Dyslipidemia in Patients with Human Immunodeficiency virus (HIV)
HIV is an important ASCVD risk factor that should be considered equivalent to one additional ASCVD risk factor
Improved HIV care has led to increased survival, but ASCVD risk is increasing
Patients not receiving ART are at increased risk possibly due to immune-mediated factors
Patients receiving ART are at increased risk, possibly due to immune-mediated factors, insulin resistance, hyperglycemia, elevated triglycerides, and low HDL-C
No valid 10-year score exists specifically applying to patients with HIV
Statins are considered first-line treatment, but may lead to drug-drug interactions with ART regimens; less potential for interaction with concomitant rosuvastatin, pravastatin, or pitavastatin
Statins generally well tolerated in absence of drug-drug interactions; some evidence of increased risk of diabetes mellitus
ASCVD=atherosclerotic cardiovascular disease; HDL-C=high density lipoprotein cholesterol; LDL-C=low density lipoprotein cholesterol; ART=antiretroviral therapy
Table 5
Dyslipidemia in Patients with Inflammatory Conditions
ASCVD is leading cause of death among patients with autoimmune diseases (eg, RA and SLE)
ASCVD risk calculators are inaccurate predictors
The United Kingdom-based QRISK2 is only ASCVD risk calculator incorporating RA as a variable
Reynolds Risk Score includes CRP but may underestimate risk in patients with inflammatory diseases
Patients with RA may have lower LDL-C levels than general population, despite increased ASCVD risk
LDL-C may be decreased during acute flares of RA, so are better measured when the disease is stabilized
Statin therapy is treatment of choices for hypercholsterolemic patients
ASCVD=atherosclerotic cardiovascular disease; HDL-C=high density lipoprotein cholesterol; LDL-C=low density lipoprotein cholesterol; RA=rheumatoid arthritis; SLE=systemic lupus erythematosus.
Table 6
Selected Recommendations: Nutrition and Physical Activity
Medical nutrition for dyslipidemia
<7%saturated fat
<200 mg/day dietary cholesterol
Avoidance of trans fat
Limited proportion of refined carbohydrates/simple sugars
Relatively high proportion of vegetables, fruits, legumes, nuts, fish, low fat dairy, lean meat, unsaturated oils
Viscous fiber 5–10g/day
Plant sterols/stanols 2–3g/day
Physical activity
Triglyceride levels may be reduced by 4%–37% through exercise training volumes of 1200-2200kcal/week (eg, 15–20 miles/week of brisk walking or jogging).
HDL-C levels may be increased by 2%–8% and LDL-C levels may be reduced by up to 7% with this regimen
HDL-C=high density lipoprotein cholesterol; LDL-C=low density lipoprotein cholesterol
Table 7
Improving Adherence
Adherence is the result of individual, social, and environmental factors, requiring broad-based interventions to address complexity of these challenges
Systems approaches and removal of organizational barriers necessary
Team-based self-management support, outreach via text, phone, or messaging, electronic prescribing, lower prescription copays, and less-frequent prescription refills may be helpful
Identifying and treating nonadherence may require a multidisciplinary team
Simplify treatment regimen, provide clear education, engage patients in decision-making, address barriers, improve health literacy, assess/evaluate adherence with every patient encounter
Health-information technologies (eg, HER-based decision support, alerts, dashboards and patient-level tools) can improve adherence