- Email: [email protected]
HDL cholesterol ratio
Journal of Infection (2005) 50, 229–235
www.elsevierhealth.com/journals/jinf
Lopinavir/ritonavir combination and total/HDL cholesterol ratio Laure Valerioa, Eric Fontasa,*, Christian Pradiera, Thibaud Lavrutb, Rodolphe Garraffob, Brigitte Dunaisa, Eric Cuac, Pierre Dellamonicac a
ˆpital de l’Archet I, Centre Hospitalier Universitaire, Route de Saint Department of Public Health, Ho `re, BP 3079-06202 Nice Cedex 3, France Antoine de Ginestie b ˆpital Pasteur, 30 avenue de la Voie Romaine, Centre Hospitalier Pharmacology Laboratory, Ho Universitaire, BP 69-06002 Nice Cedex 01, France c ˆpital de l’Archet I, Centre Hospitalier Universitaire, Route de Saint Department of Infectiology, Ho `re, BP 3079-06202 Nice Cedex 3, France Antoine de Ginestie Accepted 25 January 2004 Available online 28 February 2004
KEYWORDS Drug Monitoring; Hyperlipidemia; Lopinavir
Summary Objectives. To describe the evolution of the lipidic profile among LPV/r treated patients in a ‘real life’ situation. Methods. Lipids measurements at LPV/r initiation time and every 3 months, and pharmacological measurements at M3 and M6 were collected retrospectively in 142 patients attending our clinic. Dyslipidaemia was defined as total cholesterol $6.2 mmol/l, HDL-cholesterol $1 mmol/l, total/HDL-cholesterol ratio $6.5 and triglycerides $ 2.3 mmol/l. Results. Eighty-nine percent of patients had previously received a regimen with protease inhibitors, 4% were treatment naı¨ve. At baseline, 17% of patients had high total cholesterol, 49% high triglycerides, 63% low HDL-cholesterol, 25% a high total/HDL-cholesterol ratio. At M12, the mean HDL-cholesterol increase per patient was 21%. Lipids levels significantly increased over the study period, as early as the 3rd month (6th month for ratio) and continuously until the 12th month. Among the patients with available LPV/r plasma determinations at M3, a higher lopinavir residual concentration was observed in those with high triglycerides (6.78 vs 3.02 mg/l, p ¼ 0:05) as, at M6, in those with an elevated ratio (9.19 vs 0.96 mg/l, p ¼ 0:02). Conclusions. Those results suggest that LPV/r may induce a significant rise in the total/HDL-cholesterol ratio, despite an increase in HDL-cholesterol levels. The association between triglycerides and total/HDL-cholesterol ratio elevated levels and high residual concentrations of lopinavir may also argue for systematic drug monitoring. Q 2004 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction *Corresponding author. Tel.: þ 33-4-9203-5635; fax: þ33-49203-5627. E-mail address: [email protected]
Adverse events related to antiretroviral treatment of HIV-infected patients are a major concern for clinicians. In patients receiving protease inhibitors
0163-4453/$30.00 Q 2004 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2004.01.014
230 (IP), dyslipidemia is frequent1,2 and may lead to cardiovascular complications. Kaletraw (LPV/r) is a recent PI combining lopinavir 400 mg and ritonavir 100 mg as a booster. Studies focusing on the lipid profiles of HIV-infected patients receiving Kaletraw have mainly revealed a significant increase in total cholesterol (TC) and triglycerides.3,4 To our knowledge no data are currently available concerning trends over time for HDL-cholesterol and the total cholesterol/HDLcholesterol ratio. Given the importance of those parameters as predictive factors of cardiovascular risk,5,6 such data should be particularly useful. Moreover, results concerning trends for TC and triglycerides have been mainly provided by randomised clinical trials and should be confronted with those collected among an observational cohort of HIV-infected patients. The Nice HIV cohort offered an opportunity to describe the impact of Kaletraw on serum lipids and in particular on the TC/HDL-c ratio in a ‘real life’ situation.
