therapy, particularly insulin resistance, metabolic dyslipidemia, and inflammation. For example, atherogenic dyslipidemia, a side effect of HIV therapy, is an established risk for CVD in the non-HIV-infected population. As our understanding of atherosclerotic disease evolves, new markers of CVD risk have been identified, including metabolic syndrome definitions and C-reactive protein, a marker of inflammation. Use of these markers, in association with established risk factor guidelines, may serve as important tools in helping HIV physicians implement drug regimens that allow optimum management of metabolic complications associated with HIV and HAART, and thereby reduce CVD risk. The objective of this article is to review the mechanisms of atherosclerotic CVD and to discuss risk factors and markers that can be applied in the evaluation and treatment of CVD in the HIV-positive population.
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Affiliation(s)
- Nehal Mehta
- Cardiovascular Division, Department of Medicine, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
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Bonnet F, Aurillac-Lavignolle V, Breilh D, Thiébaut R, Peuchant E, Bernard N, Lacoste D, Dabis F, Beylot J, Chêne G, Morlat P. Pravastatin in HIV-Infected Patients Treated with Protease Inhibitors: A Placebo-Controlled Randomized Study. HIV CLINICAL TRIALS 2015; 8:53-60. [PMID: 17434849 DOI: 10.1310/hct0801-53] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The objectives of the study were to assess the effects of pravastatin on plasma HIV RNA, lipid parameters, and protease inhibitor (PI) concentrations in patients treated with PI-containing regimens and with total cholesterol (TC) > or = 5.5 mmol/L. METHOD A clinical trial including patients randomized to receive pravastatin or matching placebo for 12 weeks was implemented. RESULTS Twelve patients were included in the pravastatin group and 9 in the placebo group. At week 12 (W12), no patient had experienced virological failure. Between week 0 (W0) and W12, the median differences for TC were -1.4 mmol/L in the pravastatin group and +0.2 mmol/L in the placebo group (p = .005); for LDL, they were -1.0 mmol/L and +0.3 (p = .007), respectively. A significant decrease of the PI concentration (12 hours after administration) ratio W12 - W0/W0 was noticed in the pravastatin group (-0.2 [interquartile range, -0.3 to -0.1] as compared with the placebo group (0.1 [IQR, 0.0 to 0.3]) (p = .03). When the study was restricted to patients treated with lopinavir/ritonavir, a decrease from 3.8 microg/mL at baseline to 2.9 mug/mL at W12 was noticed in the pravastatin arm (p = .04) but not in the control arm (p = 1.00). No clinical adverse event reached a severity of grade 3. CONCLUSION We observed in this study that the use of pravastatin in PI-treated patients was not associated with major change in the plasma HIV RNA on 12 weeks of follow-up. However, we found a trend of decrease of the trough PI concentration at W12, suggesting a possible drug-drug interaction of pravastatin on PI metabolism.
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Affiliation(s)
- Fabrice Bonnet
- Service de Médecine Interne et Maladies Infectieuses, Hôpital Saint-André, Centre Hospitalier Universitaire de Bordeaux, Bordeaux, France.
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Blom DJ. Secondary dyslipidaemia. S Afr Fam Pract (2004) 2014. [DOI: 10.1080/20786204.2011.10874107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Affiliation(s)
- DJ Blom
- Division of Lipidology, Department of Medicine, University of Cape Town
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Abstract
Patients infected with the human immunodeficiency virus (HIV) are prone to a great number of lipid and lipoprotein disturbances, as a result of both the infection itself and direct effects on lipid metabolism from the drugs used to treat HIV infection. These lipid disorders account for at least part of the increased risk of cardiovascular disease seen in this population. In general, evaluation and interventions for dyslipidemia in HIV-infected individuals should follow guidelines established for the general population. Special consideration, however, must be given to the potential for adverse drug interactions between lipid lowering drugs and the agents used to treat HIV infection. In this review, we summarize what is known about the relative tendency of different antiretroviral drugs to alter lipid levels, and suggest an approach to intervention for dyslipidemia in this population.
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Affiliation(s)
- Michael P Dubé
- The Division of Infectious Diseases and the Department of Medicine, University of Southern California, Keck School of Medicine, 5P21 Rand Schrader Health and Research Clinic, Los Angeles, CA 90033, USA.
