ANNOUNCER: All drugs used to fight HIV have side effects. Some of the drugs change lipid levels in the blood.
KATHLEEN SQUIRES, MD: One of the complications that we have seen with the use of antiretroviral agents is elevation in what are called serum lipids: triglycerides, cholesterol.
ANNOUNCER: Lipids are fats, which play important roles in the body. But studies show high levels of lipids can cause harm.
EDWIN DEJESUS, MD: In the non-HIV population, it is well-documented that elevation in cholesterol, for example, can cause cardiovascular events, such as myocardial infarction, cerebrovascular accidents, which is strokes. And we presume that a patient that is HIV positive with an elevation in triglyceride and cholesterol will run the same type of problems.
ANNOUNCER: Not all drugs used against HIV have the same impact on lipid levels.
GRAEME MOYLE, MD: You have two types of cholesterol. Broadly, the good cholesterol which is called HDL, high density cholesterol, and low density cholesterol, which tends to be the one associated with risk of future heart disease. Protease inhibitors tend to push up the bad cholesterol without having much impact on the good cholesterol.
KATHLEEN SQUIRES, MD: Now we're noting that other drugs in other classes, specifically the NRTIs or the nucleoside analogs are associated with elevations in serum lipids as well.
GRAEME MOYLE, MD: When we look at combinations that involve nonnucleoside drugs like efavirenz or nevirapine, they tend to cause changes in the lipids also, but mostly what we're seeing there is a rise in the good cholesterol, the HDL cholesterol and only a more modest increase in the LDL cholesterol.
ANNOUNCER: Until recently, most protease inhibitors seemed to elevate blood lipids. But there are now drugs that may not carry that same risk.
EDWIN DEJESUS, MD: For the most part, all protease inhibitors have been associated with elevation in triglyceride and cholesterol.
But recently, new protease inhibitors in the market has been developed that actually do not have this particular complication. For example, a new protease inhibitor with the name of Reyataz was developed and has not been associated with an increase in the triglycerides and cholesterol.
ANNOUNCER: When lipid levels do rise, lifestyle changes are often a doctor's first recommendation.
KATHLEEN SQUIRES, MD: When we are coming up with treatment strategies for elevated serum lipids, the first thing that we always do before we go to drugs is to put patients on a diet that's low in fat, and to exercise them.
ANDREW CARR, MD: Diet and exercise have a role to play. I mean I do say to patients, walk to work and use stairs and don't eat and do regular exercise. The results are not always that successful. Although it's clearly the easiest place to start, a lot more needs to be done in most people.
ANNOUNCER: "Doing a lot more," sometimes means taking drugs called statins.
KATHLEEN SQUIRES, MD: The major drugs that we use to treat elevated serum lipids are drugs which are called statins, which interact with, certain of the enzymes that are used by the body to metabolize fat. And so they can substantially lower the levels of triglycerides or cholesterol.
ANDREW CARR, MD: Statins is probably the your first port-of-call. There is some concern that they may not be quite as potent in people with HIV as in people without, although that is very difficult to prove, one way or the other.
ANNOUNCER: Furthermore, there can sometimes be harmful drug interactions with protease inhibitors.
EDWIN DeJESUS, MD: Protease inhibitors inhibit some enzymes in the liver that they're used to break down the statins. So sometimes we cannot use some protease inhibitors and some statin medications.
ANNOUNCER: When lipids levels can not be adequately controlled with lifestyle changes or drugs, switching antiretroviral medications is sometimes an option.
Luckily, that can often be done without interfering with the course of HIV treatment.
KATHLEEN SQUIRES, MD: While we use this strategy we really need to be assured that the drugs that the patients are currently on are working, that we have the virus under very tight control and then switching to another agent should not be a problem. And in fact, switching studies have been done which have demonstrated that you can switch drugs with a patient who has good control of viral replication.
ANNOUNCER: Concern today, over lipid levels in people with HIV, in part reflects good news, that HIV drugs now can be very effective.
EDWIN DEJESUS, MD: Now that patients are living longer, the potential complications of having an elevated triglyceride and cholesterol over time, over five years, ten years or fifteen years, becomes something that we need to consider.
ANNOUNCER: Luckily for most people with HIV, there are good strategies to lower these lipids levels, whether it's simple changes in diet and exercise, the use of lipid-reducing drugs, or using antiretrovirals less likely to cause the problem.