Materials and methods Data source The Nice HIV cohort includes 4500 patients who have been followed at the Nice University Hospital Infectiology department day hospital since 1995. The usual follow-up schedule consists in one consultation every 3 months. At each consultation, clinical, laboratory and treatment data are entered in real time by the physician in a computerised medical record (NADISw)7 from which our data were retrieved. Quality control is conducted by a clinical research assistant.
Study design This is a retrospective study of lipid profile variations in an observational cohort of HIVinfected patients treated with Kaletra w. We included patients above 15 years of age who had received the LPV/r combination between December 1999 and January 2002, and for whom lipid measurements were available at treatment initiation. The inclusion date was the day LPV/r was prescribed for the first time. Patients who had been treated with LPV/r for less than a month and those for whom the initial lipid measurements had been obtained more than 3 months prior to LPV/r treatment initiation were not included in the study. The initial laboratory data were those obtained
L. Valerio et al.
immediately before starting LPV/r. Lipid, immunological and virological parameters (TC, HDL-cholesterol, triglycerides, CD4 T-cells and HIV viral load) were collected at treatment initiation and subsequently every 3 months. Patients who discontinued treatment or were lost to follow-up were excluded from the study. The duration of patient follow-up was calculated as the difference between the date of the most recent laboratory data and the date of inclusion.
Variables of interest The analysis focused on serum concentrations of TC, HDL-cholesterol (HDL-c), triglycerides, and the TC/HDL-c ratio. Dyslipidemia was defined according to the thresholds established by the National Cholesterol Education Program: TC $ 6.2 mmol/l, HDL-c # 1 mmol/l, triglycerides $ 2.3 mmol/l.8 The threshold for the TC/HDL-c ratio was chosen at 6.5, according to published data.5,9 Lopinavir and ritonavir measurements were performed by high pressure liquid chromatography (HPLC) coupled with ultraviolet detection set at 220 nm. Other variables included CD4 T-cell count, HIV viral load (VL), gender, mode of contamination, HIV disease stage, lipodystrophy, body mass index (BMI) and a history of treatment with ritonavir.
Statistical analysis We described trends in lipid profile, CD4 T-cell count and viral load, and percentage of patients with dyslipidemia between M0 and M12 of treatment with LPV/r. Statistically significant variations were investigated using paired samples Student’s t-test for comparison of mean values and chi-square tests. We conducted a univariate analysis to search for factors associated with an elevated TC/HDL-c ratio at M12 (Chi-square test, Fisher’s exact test, ANOVA), and those with a statistically significant association at the 15% level of significance were included in a logistic regression model. Lastly, we compared trends in TC/HDL-c ratio in two groups of patients, those who had received ritonavir during the three months prior to inclusion and those who had not received ritonavir. Differences between M0 and M12 within each group and between the two groups were analysed using chi-square tests for trend and paired samples t-tests, and analysis of variance. All tests were two-sided, with a 5% level of significance. The statistical analysis was conducted on SPSS software (Statistical Package for Social Sciences, Carry; Inc. 11.0).
Lopinavir/ritonavir in real life
231
Figure 1 Immuno-virological evolution.
Results Population One hundred and forty two patients treated with LPV/r between December 1999 and January 2002 were included in the study (Table 1). The mean duration of follow-up was 14 months. Seventy-nine percent of patients were male; the mean age was
41 ^ 8 years. Patients had previously received an average of eight different treatment regimens. Initial laboratory data indicated treatment failure: mean VL was 4.5 ^ 1.1 log10 copies/ml and in 42% of patients VL was above 100 000 copies/ml; mean CD4 T lymphocyte count was 247 ^ 199/ml and in 45% of patients the CD4 T-cell count was below 200/ml. At M0 17% of patients had elevated serum cholesterol, 25% an elevated TC/HDL-c ratio, 49%
Table 1 Baseline characteristics of the study population. Values are n; % or median (IQR) as appropriate N
%
Number of patients Male Age BMI (kg/m2) Lipodystrophy (atrophy or hypertrophy)
142 112 142 142 103
100% 79% 39.5 (36 –45) 22 (20– 23) 73%
Transmission mode Homo/bisexual Heterosexual Intravenous drug user Other/unknown AIDS stage CD4 count (cells/mm3) Viral load (copies/ml)
46 38 43 15 50 141 142
32% 27% 30% 11% 35% 228 (81– 373) 52 000 (8350–230 000)
Dyslipidemia Total cholesterol $6.2 mmol l21 HDL-c #1 mmol l21 Triglycerides $2.3 mmol l21 TC/HDL-c ratio $6.5
23 72 69 29
17% 63% 49% 25%
Previous antiretroviral treatment Naı¨ve Previous ritonavir Previous PI Previous NNRTI
6 91 126 101
4% 64% 89% 71%
Treatments associated with LPV/r PI NNRTI
10 33
7% 23%
232
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had elevated serum triglycerides and 63% had low HDL-c. LPV/r was associated with nucleoside reverse transcriptase inhibitors (NRTI) in 94% of patients, with non-nucleoside reverse transcriptase inhibitors (NNRTI) in 23% of patients, and with another PI in 7% of patients. Treatment was discontinued because of adverse events in 15 patients (due to dyslipidemia associated with a pre-existing cardiovascular risk in three patients and with isolated serum hyper-triglyceridemia in two other cases).