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Singh S, Willig JH, Mugavero MJ, Crane PK, Harrington RD, Knopp RH, Kosel BW, Saag MS, Kitahata MM, Crane HM. Comparative Effectiveness and Toxicity of Statins Among HIV-Infected Patients. Clin Infect Dis 2010; 52:387-95. [PMID: 21189273 DOI: 10.1093/cid/ciq111] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND dyslipidemia is common and is often treated with 3-hydroxy-3-methylglutaryl coenzyme A (HMG CoA) reductase inhibitors (statins). Little is known about the comparative effectiveness of statins among human immunodeficiency virus (HIV)-infected patients. This study compared the effectiveness and toxicity of statins among HIV-infected patients in clinical care. METHODS we conducted a retrospective cohort study of patients starting their initial statin medications at 2 large HIV clinics (N = 700). The primary observation was change in lipid levels during statin therapy. Secondary observations included whether individualized National Cholesterol Education Program (NCEP) goals for low density lipoprotein cholesterol (LDL-C) and non-high density lipoprotein cholesterol (non-HDL-C) levels were reached, and toxicity rates. We used linear regression to examine change in lipid levels, controlling for baseline lipid values and demographic and clinical characteristics. We conducted secondary analyses using propensity scores to address confounding by indication. RESULTS the most commonly prescribed statins were atorvastatin (N = 303), pravastatin (N = 280), and rosuvastatin (N = 95). One year after starting a statin therapy, patients who received atorvastatin or rosuvastatin had significantly greater decreases in total cholesterol, LDL-C, and non-HDL-C than patients on pravastatin. The likelihood of reaching NCEP goals for LDL-C levels was higher with the use of rosuvastatin (OR 2.1; P = .03) and atorvastatin (odds ratio [OR], 2.1; P = .001) compared with that of pravastatin. The likelihood of reaching NCEP goals for non-HDL-C levels was higher for rosuvastatin (OR 2.3; P = .045) but not atorvastatin (OR, 1.5; P = .1) compared with pravastatin. Toxicity rates were similar for all 3 statins: 7.3% for atorvastatin, 6.1% for pravastatin, and 5.3% for rosuvastatin. CONCLUSIONS our findings suggest that atorvastatin and rosuvastatin are preferable to pravastatin for treatment of HIV-infected patients with dyslipidemia, due to greater declines in total cholesterol, LDL-C, and non-HDL-C, with similar lower toxicity rates.
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Affiliation(s)
- Sudershan Singh
- Department of Medicine, University of Washington, Seattle, WA 98104, USA
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Aslangul E, Assoumou L, Bittar R, Valantin MA, Kalmykova O, Peytavin G, Fiévet MH, Boccara F, Bonnefont-Rousselot D, Melchior JC, Giral P, Costagliola D. Rosuvastatin versus pravastatin in dyslipidemic HIV-1-infected patients receiving protease inhibitors: a randomized trial. AIDS 2010; 24:77-83. [PMID: 19838098 DOI: 10.1097/qad.0b013e328331d2ab] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND HIV infection and its treatment with protease inhibitors, especially when boosted with ritonavir, can cause lipid disorders. Statins, with the exception of fluvastatin, pravastatin and rosuvastatin, interact with protease inhibitor metabolism via CYP450. Pravastatin is recommended for patients with protease inhibitor-associated dyslipidemia. Rosuvastatin is the statin most effective on low-density lipoprotein cholesterol (LDL-c) in non-HIV patients. METHODS HIV-1-infected patients treated with boosted protease inhibitor were randomized to receive either rosuvastatin 10 mg/day or pravastatin 40 mg/day for dyslipidemia (LDL-c >4.1 mmol/l and triglycerides <8.8 mmol/l). The percentage change in LDL-c, triglyceride and high-density lipoprotein-cholesterol levels, measured in a central laboratory, was determined after 45 days of statin treatment. RESULTS Eighty-eight patients were randomized and 83 took the study drugs, 41 rosuvastatin and 42 pravastatin. The median duration of prior antiretroviral treatment was 9 years. At baseline, the median LDL-c level was 4.93 mmol/l, the triglyceride level 2.29 mmol/l, and the high-density lipoprotein-cholesterol level 1.27 mmol/l. The median percentage changes in the rosuvastatin and pravastatin arms were -37 and -19% for LDL-c (P < 0.001), respectively, and -19 and -7% for triglycerides (P = 0.035), respectively. The change in the high-density lipoprotein-cholesterol level was not significantly different between the two arms. None of the four severe adverse events was attributed to the statins; in particular, there were no renal, hepatic or muscular events. CONCLUSION Rosuvastatin 10 mg/day was more effective than pravastatin 40 mg/day on LDL-c and triglyceride levels in HIV-1-infected patients receiving a boosted protease inhibitor.
