Successful Standard Treatment for Lipid Abnormalities: Experience with 44 Patients

On September 26 The Lancet published a research letter on a study at Regions Hospital in St. Paul, Minnesota on the treatment of abnormal cholesterol and triglyceride levels in persons receiving HIV protease inhibitors1; the same team had published an early report of coronary artery disease associated with protease inhibitors2 (see "Metabolic Changes: Concerns About Heart, Circulatory Risks," AIDS Treatment News #295, May 15, 1998). Patients who volunteered for this study were treated according to the guidelines of the National Cholesterol Education Program (NCEP), under the care of a lipid specialist. All of them continued to receive protease inhibitors.

Twenty patients with milder lipid abnormalities were first treated with diet and exercise alone; 12 of the 20 were judged to be treatment failures and started on lipid-lowering drugs (gemfibrozil and/or atorvastatin). Of the patients who were treated with both of these drugs and who had the highest lipid levels, cholesterol was reduced by 30%, and triglycerides by 60%, over six months; a table in the article gives the actual values for the different treatment groups. The investigators believe it is likely that these changes indicate a significantly reduced risk of heart disease.

The paper also noted that patients in their clinic who were receiving ritonavir and saquinavir were more likely to have lipid abnormalities than those on other protease inhibitors.

"The NCEP guidelines advise caution in use of gemfibrozil and statins together due to a concern about increased risk for myopathy. In addition, there is concern about an increased risk for toxicity when atorvastatin is used in combination with drugs that interfere with the cytochrome p450 metabolic pathway in the liver (such as protease inhibitors). We saw no instances of myopathy, raised creatine kinase of liver enzymes, or adverse virological events among these patients."

The authors conclude that "our preliminary data suggest that management of raised lipids associated with protease inhibitors can be done carefully following NCEP guidelines."


References

1. Henry K, Melroe H, Huebesch J, Hermundson J, and Simpson J. Atorvastatin and gemfibrozil for protease-inhibitor-related lipid abnormalities. The Lancet. September 26, 1998; volume 352, number 3133, pages 1031-1032.
2. Henry K, Melroe H, Huebesch J, and others. Severe premature coronary artery disease with protease inhibitors. The Lancet. May 2, 1998; volume 351, page 1328.