Virological and immmunological impact At M3 VL had significantly diminished ðp , 0:001Þ below detection limit (400, IQR ¼ 40 – 1900) (Fig. 1). It remained undetectable until M12 in 50% of patients. The CD4 T-cell count had increased significantly as early as M3 ðp , 0:001Þ and up to M12. The median CD4 T-cell count reached 338/ml (IQR ¼ 181 – 553) at M12, with a mean increase of 168 ^ 205/ml.
Trends in lipid profile The proportion of patients with elevated triglycerides or TC increased from M3 (respectively 66% vs 49%, p ¼ 0:003; 36% vs 17%, p , 0:001) and up to M12 (respectively 72%, p ¼ 0:001; 35%, p ¼ 0:003). Regarding the TC/HDL-c ratio, a rise was observed from M6 (37% vs 25%, p ¼ 0:056) and up to M12 (41%, p ¼ 0:019). On the other hand, the proportion of patients with HDL-c # 1 mmol/l did not overall vary significantly between M0 and M12 (53% vs 63%, NS), although it had decreased till M9 (48%, p ¼ 0:03).
During the whole study period, 11 patients (8%) had serum triglycerides above 11.2 mmol/l. Fig. 2 shows trends in serum lipid concentrations. A significant increase in mean concentrations was observed from M3 for triglycerides, TC and HDL-c, and from M6 for the TC/HDL-c ratio. At M12, mean values for the four lipid variables were significantly higher than at inclusion. For those patients for whom laboratory data were available at M0 and M3, the mean increase in triglycerides and TC over the period was respectively 0.92 ^ 2.33 mmol/l (71%; p , 0:001; n ¼ 132) and 0.96 ^ 1.20 mmol/l (23%; p , 0:001; n ¼ 121). At M12, it was 1.5 ^ 6.39 mmol/l for triglycerides (132%; p ¼ 0:042; n ¼ 78) and 1.27 ^ 2.15 mmol/l for TC (30%; p , 0:001; n ¼ 71). HDL-c increased by 0.07 ^ 0.27 mmol/l on average at M3 (17%; p ¼ 0:007; n ¼ 101) then levelled off until M12. The average rise in HDL-c over the duration of the study was 0.13 ^ 0.29 mmol/l (21%; p ¼ 0:001; n ¼ 59). Lastly, the mean increase in CT/HDL-c ratio at M12 was 0.5 ^ 1.8 (14%; p ¼ 0:033; n ¼ 59). There was no difference in TC/HDL-c ratio whether the patients had been exposed to ritonavir or not in the previous 3 months. However, patients not exposed to ritonavir experienced an increase in TC/HDL-c ratio by 0.66 ^ 1.74 at M6 (n ¼ 68; p ¼ 0:003) and by 0.56 ^ 1.83 at M12 (n ¼ 46; p ¼ 0:04), while no change was observed in patients exposed to ritonavir. The proportion of patients with an elevated ratio increased, significantly over the study period only among non exposed patients (24% at M0, 44% at M12; p , 0:001) (Fig. 3).
Figure 2 Evolution of mean lipid levels (mmol/l).