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Anuurad E, Semrad A, Berglund L. Human immunodeficiency virus and highly active antiretroviral therapy-associated metabolic disorders and risk factors for cardiovascular disease. Metab Syndr Relat Disord 2009; 7:401-10. [PMID: 19355810 DOI: 10.1089/met.2008.0096] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The successful introduction of highly active antiretroviral therapy (HAART), a combination of potent antiretroviral agents, including protease inhibitors, nucleoside reverse transcriptase inhibitors, and nonnucleoside reverse transcriptase inhibitors, has impacted positively on morbidity and mortality among human immunodeficiency virus (HIV)-positive patients. Over time, HAART has been associated with a number of metabolic and anthropometric abnormalities, including dyslipidemia and insulin resistance as well as subcutaneous fat loss and abdominal obesity, potentially contributing to cardiovascular risk. Recent studies have more firmly established that both HIV infection and HAART might increase the risk of clinical cardiovascular events. Furthermore, whereas HIV/HAART is associated with multiple aspects of endocrine dysfunction, there has been less focus on bone disease, although some studies indicate a higher prevalence of osteoporosis among HIV-positive subjects compared to HIV-negative controls. The relationship between bone and fat metabolism under HIV-positive conditions deserves further attention, and available data suggest the possibility of an intriguing connection. In the future, an increasing population of aging HIV-positive patients with a spectrum of antiretroviral therapies and accumulation of endocrine abnormalities and conventional cardiovascular risk factors will present preventive and therapeutic challenges to our health-care system.
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Affiliation(s)
- Erdembileg Anuurad
- Department of Medicine, University of California Davis, Sacramento, California 95817, USA
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Risk of premature atherosclerosis and ischemic heart disease associated with HIV infection and antiretroviral therapy. J Infect 2008; 57:16-32. [DOI: 10.1016/j.jinf.2008.02.006] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Revised: 02/04/2008] [Accepted: 02/10/2008] [Indexed: 11/20/2022]
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Sabin CA, d'Arminio Monforte A, Friis-Moller N, Weber R, El-Sadr WM, Reiss P, Kirk O, Mercie P, Law MG, De Wit S, Pradier C, Phillips AN, Lundgren JD. Changes over time in risk factors for cardiovascular disease and use of lipid-lowering drugs in HIV-infected individuals and impact on myocardial infarction. Clin Infect Dis 2008; 46:1101-10. [PMID: 18461712 PMCID: PMC2702541 DOI: 10.1086/528862] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Because of the known relationship between exposure to combination antiretroviral therapy and cardiovascular disease (CVD), it has become increasingly important to intervene against risk of CVD in human immunodeficiency virus (HIV)-infected patients. We evaluated changes in risk factors for CVD and the use of lipid-lowering therapy in HIV-infected individuals and assessed the impact of any changes on the incidence of myocardial infarction. METHODS The Data Collection on Adverse Events of Anti-HIV Drugs Study is a collaboration of 11 cohorts of HIV-infected patients that included follow-up for 33,389 HIV-infected patients from December 1999 through February 2006. RESULTS The proportion of patients at high risk of CVD increased from 35.3% during 1999-2000 to 41.3% during 2005-2006. Of 28,985 patients, 2801 (9.7%) initiated lipid-lowering therapy; initiation of lipid-lowering therapy was more common for those with abnormal lipid values and those with traditional risk factors for CVD (male sex, older age, higher body mass index [calculated as the weight in kilograms divided by the square of the height in meters], family and personal history of CVD, and diabetes mellitus). After controlling for these, use of lipid-lowering drugs became relatively less common over time. The incidence of myocardial infarction (0.32 cases per 100 person-years [PY]; 95% confidence interval [CI], 0.29-0.35 cases per 100 PY) appeared to remain stable. However, after controlling for changes in risk factors for CVD, the rate decreased over time (relative rate in 2003 [compared with 1999-2000], 0.73 cases per 100 PY [95% CI, 0.50-1.05 cases per 100 PY]; in 2004, 0.64 cases per 100 PY [95% CI, 0.44-0.94 cases per 100 PY]; in 2005-2006, 0.36 cases per 100 PY [95% CI, 0.24-0.56 cases per 100 PY]). Further adjustment for lipid levels attenuated the relative rates towards unity (relative rate in 2003 [compared with 1999-2000], 1.06 cases per 100 PY [95% CI, 0.63-1.77 cases per 100 PY]; in 2004, 1.02 cases per 100 PY [95% CI, 0.61-1.71 cases per 100 PY]; in 2005-2006, 0.63 cases per 100 PY [95% CI, 0.36-1.09 cases per 100 PY]). CONCLUSIONS Although the CVD risk profile among patients in the Data Collection on Adverse Events of Anti-HIV Drugs Study has decreased since 1999, rates have remained relatively stable, possibly as a result of a more aggressive approach towards managing the risk of CVD.
