- Category: Cardiovascular Disease
- Published on Tuesday, 30 August 2011 00:00
- Written by Liz Highleyman
A combination approach including low-fat diet, exercise, and niacin plus fenofibrate increased HDL good cholesterol and reduced bad cholesterol and triglycerides in HIV positive people on antiretroviral therapy (ART) with abnormal blood lipid levels, researchers reported in the July 2011 Journal of Clinical Endocrinology and Metabolism.
People with HIV frequently develop dyslipidemia, or abnormal blood fat levels. A common pattern features reduced high-density lipoprotein (HDL) or "good" cholesterol, high non-HDL or "bad" cholesterol, elevated triglycerides (hypertriglyceridemia), and insulin resistance, characterized by a low level of the fat hormone adiponectin (hypoadiponectinemia).
It is unclear whether this is related to HIV infection itself, resulting inflammation, antiretroviral drugs, or other risk factors -- or some combination of all of the above -- but abnormal blood lipids and metabolic syndrome are a concern because they contribute to cardiovascular disease and other progressive non-AIDS conditions. Statin drugs are often used to manage elevated cholesterol, but they can interact with antiretrovirals.
Ashok Balasubramanyam from Baylor College of Medicine and colleagues designed a study to test a targeted, comprehensive program for managing dyslipidemia, including lifestyle modification and medications.
This double-blind, placebo-controlled trial included 191 HIV positive participants on ART with elevated triglyceride levels. A majority were men and race/ethnicity was mixed, 46% Hispanic, 36% white, and 17% black. Patients were stratified into 3 groups based on combination of antiretroviral classes.
Participants were randomly allocated to 5 treatment arms:
- Group 1: Standard care;
- Group 2: Low saturated fat diet plus 75-90 minutes of supervised exercise 3 times per week;
- Group 3: Diet, exercise, and fenofibrate (Tricor);
- Group 4: Diet, exercise, and niacin (Niaspan);
- Group 5: Diet, exercise, fenofibrate, and niacin.
All interventions lasted 24 weeks. The researchers measured changes in fasting triglycerides, HDL and non-HDL cholesterol, insulin sensitivity, blood glucose, adiponectin, C-reactive protein (a biomarker of inflammation), energy expenditure, and body composition.
- Use of fenofibrate significantly lowered triglyceride, total cholesterol, and non-HDL cholesterol levels compared with the other interventions.
- Use of niacin significantly raised HDL cholesterol.
- Using both medications significantly decreased total cholesterol-to-HDL ratio, indicating improvement.
- The combination of low-fat diet, exercise, fenofibrate, and niacin provided the most benefit compared with standard care:
o Triglycerides reduced by 52.0%;
o HDL cholesterol increased by 12.0%;
o Non-HDL cholesterol reduced by 18.5%;
o Total cholesterol and total-to-HDL cholesterol ratio decreased by 24.5%.
Based on these findings, the study authors concluded, "A combination of fenofibrate and niacin with low-saturated-fat diet [and] exercise is effective and safe in increasing HDL cholesterol, decreasing non-HDL cholesterol and hypertriglyceridemia, and ameliorating hypoadiponectinemia in patients with HIV/ART-associated dyslipidemia."
"A rationally based, combinatorial approach using niacin and fenofibrate with low-saturated-fat diet and exercise is both effective and safe in improving the [cardiovascular disease] risk factors of low HDL, elevated non-HDL, and hypertriglyceridemia among HIV patients on [ART]," they elaborated in their discussion.
Investigator affiliations: Translational Metabolism Unit, Division of Diabetes, Endocrinology and Metabolism, Section of Cardiovascular Research, Section of Infectious Diseases, Department of Medicine, and Department of Pediatrics, Baylor College of Medicine, Houston, TX; Endocrine Service, Ben Taub General Hospital, Houston, TX; Center for Cardiovascular Disease Prevention, Methodist-DeBakey Heart Center, Houston, TX.
A Balasubramanyam, I Coraza, EO Smith, et al. Combination of niacin and fenofibrate with lifestyle changes improves dyslipidemia and hypoadiponectinemia in HIV patients on antiretroviral therapy: results of "heart positive," a randomized, controlled trial. Journal of Clinical Endocrinology and Metabolism 96(7):2236-2247 (abstract). July 2011.