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233
Figure 3 Percentage of patients with TC/HDL-c ratio > 6.5 depending on prior ritonavir exposure in the 3 months before M0.
In univariate analysis, factors associated with a ratio $ 6.5 among the 75 patients for whom laboratory data were available at M12 were male gender (OR ¼ 7.5 [1.4 – 52.3], p ¼ 0:005) and a ratio already $ 6.5 at inclusion (OR ¼ 10.8 [2.7 – 43.8], p ¼ 0:02). At the 5% level of significance, age, BMI, mode of contamination, lipodystrophy, HIV disease stage, CD4 T-cell count and VL at M0, and prior treatment with ritonavir during the 3 months before inclusion were not associated with an elevated ratio at M12 (data not shown). After adjusting with a logistic regression model, age (continuous), gender and a high ratio at treatment initiation were, significantly and independently associated with an increased ratio at M12. (p ¼ 0:04; p ¼ 0:03; p ¼ 0:001; respectively).
Pharmacological measurements Among the 30 patients for whom LPV/r plasma measurements were available at M3, those with elevated triglycerides had a higher mean residual serum concentration of lopinavir (6.73 ^ 2.1 vs
4.41 ^ 3.63 mg/l; p ¼ 0:05) (Table 2). At M6, 19 measurements were available and the patient group with a ratio $ 6.5 also had an elevated mean residual serum concentration of lopinavir (8.07 ^ 3.61 vs 2.00 ^ 2.78; p ¼ 0:02).
Discussion Our study, which was conducted on an observational data base and concerned patients with treatment failure after multiple treatments, confirmed the increase in serum concentrations of TC and triglycerides during antiretroviral treatment including LPV/r. It also showed a moderate increase in mean TC/HDL-c ratio and HDL cholesterol. The increase in TC and triglycerides in patients receiving Kaletraw had already been reported3,4 but in naive patients during clinical trials. In spite of an increase in triglycerides, the proportion of patients with serum triglycerides above 11.3 mmol/l was lower in our study (8%) than that observed among patients receiving full-dose ritonavir for grade III/IV
Table 2 Pharmacokinetic analysis (mg/ml) and dyslipidemia. Values are median (IQR)
M3:
M6:
a
Triglycerides ,2.3 mmol/l Triglycerides $2.3 mmol/l TC/HDL-c ratio ,6.5 TC/HDL-c ratio $6.5 Triglycerides ,2.3 mmol/l Triglycerides $2.3 mmol/l TC/HDL-c ratio ,6.5 TC/HDL-c ratio $6.5
Mann– Whitney U test
Lopinavir Cmin
pa
Ritonavir Cmin
pa
3.02 (1.89 –8.10) 6.78 (4.90 –8.17) 5.05 (3.19 –8.28) 4.85 (2.81 –8.29) 0.81 (0.04 –1.58) 7.21 (3.09 –9.44) 0.96 (0.11 –4.93) 9.19 (5.25 –10.00)
0.05
0.14 (0.08 –0.24) 0.21 (0.04 –0.32) 0.08 (0.04 –0.27) 0.16 (0.04 –0.25) 0.04 (0.04 –0.04) 0.11 (0.05 –0.29) 0.04 (0.04 –0.29) 0.16 (0.06 –0.34)
1
0.91 0.06 0.02
0.93 0.07 0.13
234
hypertriglyceridemia in the studies published by Cameron10 and Di Perri11 (12.9% . 16.9 mmol/l and 15% . 11.3 mmol/l, respectively). During our study, only two patients had to discontinue treatment due to severe hypertriglyceridemia. Our data thus suggest a weaker induction of major hypertriglyceridemia with LPV/r than with full-dose ritonavir. We also observed a significant increase in mean plasma HDL-cholesterol above 1 mmol/l as early as M3, which was sustained up to M12. Similar results were described with other PIs.12 – 14 Despite the increase in HDL-c, the mean progression of the TC/ HDL-c ratio was 14% (0.5 ^ 1.8) between M0 and M12. Berthold reported a more marked increase in the TC/HDL-c ratio with nelfinavir, ritonavir or indinavir (1.2; 95% CI ¼ [0.7 –1.7]) but in PI-naive patients, and with a lower ratio at inclusion (4.8 ^ 1.5).14 In our study, the number of patients with a TC/HDL-c ratio . 6.5 increased significantly only among patients who had not received ritonavir during the 3 months preceding LPV/r initiation. Since full-dose ritonavir is the most potent inductor of dyslipidemia,15,16 our results suggest that patients treated with ritonavir may have reached their peak TC/HDL-c ratio. The switch from ritonavir to LPV/r would thus not further affect the TC/HDL-c ratio. We showed that patients with a TC/HDL-c ratio . 