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Affiliation(s)
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- Dept. of Primary Care and Population Sciences, Royal Free and UC Medical School, Rowland Hill St., London, NW3 2PF, United Kingdom.
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Bennett MT, Johns KW, Bondy GP. Current and future treatments of HIV-associated dyslipidemia. ACTA ACUST UNITED AC 2008. [DOI: 10.2217/17460875.3.2.175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Falutz J. Therapy insight: Body-shape changes and metabolic complications associated with HIV and highly active antiretroviral therapy. ACTA ACUST UNITED AC 2008; 3:651-61. [PMID: 17710086 DOI: 10.1038/ncpendmet0587] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2006] [Accepted: 05/25/2007] [Indexed: 12/28/2022]
Abstract
Increasingly effective therapies for HIV infection are now available. These treatments, referred to collectively as highly active antiretroviral therapy, comprise various combinations of anti-HIV drugs from different drug classes. Recently, a range of metabolic complications have emerged as important toxicities in treated patients. Complications present as abnormalities of body-fat mass distribution in association with an often significant dyslipidemia and glucose homeostasis dysregulation. The body-shape changes, manifesting as peripheral lipoatrophy or central lipohypertrophy, can have a negative impact on quality of life and consequently on adherence to treatment. The combination of central lipohypertrophy, dyslipidemia and insulin resistance is associated with accelerated rates of atherosclerosis and other potentially significant long-term effects. The pathogenesis of these effects is complex and is still being actively investigated. Possible contributing factors relate to host characteristics, HIV viral parameters and specific effects of anti-HIV drugs on adipose-tissue biology and on intermediary metabolism. Management of these complications involves manipulation of the anti-HIV drugs using an understanding of their particular effects on lipid and glucose metabolism, in association with standard therapeutic interventions. Individualized approaches, taking into consideration quality-of-life issues, and assessment of potential cardiovascular risks, are now an important component of effective care of HIV-infected patients.
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Affiliation(s)
- Julian Falutz
- Montreal General Hospital, McGill University Health Center, Montreal, Quebec, Canada.
