Question:

I have been diagnosed with AIDS for 18 years and have been gone through most treatment options. During the past 6 months I have developed cardiac problems that first led to my getting 3 stents in an artery and last month, having double bypass surgery in a main artery leading to the one that had previously been stented.

My HIV doctor feels that the Aptivus/Norvir combo I take is responsible for my high triglygeride problem. I do take Tricor and Prevastatin and my triglyderides have come down from the 600's to the 400's. My cardiologist feels that dietary changes won't help much but I've decided to reduce fats, sugars and simple starches and also do more aerobic exercise (when I can). The other antivirals I use are Truvada and Isentress. Is there a better protease option for lipid problems and is there any experience with people in my situation to guide us on how to improve our risk factors?

Answer provided by:

Daniel Lee, M. D.
Assistant Clinical Professor of Medicine
UCSD Medical Center
Owen Clinic

In response to your question, there is another protease inhibitor option that may be helpful - you may want to talk to your provider about Prezista (darunavir). It is certainly possible that your Aptivus/Norvir combination may be the primary cause of your elevated triglyceride levels. Definitely, we know that Norvir can cause these elevations and that the higher the dose of Norvir, the higher the elevation. With your Aptivus/Norvir combination, you are probably taking 200 mg of Norvir twice a day (total of 400 mg per day of Norvir). Studies have definitely shown elevations in triglycerides with the combination of Aptivus and Norvir.

Given that you were prescribed Aptivus, I suspect that you have had quite a bit of drug experience and/or resistance. In regards to lipid neutral protease inhibitors, Reyataz (atazanavir) or Prezista (darunavir) are probably the most lipid-neutral.

My concern with using Reyataz with you is that I suspect that you may have a bit more resistance and thus, Reyataz may not work. However, Prezista often still works in the setting of having multiple prior resistance to other protease inhibitors. Both agents, however, still require Norvir but at a lower dose than with Aptivus (Reyataz requires 100 mg Norvir once/day, Prezista requires 100 mg Norvir twice/day). The other option would be to treat the triglycerides with medications like you are doing with Tricor and pravastatin. You may want to try fish oil or niacin, which have been shown to reduce triglycerides in HIV patients.

In terms of improving your risk factors, I believe that diet and exercise interventions definitely do help and I would not discount the potential effects of reducing fats/sugar/cholesterol in your diet and increasing exercise. Furthermore, I would strongly recommend smoking cessation as doing this will reduce your cardiovascular risk greater than any other intervention you might do (such as starting medications to treat cholesterol/triglyceride levels). Alcohol consumption may also worsen triglyceride levels, so this is also something to consider. If you have hypertension or diabetes, strict management of these problems will also help to lower your cardiovascular risk. Thank you for your question and good luck.

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