6.5 or triglycerides . 2.3 mmol/l had significantly higher residual lopinavir concentrations, above the recommended Cmin of 5 mg/l.17 Gonzales de Requena has also shown an association between the percentage of increase in triglycerides and the residual lopinavir concentration.18 Our data suggest a specific effect of lopinavir on serum lipids, and conversely no adverse effect for low-dose ritonavir (100 mg £ 2/day). Moreover, while PI residual concentration is usually one to four-fold the EC50,19 that of lopinavir, at the recommended dose for LPV/r of 400/100 mg bid is 75-fold higher,20 in an attempt to reduce the risk of treatment failure and the selection of non-susceptible mutant or resistant strains.21,22 Regular and systematic monitoring of residual lopinavir concentrations could thus be of major interest, not only with the objective of reaching adequate Cmin but also not to exceed it and thus limit the incidence of dyslipidemia. The effectiveness of LPV/r on virological and immunological criteria was observed as early as M3. At M6, viral load was below 400 copies/ml in 50% of patients, which is in line with the 31.7% rate reported by Romano in another observational study on highly treatment-experienced patients.23 Those results are quite different from the 85% at 48 weeks4 and the 79% at 24 weeks3 reported in two
L. Valerio et al.
randomised clinical trials among naive patients. Similarly, the mean increase in CD4 T-cells observed at M12 in our study differs from that reported in these two clinical trials: 168 vs 213 for Murphy and 207 for Walmsley. Our study, which was conducted on a non-selected population, allowed a more adequate assessment of the immune and virological impact of Kaletra w in a real life situation. Those results must be discussed with regard to study limitations. The observational nature of the study and the absence of a control group do not allow us to establish a definitive causal relationship between intake of LPV/r and dyslipidemia. Besides, treatment with Kaletraw was not randomly allocated and therefore our group of patients cannot be considered a representative sample of the overall patient file. Demographic characteristics of our patients are nevertheless comparable to those of the remaining cohort (data not shown). Lastly, it is impossible to ascertain that all lipid measurements were conducted on fasting patients, although this is the recommended procedure. Most previous studies focusing on lipid data during LPV/r treatment were clinical studies conducted on antiretroviral-naive patients and should be considered cautiously because of selection bias.24 It was therefore of interest to confront those initial results with observational data that reflect daily clinical practice.25
Acknowledgements The authors would like to thank Nathalie Oran and Christophe Caissotti for their help in preparing the database and for the preliminary statistical analysis.
References 1. Carr A, Samaras K, Thorisdottir A, Kaufmann GR, Chisholm DJ, Cooper DA. Diagnosis, prediction, and natural course of HIV-1 protease-inhibitor-associated lipodystrophy, hyperlipidaemia, and diabetes mellitus: a cohort study. Lancet 1999;353(9170):2093—2099. 2. Behrens G, Dejam A, Schmidt H, et al. Impaired glucose tolerance, beta cell function and lipid metabolism in HIV patients under treatment with protease inhibitors. AIDS 1999;13(10):F63—F70. 3. Walmsley S, Bernstein B, King M, et al. Lopinavir—ritonavir versus nelfinavir for the initial treatment of HIV infection. N Engl J Med 2002;346(26):2039—2046. 4. Murphy RL, Brun S, Hicks C, et al. ABT-378/ritonavir plus stavudine and lamivudine for the treatment of antiretroviral-naive adults with HIV-1 infection: 48-week results. AIDS 2001;15(1):F1—F9.