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Behrens GMN. Treatment options for lipodystrophy in HIV-positive patients. Expert Opin Pharmacother 2007; 9:39-52. [DOI: 10.1517/14656566.9.1.39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Oh J, Hegele RA. HIV-associated dyslipidaemia: pathogenesis and treatment. THE LANCET. INFECTIOUS DISEASES 2007; 7:787-96. [DOI: 10.1016/s1473-3099(07)70287-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Normén L, Yip B, Montaner J, Harris M, Frohlich J, Bondy G, Hogg RS. Use of metabolic drugs and fish oil in HIV-positive patients with metabolic complications and associations with dyslipidaemia and treatment targets. HIV Med 2007; 8:346-56. [PMID: 17661842 DOI: 10.1111/j.1468-1293.2007.00449.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Highly active antiretroviral therapy (HAART) with protease inhibitors (PI) is successful in suppressing viral replication, but may lead to a range of metabolic abnormalities associated with cardiovascular disease (CVD). OBJECTIVES The first objective of the study was to compare baseline demographic and clinical characteristics between PI users and non-PI users referred to a specialized metabolic clinic during 1999-2003. The second objective was to assess the associations of prescription drugs and fish oil with dyslipidaemia and to determine whether or not patients achieved treatment targets during 6 months of treatment. METHODS A retrospective analysis was performed using two sets of charts based on standardized forms with entries for personal data, drug treatment and clinical history. Anonymous linkage with the British Columbia HIV/AIDS Drug Treatment Program and the hospital laboratory was performed to gather information about HAART prescriptions and blood work. RESULTS In total, 237 patients were included in the study. There were few differences in any demographic or clinical factors between PI users and non-PI users. Compared with controls not taking lipid-lowering drugs or fish oil (n=48), statins appeared to be the only agent that was significantly associated with a reduced total cholesterol concentration (-15.6%; P=0.009). Fibrate treatment was associated with the largest reduction of triglyceride concentration (-37.4%; P=0.012), closely followed by fish oil (n=18;-32%; P=0.027). Six-month treatment success rates ranged between 17 and 43% of patients for total cholesterol (<5.2 mmol/L) and between 15 and 44% of patients for triglycerides (<2.3 mmol/L). CONCLUSIONS Despite the apparent lowering of blood lipids with drug and fish oil treatments, a majority of patients in these treatment groups (56.5-83.3%) still had elevated concentrations after 6 months.
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Affiliation(s)
- L Normén
- Canadian HIV Trials Network, Pacific Region, St Paul's Hospital, and Healthy Heart Program, St Paul's Hospital, Vancouver, British Columbia, Canada.
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Rodriguez B, Valdez H, Mijch A, Watson K, Lederman MM, McComsey GA, Loupa CV, Woolley I. Statins Blunt HAART-Induced CD4 T-Cell Gains but Have No Long-Term Effect on Virologic Response to HAART. ACTA ACUST UNITED AC 2007; 6:198-202. [PMID: 17579125 DOI: 10.1177/1545109707300684] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Statins are increasingly used in HIV-infected patients, but the effect of their immunomodulatory properties on antiretroviral-induced immune reconstitution is unknown. METHODS The authors compared 6-month and 1-year changes in CD4 T-cell count, plasma HIV ribonucleic acid (RNA), and serum lipids in 69 HIV-infected patients receiving statins and 127 controls matched by age, nadir CD4 T-cell count, and hepatitis C serostatus. All patients were receiving highly active antiretroviral therapy (HAART). The authors used standard statistical tests for univariate comparisons and estimated average change in outcome measurements through repeated measures general linear models. RESULTS Patients receiving statins had significantly higher median CD4 T-cell counts (430 vs 225 cells/microL, P < .001) and lower HIV RNA levels (2.3 vs 2.9 log10 copies/mL, P < .001) than controls. Statin-treated patients had diminished CD4 T-cell gain at 6 months, but this difference was not statistically significant at 12 months, despite similar 12-month virologic success rates. Patients receiving statins gained, on average, an estimated 60 fewer CD4 T-cells in the first 6 months than controls. CONCLUSIONS Exposure to statins was associated with decreased CD4 T-cell gains during HAART in a cohort of HIV-infected patients, despite adequate virologic response. Studies with longer follow-up and detailed metabolic and immunologic monitoring are needed to confirm these findings and assess their significance and mechanisms.
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Affiliation(s)
- Benigno Rodriguez
- University Hospitals of Cleveland and Case Western Reserve University Center for AIDS Research, Cleveland, OH 44106-5083, USA.
