The Art of War/Medicine

Recently updated guidelines for treatment of high cholesterol levels have just been released by the American College of Cardiology – American Heart Association Task Force on Practice Guidelines. They represent a change from the prior recommendations which targeted specific lipid goals. Now, the new guidelines emphasize the intensity of statin therapy.1

High-intensity statin therapy is now recommended for three groups, those with:       (1) clinically evident CVD                                                                                                (2) primary LDL-C levels of at least 190mg/dl                                                                     (3) type 1 or type 2 DM who are ages 40-75, have LDL levels of 70 mg/dl or higher, and who have a 10-year risk of ASCVD of 7.5% or higher 2,3

Those in the third group can be treated with high- or moderate-intensity statins. Those with diabetes types 1 or 2, ages 40-75, who have an LDL of 70-189 mg/dl and a 10-year ASCVD risk of < 7.5% can be treated with moderate-intensity statin therapy. 

Moderate-intensity statin therapy is recommended for those who cannot tolerate otherwise-indicated high-intensity treatment.

High-intensity statin treatment includes formulary agent atorvastatin 40-80 mg and non-formulary rosuvastatin 20-40 mg. Moderate-intensity treatment includes formulary agents atorvastatin 10-20 mg, simvastatin 20-40 mg, pravastatin 40-80 mg, lovastatin 40 mg, and fluvastatin 40 mg bid. Non-formulary agents in the moderate-intensity category include rosuvastatin 5-10 mg, pitavastatin 2-4 mg, and fluvastatin ER 80 mg.

The new guidelines reduce the need for treatment of some groups; eliminate LDL assessments in patients on appropriate statin treatment; avoid non-statin treatments if statins are tolerated; reduce statin treatment in those older than 75 years of age; diminish the use of surrogate markers like CRP; and use a new, more inclusive risk calculator. Non-statin lipid-reducing treatment should not be given in place of appropriate-intensity statin treatment. However, it can be given to those at high risk (those with established ASCVD, LDL > 190 mg/dl, or with diabetes) who cannot tolerate a less-than-recommended-intensity statin or who are statin intolerant, taking into consideration potential adverse drug effects.

This move to high-intensity statin treatment has immediate application in my clinical practice. This past week I saw a relatively new patient in my HIV consultation clinic. This patient is a veteran of the HIV wars of the 80s and 90s but made it through with good adherence. Unfortunately, this patient, a non-smoker, had also had a coronary artery stent placed for CAD manifest by angina. He was on atorvastatin at 20 mg/day and a fibrate for elevated triglycerides, along with ASA.

The cascade of decisions began to fall into place.                                                        (1) Per the new guidelines, he needs a higher dose of atorvastatin.                                (2) This may cause trouble with the fibrate he is also taking.                                            (3) Maybe he does not need the fibrate, depending on his triglyceride level?             (4) Could he use omega fatty acids instead?                                                                (5) The HIV medicine he is now on, efavirenz, raises LDL and, even more so, triglycerides.(6) So, should I change his HIV meds? To what?                                                                    a. Could he harbor HIV resistance that would cause failure of a new regimen and what would be the consequence – back-up regimens?                                                                 b. His history of control with the current HIV regimen argues against significant resistance to a possible change in regimens. In particular, it is highly unlikely he has resistance to integrase strand transfer inhibitors.                                                                                       c. Once daily, relatively simple regimens that don’t raise lipids include:                          i. Dolutegravir (an integrase inhibitor) plus either a tenofovir/emtricitabine combination pill or an abacavir/lamivudine combination pill – this is a two-pill once-a-day choice.                                                                                                                                                                            ii. The 3-in-1 pill tenofovir/emtricitabine/rilpivirine, a change that swaps one non-nucleoside reverse transcriptase (efavirenz) for another (rilpivirine), but this combination is not approved for HIV medication-experienced patients.                                                              iii. The 4-in-1pill tenofovir/emtricitabine/cobicistat/elvitegravir; this regimen is also integrase inhibitor based but with a CYP3A inhibitor (cobicistat) that can have other drug interactions.                                                                                                          iv. Numerous other regimens are possible – but they involve more pills and are more complex.

Well, I am fully confident we can move this patient to high-intensity statin treatment while maintaining control of HIV. Ideally this will be done while minimizing side effects and drug interactions and simultaneously helping maintain adherence in this veteran of HIV history.

Marshall Kubota, MD

1. J Am Coll Cardiol. 2013;():. doi:10.1016/j.jacc.2013.11.002                                         2. http://my.americanheart.org/cvriskcalculator          3http://my.americanheart.org/cvriskcalculator or at http://www.cardiosource.org/science-and-quality/practice-guidelines-and-quality-standards/2013-prevention-guideline-tools.aspx.

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