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5. Kinosian B, Glick H, Garland G. Cholesterol and coronary heart disease: predicting risks by levels and ratios. Ann Intern Med 1994;121(9):641—647. 6. Lemieux I, Lamarche B, Couillard C, et al. Total cholesterol/ HDL cholesterol ratio vs LDL cholesterol/HDL cholesterol ratio as indices of ischemic heart disease risk in men: the Quebec Cardiovascular Study. Arch Intern Med 2001; 161(22):2685—2692. 7. Pugliese P, Cuzin L, Enel P, et al. NADIS 2000, development of an electronic medical record for patients infected by HIV, HBV and HCV. Presse Med 2003;32(7):299—303. 8. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA 2001; 285(19):2486—97. 9. Criqui MH, Golomb BA. Epidemiologic aspects of lipid abnormalities. Am J Med 1998;105(1A):48S—57S. 10. Cameron DW, Heath-Chiozzi M, Danner S, et al. Randomised placebo-controlled trial of ritonavir in advanced HIV-1 disease. The Advanced HIV Disease Ritonavir Study Group. Lancet 1998;351(9102):543—549. 11. Di Perri G, Del Bravo P, Concia E. HIV-protease inhibitors. N Engl J Med 1998;339(11):773—774. Author reply 774. 12. Dube MP, Qian D, Edmondson-Melancon H, et al. Prospective, intensive study of metabolic changes associated with 48 weeks of amprenavir-based antiretroviral therapy. Clin Infect Dis 2002;35(4):475—481. 13. Pradier C, Sabin CA, Friis-Moller N. et al. Lipid profiles on therapy with PI. The D:A:D (data collection on adverse events of anti HIV drugs) study. Sixth International Congress on Drug Therapy in HIV Infection. Glasgow, UK. November 17—21, 2002. 14. Berthold HK, Parhofer KG, Ritter MM, et al. Influence of protease inhibitor therapy on lipoprotein metabolism. J Intern Med 1999;246(6):567—575. 15. Periard D, Telenti A, Sudre P, et al. Atherogenic dyslipidemia in HIV-infected individuals treated with protease inhibitors. The Swiss HIV Cohort Study. Circulation 1999;100(7): 700—705. 16. Manfredi R, Chiodo F. Disorders of lipid metabolism in
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patients with HIV disease treated with antiretroviral agents: frequency, relationship with administered drugs, and role of hypolipidaemic therapy with bezafibrate. J Infect 2001; 42(3):181—188. Delfraissy J. Prise en charge des personnes infecte ´es par le VIH. Recommandations du groupe d’experts. Flammarion: Me ´decine-Sciences; 2002. Gonzales de Requena D, Gallego O, Blanco F, et al. Lopinavir drug levels predict the virological and immunological outcome as well as lipid elevations in HIV-infected patients treated with Kaletra. Tenth Conference on Retroviruses and Opportunistic Infections. Boston, USA; February 10—14, 2003. Condra JH, Petropoulos CJ, Ziermann R, Schleif WA, Shivaprakash M, Emini EA. Drug resistance and predicted virologic responses to human immunodeficiency virus type 1 protease inhibitor therapy. J Infect Dis 2000;182(3): 758—765. Bertz R, Renz C, Foit C. Steady-state pharmacokinetics of Kaletra (lopinavir/ritonavir 400/100 mg bid) in HIV-infected subjects when taken with food. Second International Workshop on Clinical Pharmacology of HIV Therapy. Noordwijk, The Netherlands; April 2—4, 2001. Molla A, Korneyeva M, Gao Q, et al. Ordered accumulation of mutations in HIV protease confers resistance to ritonavir. Nat Med 1996;2(7):760—766. Durant J, Clevenbergh P, Garraffo R, et al. Importance of protease inhibitor plasma levels in HIV-infected patients treated with genotypic-guided therapy: pharmacological data from the Viradapt Study. AIDS 2000;14(10):1333—1339. Romano L, Peduzzi C, Venturi G, et al. Treatment with lopinavir/ritonavir in heavily pretreated subjects failing multiple antiretroviral regimens in clinical practice. J Acquir Immune Defic Syndr 2002;30(5):533—535. Grimes DA, Schulz KF. Bias and causal associations in observational research. Lancet 2002;359(9302):248—252. Ghani AC, Henley WE, Donnelly CA, Mayer S, Anderson RM. Comparison of the effectiveness of non-nucleoside reverse transcriptase inhibitor-containing and protease inhibitorcontaining regimens using observational databases. AIDS 2001;15(9):1133—1142.
