Dyslipidaemia

Principles

Higher LDL-c levels increase risk of CVD and reduction diminishes this risk (see table below for drugs used on this indication). For triglycerides (TG), there is no goal, but < 1.7 mmol/L (< 150 mg/dL) indicates lower risk and higher levels indicate a need to look for other risk factors. Statin treatment is recommended as the first drug of choice to reduce CVD risk in high-risk individuals with hypertriglyceridemia [TG > 2.3 mmol/L (> 200 mg/dL)]. Confirmation of hypertriglyceridemia needs to be verified with fasting lipid testing. Very high TG (> 10 mmol/L or > 900 mg/dL) increase risk of pancreatitis, fibrates should be used.

Less calories, more exercise, reducing bodyweight, and stopping smoking tend to improve (increase) HDL. Eating fish, reducing calories, saturated fat and alcohol intake reduce triglyceride levels. Reducing dietary saturated fat intake improves LDL-levels; if not effective, consider change of ART, then consider lipid-lowering medicine, see Prevention of Cardiovascular Disease (CVD).

Statins should be used by all those with established vascular disease and in persons who are not at LDL-c goals considering their level of CVD risk, irrespective of lipid levels, see Treatment goal for LDL-c for very high and high CVD risk persons. In high risk PLWH with statin intolerance, drug-drug interactions between high intensity statins and ART, or those unable to reach LDL-c goals on statins and/or ezetimibe, a PCSK9 inhibitor should be considered.

Drugs used to lower LDL-c

Drug class

Drug

Dose

Adverse effects

Advice on use of lipid lowering therapy together with ART

use with PI/r

use with NNRTIs

Statin(i,viii)

atorvastatin(ii)

10-80 mg qd

Gastrointestinal symptoms, headache, insomnia, rhabdomyolysis (rare) and toxic hepatitis

Start with low dose(v) (max daily dose: 10 mg (ATV/r); 20 mg (LPV/r); 40 mg (DRV/r)

Consider higher dose(vi)

fluvastatin(iii)

20-80 mg qd

Consider higher dose(vi)

Consider higher dose(vi)

pravastatin(iii)

20-80 mg qd

Consider higher dose(vi,vii)

Consider higher dose(vi)

rosuvastatin(ii)

5-40 mg qd

Start with low dose(v) (max daily dose: 10 mg (ATV/r, LPV/r) 20 mg (DRV/r)

Start with low dose(v)

simvastatin(ii)

10-40 mg qd

Contraindicated

 

pitavastatin(viii)

1-4 mg qd

No interaction expected

Intestinal cholesterol absorption inhibitor↓(i,viii)

ezetimibe(iv)

10 mg qd

Gastrointestinal symptoms

No interaction expected

PCSK9-inhibitors(x)

evolocumab

140 mg 2 weekly or 420 mg monthly

Nil

 

No interaction expected

 

 

 

alirocumab

75 mg or 150 mg 2 weekly

 

i A statin is preferred first-line therapy; different statins have variable intrinsic LDL-c lowering ability
ii, iii, iv Target levels for LDL-c, see Prevention of Cardiovascular Disease (CVD). In PLWH where LDL-c targets are difficult to achieve, consult/refer to specialist Expected range of reductions of LDL-c: ii 1.5-2.5 mmol/L (60-100 mg/dL), iii 0.8-1.5 mmol/L (35-60 mg/dL), iv 0.2-0.5 mmol/L (10-20 mg/dL)
v, vi The ARV may v inhibit (statin toxicity, ↓ dose) or vi induce (= less effect of statin, ↑ dose gradually to achieve expected benefit ii, iii) the excretion of the statin
vii Exception: If used with DRV/r, start with lower dose of pravastatin
viii Pitavastatin has as yet no morbidity/mortality trial data to support its use but may have advantages of reducing immune activation and arterial inflammation, fewer drug-drug interactions, more HDL increase and less adverse glucose effect than other statins
ix This agent can be used for PLWH intolerant of statins or added to a statin when LDL-c reduction is inadequate despite maximally tolerated statin
x Data in PLWH available for evolocumab