US guidelines recommend earlier use of statins in people living with HIV

1 March 2024. Related: Guidelines, Lipodystrophy and metabolic complications.

Simon Collins, HIV i-Base

US guidelines for management of HIV have just been updated to recommend earlier use of statins. [1]

The recommendations were released just before CROI 2024 which is likely to include additional studies and analyses from the REPRIEVE study that was presented at last year’s conference. [2]

These results prompted BHIVA to update guidelines for statin use and HIV in the UK. [3]

Summary of new recommendations

The main US recommendations and considerations are summarised below but please refer to the full guidelines for full details.

For people with HIV who have low to intermediate (<20%) 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimates

Age 40–75 years
- When 10-year ASCVD risk estimates are 5% to <20%, the Panel for the Use of Antiretroviral Agents in Adults and Adolescents with HIV (the Panel) recommends initiating at least moderate-intensity statin therapy (AI).
  - Recommended options for moderate-intensity statin therapy include the following:
    - Pitavastatin 4 mg once daily (AI)
    - Atorvastatin 20 mg once daily (AII)
    - Rosuvastatin 10 mg once daily (AII)
- When 10-year ASCVD risk estimates are <5%, the Panel favours initiating at least moderate-intensity statin therapy (CI). The absolute benefit from statin therapy is modest in this population; therefore, the decision to initiate a statin should take into account the presence or absence of HIV-related factors that can increase ASCVD risk.^a
  - Same options for moderate-intensity statin therapy as recommended for 10-year ASCVD risk estimates of 5% to <20% (see above).
Age <40 years
- Data are insufficient to recommend for or against statin therapy as primary prevention of ASCVD in people with HIV. In the general population, lifestyle modifications are recommended for people age <40 years, with statin therapy considered only in select populations (see American Heart Association (AHA)/American College of Cardiology (ACC)/Multisociety Guidelines).

Key Recommendations for the General Population (Including People with HIV) Based on AHA/ACC/Multisociety Guidelines
For people age 40–75 years who have high (≥20%) 10-year ASCVD risk estimates Initiate high-intensity statin therapy. For people age 20–75 years who have low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dL Initiate high-intensity statin therapy at maximum tolerated dose. For people age 40–75 years with diabetes mellitus Initiate at least moderate-intensity statin therapy. Perform further risk assessment to consider using a high-intensity statin.

Key Recommendations for the General Population (Including People with HIV) Based on AHA/ACC/Multisociety Guidelines

For people age 40–75 years who have high (≥20%) 10-year ASCVD risk estimates

Initiate high-intensity statin therapy.

For people age 20–75 years who have low-density lipoprotein cholesterol (LDL-C) ≥190 mg/dL

Initiate high-intensity statin therapy at maximum tolerated dose.

For people age 40–75 years with diabetes mellitus

Initiate at least moderate-intensity statin therapy. Perform further risk assessment to consider using a high-intensity statin.

Key Considerations
Co-administration of certain statins and antiretroviral drugs may result in significant drug–drug interactions. In some cases, the interaction may require statin dose adjustment, switching to another statin, or increased monitoring for statin-related adverse effects (see the Drug–Drug Interaction section below for details). Initiation of statin therapy should be deferred in pregnant individuals at low to intermediate ASCVD risk until after pregnancy, and statin therapy should be discontinued if a person with HIV becomes pregnant. Breastfeeding is not recommended while a person is on statin therapy.

Key Considerations

Co-administration of certain statins and antiretroviral drugs may result in significant drug–drug interactions. In some cases, the interaction may require statin dose adjustment, switching to another statin, or increased monitoring for statin-related adverse effects (see the Drug–Drug Interaction section below for details).
Initiation of statin therapy should be deferred in pregnant individuals at low to intermediate ASCVD risk until after pregnancy, and statin therapy should be discontinued if a person with HIV becomes pregnant.
Breastfeeding is not recommended while a person is on statin therapy.

References

US HHS. Recommendations for the Use of Statin Therapy as Primary Prevention of Atherosclerotic Cardiovascular Disease in People with HIV. (27 February 2024).
https://clinicalinfo.hiv.gov/en/guidelines/hiv-clinical-guidelines-adult-and-adolescent-arv/statin-therapy-people-hiv
Statins reduce heart disease by 35% in the international HIV REPRIEVE study. HTB (April 2023).
https://i-base.info/htb/45288
HIV guidelines recommend a statin for all people older than 40: new BHIVA document. HTB (December 2023).
https://i-base.info/htb/46628

Panel’s Recommendations
For people with HIV who have low to intermediate (<20%) 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimates Age 40–75 years When 10-year ASCVD risk estimates are 5% to <20%, the Panel for the Use of Antiretroviral Agents in Adults and Adolescents with HIV (the Panel) recommends initiating at least moderate-intensity statin therapy (AI). Recommended options for moderate-intensity statin therapy include the following: Pitavastatin 4 mg once daily (AI) Atorvastatin 20 mg once daily (AII) Rosuvastatin 10 mg once daily (AII) When 10-year ASCVD risk estimates are <5%, the Panel favours initiating at least moderate-intensity statin therapy (CI). The absolute benefit from statin therapy is modest in this population; therefore, the decision to initiate a statin should take into account the presence or absence of HIV-related factors that can increase ASCVD risk.^a Same options for moderate-intensity statin therapy as recommended for 10-year ASCVD risk estimates of 5% to <20% (see above) Age <40 years Data are insufficient to recommend for or against statin therapy as primary prevention of ASCVD in people with HIV. In the general population, lifestyle modifications are recommended for people age <40 years, with statin therapy considered only in select populations (see American Heart Association (AHA)/American College of Cardiology (ACC)/Multisociety Guidelines).

Panel’s Recommendations

For people with HIV who have low to intermediate (<20%) 10-year atherosclerotic cardiovascular disease (ASCVD) risk estimates

Age 40–75 years
- When 10-year ASCVD risk estimates are 5% to <20%, the Panel for the Use of Antiretroviral Agents in Adults and Adolescents with HIV (the Panel) recommends initiating at least moderate-intensity statin therapy (AI).
  - Recommended options for moderate-intensity statin therapy include the following:
    - Pitavastatin 4 mg once daily (AI)
    - Atorvastatin 20 mg once daily (AII)
    - Rosuvastatin 10 mg once daily (AII)
- When 10-year ASCVD risk estimates are <5%, the Panel favours initiating at least moderate-intensity statin therapy (CI). The absolute benefit from statin therapy is modest in this population; therefore, the decision to initiate a statin should take into account the presence or absence of HIV-related factors that can increase ASCVD risk.^a
  - Same options for moderate-intensity statin therapy as recommended for 10-year ASCVD risk estimates of 5% to <20% (see above)
Age <40 years
- Data are insufficient to recommend for or against statin therapy as primary prevention of ASCVD in people with HIV. In the general population, lifestyle modifications are recommended for people age <40 years, with statin therapy considered only in select populations (see American Heart Association (AHA)/American College of Cardiology (ACC)/Multisociety Guidelines).