www.elsevierhealth.com/journals/jinf
Lopinavir/ritonavir combination and total/HDL cholesterol ratio Laure Valerioa, Eric Fontasa,*, Christian Pradiera, Thibaud Lavrutb, Rodolphe Garraffob, Brigitte Dunaisa, Eric Cuac, Pierre Dellamonicac a
ˆpital de l’Archet I, Centre Hospitalier Universitaire, Route de Saint Department of Public Health, Ho `re, BP 3079-06202 Nice Cedex 3, France Antoine de Ginestie b ˆpital Pasteur, 30 avenue de la Voie Romaine, Centre Hospitalier Pharmacology Laboratory, Ho Universitaire, BP 69-06002 Nice Cedex 01, France c ˆpital de l’Archet I, Centre Hospitalier Universitaire, Route de Saint Department of Infectiology, Ho `re, BP 3079-06202 Nice Cedex 3, France Antoine de Ginestie Accepted 25 January 2004 Available online 28 February 2004
KEYWORDS Drug Monitoring; Hyperlipidemia; Lopinavir
Summary Objectives. To describe the evolution of the lipidic profile among LPV/r treated patients in a ‘real life’ situation. Methods. Lipids measurements at LPV/r initiation time and every 3 months, and pharmacological measurements at M3 and M6 were collected retrospectively in 142 patients attending our clinic. Dyslipidaemia was defined as total cholesterol $6.2 mmol/l, HDL-cholesterol $1 mmol/l, total/HDL-cholesterol ratio $6.5 and triglycerides $ 2.3 mmol/l. Results. Eighty-nine percent of patients had previously received a regimen with protease inhibitors, 4% were treatment naı¨ve. At baseline, 17% of patients had high total cholesterol, 49% high triglycerides, 63% low HDL-cholesterol, 25% a high total/HDL-cholesterol ratio. At M12, the mean HDL-cholesterol increase per patient was 21%. Lipids levels significantly increased over the study period, as early as the 3rd month (6th month for ratio) and continuously until the 12th month. Among the patients with available LPV/r plasma determinations at M3, a higher lopinavir residual concentration was observed in those with high triglycerides (6.78 vs 3.02 mg/l, p ¼ 0:05) as, at M6, in those with an elevated ratio (9.19 vs 0.96 mg/l, p ¼ 0:02). Conclusions. Those results suggest that LPV/r may induce a significant rise in the total/HDL-cholesterol ratio, despite an increase in HDL-cholesterol levels. The association between triglycerides and total/HDL-cholesterol ratio elevated levels and high residual concentrations of lopinavir may also argue for systematic drug monitoring. Q 2004 The British Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction *Corresponding author. Tel.: þ 33-4-9203-5635; fax: þ33-49203-5627. E-mail address: [email protected]
Adverse events related to antiretroviral treatment of HIV-infected patients are a major concern for clinicians. In patients receiving protease inhibitors
0163-4453/$30.00 Q 2004 The British Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jinf.2004.01.014
230 (IP), dyslipidemia is frequent1,2 and may lead to cardiovascular complications. Kaletraw (LPV/r) is a recent PI combining lopinavir 400 mg and ritonavir 100 mg as a booster. Studies focusing on the lipid profiles of HIV-infected patients receiving Kaletraw have mainly revealed a significant increase in total cholesterol (TC) and triglycerides.3,4 To our knowledge no data are currently available concerning trends over time for HDL-cholesterol and the total cholesterol/HDLcholesterol ratio. Given the importance of those parameters as predictive factors of cardiovascular risk,5,6 such data should be particularly useful. Moreover, results concerning trends for TC and triglycerides have been mainly provided by randomised clinical trials and should be confronted with those collected among an observational cohort of HIV-infected patients. The Nice HIV cohort offered an opportunity to describe the impact of Kaletraw on serum lipids and in particular on the TC/HDL-c ratio in a ‘real life’ situation.
