Consensus statement
Executive summary of the consensus document on metabolic disorders and cardiovascular risk in patients with HIV infectionExecutive summary del documento de consenso sobre alteraciones metabólicas y riesgo cardiovascular en pacientes con infección por el VIH

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Abstract

The importance of the metabolic disorders and their impact on patients with HIV infection requires an individualized study and continuous updating. HIV patients have the same cardiovascular risk factors as the general population. The HIV infection per se increases the cardiovascular risk, and metabolic disorders caused by some antiretroviral drugs are added risk factors. For this reason, the choice of drugs with a good metabolic profile is essential.

The most common metabolic disorders of HIV infected-patients (insulin resistance, diabetes, hyperlipidemia or osteopenia), as well as other factors of cardiovascular risk, such as hypertension, should also be dealt with according to guidelines similar to the general population, as well as insisting on steps to healthier lifestyles.

The aim of this document is to provide a query tool for all professionals who treat HIV-patients and who may present or display any metabolic disorders listed in this document.

Resumen

La importancia de las alteraciones metabólicas y su repercusión en los pacientes con VIH requiere un estudio particularizado y actualización continua. A los factores de riesgo presentes en población general se añaden los propios de la infección y/o del tratamiento antirretroviral que obligan a la adecuación de las pautas terapéuticas con fármacos antirretrovirales actualmente disponibles, con un mejor perfil metabólico.

Actualmente, las alteraciones metabólicas más comunes de los pacientes con el VIH (resistencia a la insulina, diabetes, hiperlipidemias u osteopenia), así como otros factores de riesgo vascular como la hipertensión arterial, deben tratarse según directrices similares a las de la población general, debiendo insistir en medidas encaminadas a estilos de vida más saludables.

El objetivo del presente documento es proporcionar una herramienta de consulta para todos los profesionales que atienden a pacientes con infección por el VIH y que pueden presentar o presentan alguna de las alteraciones metabólicas recogidas en este documento.

Introduction

The importance of alterations in carbohydrate, lipid metabolism, and its impact on organ systems in patients infected with the human immunodeficiency virus (HIV) requires specific study and continuous update.

The purpose of this document is to provide practical information from the health care perspective on the major metabolic changes that occur in HIV infection in order to offer appropriate treatment strategies to each patient and provide a reference tool for all professionals caring for patients with HIV infection who present with any of the metabolic alterations contained in this paper.1

Section snippets

Clinical evaluation

Recommendations for clinical evaluation of metabolic disorders in HIV infection are shown in Table 1.

Healthy lifestyle

It should be based on three fundamental aspects, healthy nutrition, quitting tobacco smoking and doing exercise regularly. The objectives depend on the cardiovascular risk of each individual.

Alterations in body fat distribution

There may be two important body fat abnormalities in HIV-infected patients: lipoatrophy (LA) and fat accumulation, which likely have different pathogenic mechanisms.

HIV infection contributes to the development of lipoatrophy by alteration of gene expression in adipose tissue, resulting in an increase of PGC-1a, TNFa, and α-2 microglobulin and a decline in COX-2 mRNA, COX-4, UCP2, C/EBP-a, PPAR-γ, GLUT4, LPL, leptin, and adiponectin.

Antiretroviral drugs (ARV) mainly thymidine analogs (NRTIs),

Alterations of carbohydrate metabolism

Alterations in glucose metabolism are a risk factor for developing cardiovascular disease, and the risk is directly proportional to the duration of hyperglycaemia. It is recommended to measure fasting blood glucose levels at the time of HIV diagnosis, before the beginning of treatment, at 3–6 months of any antiretroviral change, and annually in patients with stable antiretroviral therapy. In case of impaired fasting glucose (≥100 mg/dL) or known diabetes, glycosylated hemoglobin (HbA1c) should

Lipid metabolism disorders

Lipid pattern more frequently detected in HIV-infected patients is usually that of atherogenic dyslipidaemia characterized by low HDL cholesterol and increased triglyceride (TG) levels, accompanied by variable elevations of total (TC) and LDL cholesterol. This pattern is usually associated with atherogenic particles, including small dense LDL. Antiretroviral-naïve patients usually have low CT and HDL and high TG.

HIV patients should achieve LDL cholesterol levels below 100 mg/dL. In case that

Hypertension

There is no evidence that HIV infection per se is associated with an increased risk of hypertension (HT). Therefore, it is assumed that monitoring, clinical implications and treatment should be similar to the general population with the exception of considering avoiding risk of interactions between antiretroviral therapy and antihypertensive.

Correct blood pressure (BP) measurement should be routine practice in the care of patients with HIV infection. It is recommended to be performed at the

Cardiovascular impact

Patients with HIV infection have a higher risk of CVD than the general population. Although the mechanism of vascular injury are not well known, different factors are involved including traditional cardiovascular risk factors, ART and HIV-related parameters such as inflammation and immunodeficiency even in patients with good immunovirological control. It is plausible that the immunological and inflammatory consequences of chronic HIV infection may promote development of premature

Sexual dysfunction

Erectile dysfunction, decreased libido, and impaired ejaculation and orgasm have been described in men. Decreased sexual desire and less satisfaction in sex have been reported in women.

Sexual dysfunction (SD) assessment should include plasma lipids and testosterone and estradiol, preferably determination of free/total testosterone ratio, as HIV seropositive patients may have increased levels of sex-binding globulin. If hypogonadism is detected, gonadotropins and prolactin should be also

Implication of liver metabolic disturbances. Hepatic steatosis

HIV infection and ARVs may promote side effects similar to those observed in the metabolic syndrome, including hepatic steatosis. Its prevalence in HIV positive patients is 30–50%.

Insulin resistance is a key pathogenic factor. Steatosis per se does not usually cause symptoms. Laboratory diagnosis usually shows elevated transaminases below five times normal upper limits with GPT > GOT, and elevated GGT and alkaline phosphatase; hypertriglyceridemia is not uncommon. Ultrasound is the confirmatory

Funding

The preparation of this document has been financed with the funds from the SPNS (Spanish National AIDS Plan Secretariat).

Conflicts of interests

In order to avoid and/or minimize any conflicts of interests, the individuals who make up this Expert Group have made a formal declaration of interests. In this declaration, some of the authors have received funding to take part in conferences and to conduct research, as well as having received payments as speakers for public institutions and pharmaceutical companies. These activities do not affect the clarity of the present document as the fees and/or grants received do enter into the

Acknowledgements

The SPNS (Spanish National AIDS Plan Secretariat) and the Board of Directors of GEAM (Study Group on AIDS metabolic disorders) and GeSIDA (AIDS Study Group) Directorates are grateful for the support and opinions of Adrián Curran and Juan Emilio Losa, that have contributed to improve the writing and enrich the contents of the document.

Reference (1)

  • Documento de consenso sobre alteraciones metabólicas y riesgo cardiovascular en pacientes con infección por el VIH....

Cited by (4)

1

All members of the Panel are authors of this publication. Writing Committee is presented in Appendix A.

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