Strong indication for statin-based therapy in HIV+ patients

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Despite having a strong indication for statin-based therapy according to the 2013 ACA/AHA blood cholesterol guidelines, two-thirds of HIV+ patients were not prescribed appropriate therapy, according to a study presented at IDWeek 2017.

During the study, the authors reviewed charts of 1,087 HIV+ patients ≥40 years old from the Washington University Virology Clinic, a large urban outpatient centre. Dr Lemuel Nom, of the Washington University School of Medicine – Saint Louis, explained, “Patients were classified according to the 4 statin benefit groups from the guideline: one, those with clinical atherosclerotic cardiovascular disease (ASCVD); two, those with primary hyperlipidaemia (LDL-C ≥190mg/dL); three, individuals 40 to 75 years of age with diabetes and an LDL 70 to 189mg/dL without ASCVD; and four, those 40 to 75 years of age without ASCVD or diabetes, with LDL 70 to 189mg/dL, and with a 10-year ASCVD risk of ≥7.5%.”

Of the patients included in the study, 67.6% were black and 31.4% were white. Additionally, 71.0% of patients were male, 98.3% were on antiretroviral therapy, 86.4% had a suppressed HIV viral load, and 44.9% smoked. The average age of patients was reported as 51.9 years. Comorbidities present in included patients (%) were: hypertension (55.8%), type 2 diabetes mellitus (15.7%), chronic kidney diseases (9.2%), coronary artery disease (5.4%), cerebrovascular disease (3.6%), and peripheral arterial disease (3.4%).

The study authors reported that of the patients who should be classified in Group 1 based on the ACA/AHA guidelines, 78 (64%) were not taking a statin and 43 (36%) were on statin therapy. For Group 2 patients, 5 (56%) were not taking a statin while 4 patients (36%) were – 55 Group 3 patients (51%) were not on a statin while 52 (49%) were. Lastly, 151 patients in Group 4 (71%) were not on a statin while 62 (29%) were.

For each group, the percentage of patients on low-, moderate-, and high-intensity statin doses, respectively, were reported as 30%, 56%, and 14% for Group 1, 29%, 63%, and 8% for Group 3, and 21%, 64%, and 15% for Group 4. For Group 2 patients, 75% were taking high-dose statins while 25% were taking moderate-dose statins.

The study authors stated: “Among patients who should be on statins based on guideline, the proportion of patients on antiretrovirals with potential drug-drug interaction with statins, specifically ritonavir, cobicistat and efavirenz, was similar between those who were prescribed statin and those who were not.” No significant differences were seen in the patients taking statins compared to those not taking statins in regards to CD4 count, chronic kidney disease, and pill burden.

Additionally, similar rates of ritonavir, cobicistat, and efavirenz use were observed between the two groups. It was noted that 95% of Group 4 patients that had viral suppression were prescribed a statin vs. 87% of Group 4 patients that did not have viral suppression (P=0.031).

“Our finding stresses the critical need to address this gap among HIV+ individuals,” Nom stated. He added, “It also emphasises the need to prioritise ASCVD prevention in the care of the aging HIV-infected population.”

Abstract
Background: There are limited data on statin utilization among HIV+ individuals in real-world settings using the new 2013 ACC/AHA blood cholesterol guideline. We aimed to determine the proportion of appropriate statin use based on this guideline in a large urban outpatient center.
Methods: Chart review of 1087 HIV+ patients 40 years and over from the Washington University Virology Clinic was done from January 1 to December 31, 2015. Patients were classified according to the 4 statin benefit groups from the guideline: 1- those with clinical atherosclerotic cardiovascular disease (ASCVD); 2- those with primary hyperlipidemia (LDL-C ≥ 190mg/dL); 3- individuals 40 to 75 years of age with diabetes and an LDL 70 to 189 mg/dL without ASCVD; and 4- those 40 to 75 years of age without ASCVD or diabetes, with LDL 70 to 189 mg/dL, and with a 10-year ASCVD risk of ≥ 7.5%. Factors that may influence receipt of statin were analyzed using the Chi square test, t-test, or the Wilcoxon rank sum test when applicable.
Results: The median age of patients was 51 years and the majority were male (71%), black (67%), receiving antiretroviral therapy (98%), had HIV RNA ≤ 20 copies/ml (87%) and median CD4 count of 523 cells/µL. Overall, 450 (41%) patients had an indication for statin use, with the majority classified under group 4. However, only 160 (36%) were on statins, of whom 89% were on appropriate doses. The percentages of patients on statins were only 36%, 44%, 49%, and 30% for groups 1, 2, 3, and 4, respectively. There was no significant difference between those who were and were not on statins in terms of CD4 count and pill burden. The rates of ritonavir, cobicistat, and efavirenz use were also similar between the two groups. In group 4, however, those who had viral suppression were more likely to be prescribed a statin compared to those who had no viral suppression (95% vs 87%, p = 0.031).
Conclusion: Two-thirds of our patients were not prescribed statins despite a strong indication for it based on the new guideline. Our finding stresses the critical need to address this gap among HIV+ individuals. It also emphasizes the need to prioritize ASCVD prevention in the care of the aging HIV-infected population.

Authors
Lemuel Non, Naureen Ali, Rachel Presti, William G Powderly, Gerome Escota

MPR material
IDWeek abstract


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