In the United States, about 1.2 million people are HIV positive. 1 Patients with HIV are living longer thanks to the development of contemporary antiretroviral therapy. Nearly two-thirds of HIV-positive people in the US were predicted to be 45 years of age or older in 2021. 2 Treatment of co-morbid conditions must be addressed as the HIV population ages, even though antiretroviral therapy that permanently suppresses HIV replication is of the utmost importance. Statin drugs for HIV, heart disease, stroke, and cholesterol management.

It is well known from research that those living with HIV have an increased risk of heart disease. For instance, research has shown that this patient population has a 20–100% increased risk of myocardial infarction. 3 Unfortunately, even with HIV under control, this risk remains. Research is still ongoing to determine the mechanisms underlying the elevated risk of cardiovascular disease. Nonetheless, current theories include immunological activation and persistent inflammation; depletion of CD4-positive cells; exposure to toxic, older antiretroviral therapies; and conventional risk factors like diabetes, smoking, and unhealthy eating patterns. Before recently, there was no particular advice available for HIV patients on how to prevent cardiovascular events. Now that the results of the REPRIEVE trial (NCT03455390) have been released, medical professionals have access to data unique to this significant patient population.

7769 people with HIV infection between the ages of 40 and 75 who were receiving antiretroviral therapy and had a low-to-moderate risk of cardiovascular disease were enrolled in the phase 3 Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE)4. A placebo or 4 mg of daily pitavastatin calcium (Livalo; Kowa) was administered at random as a form of treatment. Pitavastatin calcium was selected due to its incompatibility with medications utilized in antiretroviral therapy.

According to a time-to-event analysis, the main outcome was the occurrence of a major adverse cardiovascular event (MACE), which included peripheral arterial ischemia, myocardial infarction, hospitalization for unstable angina, stroke, revascularization of a peripheral artery or coronary carotid, cardiovascular death, and death from an unknown cause. A composite of a fatality from any cause or a MACE was a significant secondary outcome.

Thirty-one percent were women, 65 percent were non-White, and the median age was 50 years. The median screening CD4-positive count was 621 cells/mm3, and the median screening low-density lipoprotein cholesterol (LDL-C) level was 108 mg/dL. At the time of the report, 83% of participants were still in follow-up, with 74.8 percent of the pitavastatin group and 71% of the placebo group still receiving their randomized treatment. The median 10-year Atherosclerotic Cardiovascular Disease risk score was 4.5 percent. In the pitavastatin and placebo groups, the rates of treatment discontinuation due to adverse events were 2 points 1 percent and 1 point 2 percent, respectively.

After a median of five years, the trial was terminated early for efficacy because the pitavastatin group experienced a twenty-one percent reduction in MACE and a thirty-five percent reduction in MACE or death. Antiretroviral medication plus statins may be even more beneficial in lowering the risk of cardiovascular disease. Even though the results are unique to pitavastatin, other statins might offer comparable protection.

The Department of Health and Human Services/National Institutes of Health HIV Clinical Guidelines updated their recommendation to include that all individuals with HIV who are between the ages of 40 and 75 and have a risk of atherosclerotic cardiovascular disease of at least five percent should receive a moderate-intensity statin due to the trial’s efficacy. 5 The majority of people living with HIV can benefit from starting a moderate-intensity statin between the ages of 40 and 75, as nearly two-thirds of those living with HIV are at least 45 years old.

Regardless of the practice setting, pharmacists are especially qualified to assist in putting these recommendations into practice. Enhancing patient health is a shared responsibility among those working in primary care, inpatient, retail, and HIV-focused clinical settings, among others. Proactive chart reviews to ensure appropriate statin use are already standard practice in many of these settings; the patient population that qualifies has simply grown. In other contexts, the payment for medication therapy management may serve as a catalyst for the adoption of statins in this patient population.

Pharmacists can discuss statin use with patients at every interaction, including admission and refills, and can help with the right statin selection when necessary. As the second most prescribed class of drugs, antilipidemic agents require special handling from pharmacists when it comes to insurance claims, formulary substitutions, and appropriate counseling. This may make it possible to switch to a better option or start taking a statin with ease.

When selecting the appropriate statin, it’s important to understand the pharmacokinetics of both antiretrovirals and statins to look for any potential side effects that might be mitigated. The commercially available statins are listed in tables 15, 7, and 25, 7 below according to how much they lower LDL. Based on data from REPRIEVE, guidelines recommend 10 mg of rosuvastatin, 4 mg of pitavastatin, and 20 mg of atorvastatin as the recommended statins and dosages. Consequently, a list of potential drug interactions between them and commonly used antiretrovirals is available.

HIV-positive people live longer and are more likely to experience cardiovascular events. The recent release of REPRIEVE data has impacted the revision of guidelines to include a broader use of statins. The majority of HIV patients are now advised to take a moderate-intensity statin, and pharmacists are well-positioned to assist in putting these new guidelines into practice and helping their patients’ cardiovascular outcomes.

REFERENCES
https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv
https://stacks.cdc.gov/view/cdc/156513
https://dx.doi.org/10.15620/cdc:123251