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09/16/2013

Managing Cardiovascular Disease in HIV-Infection: News from ICAAC 2013


Cardiovascular disease (CVD), including MI and stroke, is one of the three leading non-AIDS-related causes of death in HIV-infected individuals. Despite metabolic disturbances associated with certain antiretrovirals (ARVs), antiretroviral therapy (ART) reduces overall CVD risk, presumably by reducing the chronic immune activation and inflammation present in untreated HIV. Management of CVD in HIV is complicated by the metabolic effects of ART, drug-drug interactions, and the possibility that a different balance of pathogenic factors may require different therapies. For individuals in the general population both statins and aspirin are effective for primary and secondary CVD prevention. Although there is little efficacy data in the HIV population, most experts believe statins and ASA should be used for the same indications as in the general population.

Park et al. retrospectively reviewed aspirin and statin use among patients seen at an HIV specialty clinic during 2012 [1]. Patients were included if they had no history of stroke or MI, no contraindication to aspirin and were within the age range specified by the USPSTF for consideration of primary prophylaxis with aspirin. Risk of MI was assessed using both the Framingham and DAD systems. Risk of stroke was assessed by the Framingham system. Half of the 258 patients analyzed were at sufficiently increased risk of MI to warrant aspirin prophylaxis, but only 43% of the high risk group were using it. Fourteen percent were at increased risk of stroke, and only half were using aspirin. Statins also appeared to be underutilized, but since the patient population was selected to analyze the appropriateness of primary aspirin prophylaxis, conclusions about statin use were less clear. The study suggests aspirin is underutilized for primary prevention of both MI and stroke in HIV. Increased provider education and clinical trials demonstrating efficacy in HIV-infected patients may help increase utilization.

Use of statins in HIV is complicated by many drug-drug interactions with ARVs, mostly because of the effects of commonly used ARVs on CYP450 metabolic pathways. Pitavastatin is a potent member of the statin class that is metabolized primarily by glucuronidation. Malvestutto et al [2] investigated the pharmacokinetic (PK) interactions between pitavastatin and two commonly used ARVs that interact with multiple other statins. In healthy volunteers, neither efavirenz nor ritonavir-boosted darunavir coadministration significantly altered pitavastatin PK. Levels of the ARVs also were unaltered by coadministration. Although interaction studies with other ARVs will be needed, this study suggests pitavastatin may be useful in the management of CVD risk in HIV-infected individuals. However, no generic formulation is available, so access for some patients may be limited by insurers.

References:
1. Park TE, Sharma R, Yusuff J. Use of Aspirin and Statins for the Primary Prevention of Myocardial Infarction and Stroke in Patients with Human Immunodeficiency Virus. 53rd ICAAC, Denver CO, Sept 10-13, 2013, Abstract H-1257.
2. Malvestutto CD, Ma Q, Morse GD,et al. Pharmacokinetic Study Assessing Drug Interactions of Pitavastatin with Darunavir/Ritonavir and Pitavastatin with Efavirenz in Healthy Volunteers. 53rd ICAAC, Denver CO, Sept 10-13, 2013, Abstract A-1577c.


Source: Reporting from Denver for the PRN News: David H Shepp, MD