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Calza DL, Manfredi R, Chiodo F. Cardiovascular risk associated with antiretroviral therapy in HIV-infected patients. Expert Opin Ther Pat 2006. [DOI: 10.1517/13543776.16.11.1497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Before the availability of protease inhibitors, elevated triglyceride levels were frequently observed in patients with advanced-stage HIV infection. Since the addition of protease inhibitors to combination treatments, metabolic side effects (alterations in distribution of adipose tissue and metabolic disorders combining dyslipidemia, insulin-resistance and glucose intolerance) have been observed in HIV-positive patients receiving these treatments. Reverse transcriptase nucleoside inhibitors also provoke metabolic disorders. Dyslipidemia is defined by an increase in triglyceride levels of varying and sometimes major intensity, either isolated or combined with a more moderate increase in LDL-cholesterol, while HDL-cholesterol levels may decrease or remain unchanged. These metabolic alterations are potentially atherogenic and may explain these patients' increased risk of cardiovascular disorders. Their mechanism is complex and not yet clearly elucidated. The infection, the improvement in patients' general health and immune status, and individual predisposing factors are probably involved. Treatment probably plays a major role, since the different drugs in these two classes show effects of clearly different intensity. In vitro and ex vivo studies suggest that protease inhibitors alter adipocyte differentiation and induce insulin resistance. Reverse transcriptase nucleoside inhibitors modify adipocyte metabolism too, promoting tissue atrophy. Endocrine factors (cortisol and growth hormones) are also likely to have a role in this hypertrophy of adipose, especially visceral, tissue. These metabolic abnormalities result mainly from the effects of the antiretroviral drugs, notably protease inhibitors, on the hepatic lipid metabolism and on tissue sensitivity to insulin. Lipodystrophy contributes to these abnormalities, as does the reduction in cytokine secretion by adipose tissue. Management of these metabolic disorders is based primarily on a change in the drug regimen (administration of the least deleterious combinations), followed by standard dietary measures and, when necessary, lipid-lowering agents.
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Affiliation(s)
- B Chanu
- Service d'endocrinologie, de diabétologie et de nutrition, Hôpital Jean Verdier, Bondy (93).
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Calza L, Manfredi R, Colangeli V, Tampellini L, Sebastiani T, Pocaterra D, Chiodo F. Substitution of nevirapine or efavirenz for protease inhibitor versus lipid-lowering therapy for the management of dyslipidaemia. AIDS 2005; 19:1051-8. [PMID: 15958836 DOI: 10.1097/01.aids.0000174451.78497.8f] [Citation(s) in RCA: 84] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To evaluate simplified protease inhibitor (PI)-sparing antiretroviral treatment versus lipid-lowering therapy for the management of highly active antiretroviral therapy (HAART)-induced hyperlipidaemia. DESIGN Randomized, open-label clinical trial assessing the efficacy on hyperlipidaemia of a switching therapy from PI to non-nucleoside reverse transcriptase inhibitor (NNRTI) nevirapine or efavirenz versus a hypolipidaemic treatment (with pravastatin or bezafibrate) added to current, unchanged antiretroviral combination. METHODS All HIV-infected patients on their first HAART regimen, with stable immuno-virological features, naive to all NNRTIs, and with mixed hyperlipidaemia, were randomized to replace PI with nevirapine (arm A) or efavirenz (arm B), or to receive pravastatin (arm C) or bezafibrate (arm D) with unchanged HAART regimen, and were followed-up for 12 months. RESULTS One hundred and thirty patients were evaluated: 29 patients were randomized to arm A, 34 to arm B, 36 to arm C, and 31 to arm D. At the end of the 12-month follow-up, a reduction of 25.2, 9.4, 41.2 and 46.6% in mean triglyceridaemia versus respective baseline values was reported in groups A, B, C and D, respectively, with statistically significant difference between arms A-B and C-D (P < 0.01). Similar results were reported for total and low-density lipoprotein cholesterol levels. Viro-immunological efficacy and tolerability profile were comparable in all considered arms. CONCLUSION Pravastatin and bezafibrate proved significantly more effective in the management of HAART-related hyperlipidaemia than the switching therapy from PI to nevirapine or efavirenz.
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Affiliation(s)
- Leonardo Calza
- Department of Clinical and Experimental Medicine, Division of Infectious Diseases, "Alma Mater Studiorum" University of Bologna, S. Orsola Hospital, Bologna, Italy.
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Thiébaut R, Aurillac-Lavignolle V, Bonnet F, Ibrahim N, Cipriano C, Neau D, Dupon M, Dabis F, Mercié P. Change in atherosclerosis progression in HIV-infected patients: ANRS Aquitaine Cohort, 1999-2004. AIDS 2005; 19:729-31. [PMID: 15821400 DOI: 10.1097/01.aids.0000166097.46940.35] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This study reported the changes in carotid intima-media thickness (IMT) during a 36-month period in 233 HIV-infected patients. Median IMT increased in the first 12 months and then decreased by month 36. The prevalence of treatment with lipid-lowering agents and protease inhibitor-free highly active antiretroviral therapy regimens increased, whereas smoking prevalence decreased. The progression of atherosclerosis in HIV-infected patients can be controlled. The impact of individual measures to reduce the cardiovascular risk should be evaluated further.