KATHLEEN SQUIRES, MD: One of the complications that we have seen with the use of antiretroviral agents is elevation in what are called serum lipids: triglycerides, cholesterol.
ANNOUNCER: Lipids are fats, which play important roles in the body. But studies show high levels of lipids can cause harm.
EDWIN DEJESUS, MD: In the non-HIV population, it is well-documented that elevation in cholesterol, for example, can cause cardiovascular events, such as myocardial infarction, cerebrovascular accidents, which is strokes. And we presume that a patient that is HIV positive with an elevation in triglyceride and cholesterol will run the same type of problems.
ANNOUNCER: Not all drugs used against HIV have the same impact on lipid levels.
GRAEME MOYLE, MD: You have two types of cholesterol. Broadly, the good cholesterol which is called HDL, high density cholesterol, and low density cholesterol, which tends to be the one associated with risk of future heart disease. Protease inhibitors tend to push up the bad cholesterol without having much impact on the good cholesterol.
KATHLEEN SQUIRES, MD: Now we're noting that other drugs in other classes, specifically the NRTIs or the nucleoside analogs are associated with elevations in serum lipids as well.
GRAEME MOYLE, MD: When we look at combinations that involve nonnucleoside drugs like efavirenz or nevirapine, they tend to cause changes in the lipids also, but mostly what we're seeing there is a rise in the good cholesterol, the HDL cholesterol and only a more modest increase in the LDL cholesterol.
ANNOUNCER: Until recently, most protease inhibitors seemed to elevate blood lipids. But there are now drugs that may not carry that same risk.
EDWIN DEJESUS, MD: For the most part, all protease inhibitors have been associated with elevation in triglyceride and cholesterol.
But recently, new protease inhibitors in the market has been developed that actually do not have this particular complication. For example, a new protease inhibitor with the name of Reyataz was developed and has not been associated with an increase in the triglycerides and cholesterol.
ANNOUNCER: When lipid levels do rise, lifestyle changes are often a doctor's first recommendation.
KATHLEEN SQUIRES, MD: When we are coming up with treatment strategies for elevated serum lipids, the first thing that we always do before we go to drugs is to put patients on a diet that's low in fat, and to exercise them.
ANDREW CARR, MD: Diet and exercise have a role to play. I mean I do say to patients, walk to work and use stairs and don't eat and do regular exercise. The results are not always that successful. Although it's clearly the easiest place to start, a lot more needs to be done in most people.
ANNOUNCER: "Doing a lot more," sometimes means taking drugs called statins.
KATHLEEN SQUIRES, MD: The major drugs that we use to treat elevated serum lipids are drugs which are called statins, which interact with, certain of the enzymes that are used by the body to metabolize fat. And so they can substantially lower the levels of triglycerides or cholesterol.
ANDREW CARR, MD: Statins is probably the your first port-of-call. There is some concern that they may not be quite as potent in people with HIV as in people without, although that is very difficult to prove, one way or the other.
ANNOUNCER: Furthermore, there can sometimes be harmful drug interactions with protease inhibitors.
EDWIN DeJESUS, MD: Protease inhibitors inhibit some enzymes in the liver that they're used to break down the statins. So sometimes we cannot use some protease inhibitors and some statin medications.
ANNOUNCER: When lipids levels can not be adequately controlled with lifestyle changes or drugs, switching antiretroviral medications is sometimes an option.
Luckily, that can often be done without interfering with the course of HIV treatment.
KATHLEEN SQUIRES, MD: While we use this strategy we really need to be assured that the drugs that the patients are currently on are working, that we have the virus under very tight control and then switching to another agent should not be a problem. And in fact, switching studies have been done which have demonstrated that you can switch drugs with a patient who has good control of viral replication.
ANNOUNCER: Concern today, over lipid levels in people with HIV, in part reflects good news, that HIV drugs now can be very effective.
EDWIN DEJESUS, MD: Now that patients are living longer, the potential complications of having an elevated triglyceride and cholesterol over time, over five years, ten years or fifteen years, becomes something that we need to consider.
ANNOUNCER: Luckily for most people with HIV, there are good strategies to lower these lipids levels, whether it's simple changes in diet and exercise, the use of lipid-reducing drugs, or using antiretrovirals less likely to cause the problem.