Question
Is taking nevirapine a risk factor for heart disease?
18 October 2007. Related: All topics, CD4 and viral load, Changing treatment, Opportunistic infections, Side effects.
Dear i-Base
I recently read an article on the aidsmap site about heart disease and treatment interruptions (about the SMART study).
In the article I read that the hazard ratio for those taking viramune /nevirapine was extremely high compared with all others.
I have been on HAART for over 10 years and for the majority of that time nevirapine has been the third drug. Although not part of the SMART study, with the consent of my consultant I made several interruptions to treatment in order to have respite from side effects which I was suffering. This was over a four year period.
However in 2004 I then suffered a heart attack and was diagnosed with coronary artery disease and was given angioplasty and stenting. This was repeated a year later due to ongoing problems.
I have remained on HAART since this time on the recommendation of my consultant, but am still on nevirapine. Am I right to be concerned by this or to suggest to my consultant a swap.
My CD4 counts are 170 appox and have been for around 2 years so coming off treatment is obviously problematic, but I am in considerable pain from side effects these days and wondering if in some way nevirapine could be causing some of these problems.
Any more information you may be able to offer on this would be gratefully received.
Answer
Hi
I had a look on aidsmap to look for this story which I think is this link reporting the presentation at CROI in February this year.
Although the aidsmap report linked use of nevirapine to risk of heart disease, it doesn’t go into enough detail about the actual results, and is wrong to interpret this as finding a link between taking nevirpine and risk of heart disease.
The link to nevirapine was actually only seen in the treatment interruption arm – 9 cases – compared to only 1 case in the continuous treatment arm. So the higher risk was in people who stopped treatment. This shows that if anything nevirapine may have been protective in people who stayed on treatment, though I doubt the study is powered to show this because the numbers are so small.
Also, fthis may just be an indication that people who were originally prescribed nevirapine, may have been those patients who already had higher risk factors for heart disease. This would makes sense given that nevirapine was thought to be a better drug in these patients because of its better lipid profile.
As the numbers in this analysis are so low, I don’t think the researchers are giving much significance to the nevirapine findings, even in the treatment interruption arm.
SMART certainly showed that taking a treatment break increased your relative risk of having a serious illness, including heart disease, by about four-fold compared to staying on treatment with an undetectable viral load.
This is a really important question, as the most recent data from the SMART study seems to indicate one of the risks for heart disease, is ‘not being on treatment’. Having detectable viral load increased one of the markers for heart disease, as did stopping treatment. These markers improved significantly when people started, or restarted treatment in that study. A report in HTB from the conference in Sydney covered this.
The largest study to look at the effects of HIV treatment, including drug class (but also not individual drugs yet) is the D:A:D study.
After 7 years of collecting data, they reported that the increase in risk of heart disease that they observed in people on HIV treatment, was largely related to the increase in blood lipids, which itself was largely related to protease inhibitors. They also found an independent effect of protease inhibitors though, when adjusting for other factors including lipids.
This report from D:A:D study provides details that the use of NNRTI-based regimens (ie efavirenz or nevirapine) showed no impact on risk of heart disease.
In your own case, the nevirapine is unlikely to have increased the risk of heart disease, but the treatment interruptions might have. But this is not something that anyone expected a few years ago, when many people thought treatment interruptions might have a beneficial effect.
Staying on HAART now is a good idea, including the nevirapine, so long as your viral load is currently undetectable and you do not have hepatitis C coinfection. Nevirapine has a beneficially effect on lipids, so if anything, this should help with any heart problems.
What other drugs are you taking? There may be a reason to modify your treatment to improve your CD4 count. This would also depend on your age and your previous CD4 and other treatment history.
The ‘considerable pain’ that you mention is something that your doctor should take seriously. Is this related to the heart problems? If not, what is causing this? Every clinic also has access to a pain management specialist and you should be referred there if this is likely to be an ongoing problem.
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