Guidelines urged for children with HIV and high cholesterol levels

Ross AC, McComsey GA. JAIDS. 2011: 57:351-354.

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 antiretroviral regimen 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 antiretroviral drugs on lipid levels in 449 children with HIV. All classes of antiretroviral drugs were associated with increased cholesterol — although the increases were most significant for children receiving one specific class of antiretroviral 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 antiretroviral regimens to improve lipoprotein profiles,” including possibly switching lipid-lowering agents instead of antiretroviral 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 American Academy of Pediatrics 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.

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