Children with HIV have “additional challenges”
that should be addressed with formal practice guidelines, according to an
editorial published online today.
Allison C. Ross, MD, of Emory University School
of Medicine, and Grace A. McComsey, MD, of Case Western Reserve
University, wrote the editorial to accompany two papers that help provide
insight into the lipoprotein profiles of children with HIV.
In the first of the two papers, Denise L. Jacobson,
PhD, MPH, of Harvard School of Public Health and colleagues monitored
trends in cholesterol and lipid levels in 240 children who had HIV and high
cholesterol. During two years of follow-up, the children had persistently
elevated lipid levels. Cholesterol levels were more likely to decrease in
children whose antiretroviral drug therapy was changed during follow-up.
Although the study did not include information on why their ART changed, in
most cases it was likely to control HIV levels, not in response to high
cholesterol levels. Just 15 of the children were started on
cholesterol-lowering statin drugs.
In the other study, Margaret P. Rhoads, of
Imperial College School of Medicine, London, and colleagues compared the
effects of different types of ART drugs on lipid levels in 449 children with
HIV. All classes of ART drugs were associated with increased cholesterol —
although the increases were most significant for children receiving one
specific class of ART drugs (protease inhibitors).
During the five-year follow-up period, 10% of the
children developed low-density lipoprotein cholesterol levels above the 95th
percentile. However, just three patients had cholesterol levels high enough to
call for drug treatment.
The authors of the editorial suggested that taken
together, these findings suggest that “HIV-infected children have
additional challenges that must be considered before changing ART regimens to
improve lipoprotein profiles,” including possibly switching lipid-lowering
agents instead of ART regimens.
“One striking observation in the Jacobson study was
the low percentage of children with hypercholesterolemia who initiated
lipid-lowering medications, particularly statins, and the time with which it
took to initiate a medication after development of hypercholesterolemia.
Likewise, Rhoads and colleagues observed 20 children who may have met AAP
criteria for pharmacologic intervention during the study period depending on
associated risk factors; yet, no child received any lipid-lowering
medications," the editorialists wrote, which they attributed to a lack of
cholesterol guidelines specific to children with HIV.
While the AAP calls for “statin use for healthy
children with LDL-C levels less than 190 mg/dL only after dietary interventions
have failed … these guidelines likely are not relevant to HIV-infected
children,” so the editorialists reasoned, criteria may be needed for this
population. Ross and McComsey advocated a combined approach consisting of a
lipid-friendly drug regimen along with nondrug treatments (such as diet and
exercise). More research is needed to evaluate these and other strategies
— including the role of cholesterol-lowering medications, they noted.
“Statin use may be used in the future, not only to
improve lipids, but also as a means of further decreasing inflammation.
Similarly, biomarker monitoring or initiation of anti-inflammatory medications
may also prove to be beneficial,” the researchers concluded. “Formal
guidelines are the first crucial step in minimizing CVD complications and
maximizing quality of life in this vulnerable population.”
Disclosures: Dr. McComsey reports having served as a consultant,
speaker and receiving research funding from Bristol-Myers Squibb,
GlaxoSmithKline, Gilead, Merck, Tibotec, and Abbott, and currently chairing a
Pfizer-funded study. Dr. Ross reports receiving research funding from
Bristol-Myers Squibb, Cubist Pharmaceuticals and GlaxoSmithKline.