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Affiliation(s)
- Rodolphe Thiébaut
- INSERM EMI 0338, ISPED, Université Victor Segalen Bordeaux 2, 33076 Bordeaux, France
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Shafiq N, Malhotra S, Pandhi P, Grover A. The "Statinth" wonder of the world: a panacea for all illnesses or a bubble about to burst. J Negat Results Biomed 2005; 4:3. [PMID: 15788096 PMCID: PMC1079931 DOI: 10.1186/1477-5751-4-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2005] [Accepted: 03/23/2005] [Indexed: 12/20/2022] Open
Abstract
After the introduction of statins in the market as effective lipid lowering agents, they were shown to have effects other than lipid lowering. These actions were collectively referred to as 'pleiotropic actions of statins.' Pleiotropism of statins formed the basis for evaluating statins for several indications other than lipid lowering. Evidence both in favour and against is available for several of these indications. The current review attempts to critically summarise the available data for each of these indications.
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Affiliation(s)
- Nusrat Shafiq
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Samir Malhotra
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Promila Pandhi
- Department of Pharmacology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
| | - Anil Grover
- Department of Cardiology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India
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van Leth F, Phanuphak P, Stroes E, Gazzard B, Cahn P, Raffi F, Wood R, Bloch M, Katlama C, Kastelein JJP, Schechter M, Murphy RL, Horban A, Hall DB, Lange JMA, Reiss P. Nevirapine and efavirenz elicit different changes in lipid profiles in antiretroviral-therapy-naive patients infected with HIV-1. PLoS Med 2004; 1:e19. [PMID: 15526045 PMCID: PMC523838 DOI: 10.1371/journal.pmed.0010019] [Citation(s) in RCA: 190] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2004] [Accepted: 08/17/2004] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patients infected with HIV-1 initiating antiretroviral therapy (ART) containing a non-nucleoside reverse transcriptase inhibitor (NNRTI) show presumably fewer atherogenic lipid changes than those initiating most ARTs containing a protease inhibitor. We analysed whether lipid changes differed between the two most commonly used NNRTIs, nevirapine (NVP) and efavirenz (EFV). METHODS AND FINDINGS Prospective analysis of lipids and lipoproteins was performed in patients enrolled in the NVP and EFV treatment groups of the 2NN study who remained on allocated treatment during 48 wk of follow-up. Patients were allocated to NVP (n = 417), or EFV (n = 289) in combination with stavudine and lamivudine. The primary endpoint was percentage change over 48 wk in high-density lipoprotein cholesterol (HDL-c), total cholesterol (TC), TC:HDL-c ratio, non-HDL-c, low-density lipoprotein cholesterol, and triglycerides. The increase of HDL-c was significantly larger for patients receiving NVP (42.5%) than for patients receiving EFV (33.7%; p = 0.036), while the increase in TC was lower (26.9% and 31.1%, respectively; p = 0.073), resulting in a decrease of the TC:HDL-c ratio for patients receiving NVP (-4.1%) and an increase for patients receiving EFV (+5.9%; p < 0.001). The increase of non-HDL-c was smaller for patients receiving NVP (24.7%) than for patients receiving EFV (33.6%; p = 0.007), as were the increases of triglycerides (20.1% and 49.0%, respectively; p < 0.001) and low-density lipoprotein cholesterol (35.0% and 40.0%, respectively; p = 0.378). These differences remained, or even increased, after adjusting for changes in HIV-1 RNA and CD4+ cell levels, indicating an effect of the drugs on lipids over and above that which may be explained by suppression of HIV-1 infection. The increases in HDL-c were of the same order of magnitude as those seen with the use of the investigational HDL-c-increasing drugs. CONCLUSION NVP-containing ART shows larger increases in HDL-c and decreases in TC:HDL-c ratio than an EFV-containing regimen. Based on these findings, protease-inhibitor-sparing regimens based on non-nucleoside reverse transcriptase inhibitor, particularly those containing NVP, may be expected to result in a reduced risk of coronary heart disease.
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Affiliation(s)
- Frank van Leth
- International Antiviral Therapy Evaluation Center, Division of Infectious Diseases, Tropical Medicine, and AIDS, Department of Internal Medicine, Academic Medical Center, University of Amsterdam, The Netherlands.
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