Materials and methods Data source The Nice HIV cohort includes 4500 patients who have been followed at the Nice University Hospital Infectiology department day hospital since 1995. The usual follow-up schedule consists in one consultation every 3 months. At each consultation, clinical, laboratory and treatment data are entered in real time by the physician in a computerised medical record (NADISw)7 from which our data were retrieved. Quality control is conducted by a clinical research assistant.
Study design This is a retrospective study of lipid profile variations in an observational cohort of HIVinfected patients treated with Kaletra w. We included patients above 15 years of age who had received the LPV/r combination between December 1999 and January 2002, and for whom lipid measurements were available at treatment initiation. The inclusion date was the day LPV/r was prescribed for the first time. Patients who had been treated with LPV/r for less than a month and those for whom the initial lipid measurements had been obtained more than 3 months prior to LPV/r treatment initiation were not included in the study. The initial laboratory data were those obtained
L. Valerio et al.
immediately before starting LPV/r. Lipid, immunological and virological parameters (TC, HDL-cholesterol, triglycerides, CD4 T-cells and HIV viral load) were collected at treatment initiation and subsequently every 3 months. Patients who discontinued treatment or were lost to follow-up were excluded from the study. The duration of patient follow-up was calculated as the difference between the date of the most recent laboratory data and the date of inclusion.
Variables of interest The analysis focused on serum concentrations of TC, HDL-cholesterol (HDL-c), triglycerides, and the TC/HDL-c ratio. Dyslipidemia was defined according to the thresholds established by the National Cholesterol Education Program: TC $ 6.2 mmol/l, HDL-c # 1 mmol/l, triglycerides $ 2.3 mmol/l.8 The threshold for the TC/HDL-c ratio was chosen at 6.5, according to published data.5,9 Lopinavir and ritonavir measurements were performed by high pressure liquid chromatography (HPLC) coupled with ultraviolet detection set at 220 nm. Other variables included CD4 T-cell count, HIV viral load (VL), gender, mode of contamination, HIV disease stage, lipodystrophy, body mass index (BMI) and a history of treatment with ritonavir.
Statistical analysis We described trends in lipid profile, CD4 T-cell count and viral load, and percentage of patients with dyslipidemia between M0 and M12 of treatment with LPV/r. Statistically significant variations were investigated using paired samples Student’s t-test for comparison of mean values and chi-square tests. We conducted a univariate analysis to search for factors associated with an elevated TC/HDL-c ratio at M12 (Chi-square test, Fisher’s exact test, ANOVA), and those with a statistically significant association at the 15% level of significance were included in a logistic regression model. Lastly, we compared trends in TC/HDL-c ratio in two groups of patients, those who had received ritonavir during the three months prior to inclusion and those who had not received ritonavir. Differences between M0 and M12 within each group and between the two groups were analysed using chi-square tests for trend and paired samples t-tests, and analysis of variance. All tests were two-sided, with a 5% level of significance. The statistical analysis was conducted on SPSS software (Statistical Package for Social Sciences, Carry; Inc. 11.0).
Lopinavir/ritonavir in real life
231
Figure 1 Immuno-virological evolution.
Results Population One hundred and forty two patients treated with LPV/r between December 1999 and January 2002 were included in the study (Table 1). The mean duration of follow-up was 14 months. Seventy-nine percent of patients were male; the mean age was
41 ^ 8 years. Patients had previously received an average of eight different treatment regimens. Initial laboratory data indicated treatment failure: mean VL was 4.5 ^ 1.1 log10 copies/ml and in 42% of patients VL was above 100 000 copies/ml; mean CD4 T lymphocyte count was 247 ^ 199/ml and in 45% of patients the CD4 T-cell count was below 200/ml. At M0 17% of patients had elevated serum cholesterol, 25% an elevated TC/HDL-c ratio, 49%
Table 1 Baseline characteristics of the study population. Values are n; % or median (IQR) as appropriate N
%
Number of patients Male Age BMI (kg/m2) Lipodystrophy (atrophy or hypertrophy)
142 112 142 142 103
100% 79% 39.5 (36 –45) 22 (20– 23) 73%
Transmission mode Homo/bisexual Heterosexual Intravenous drug user Other/unknown AIDS stage CD4 count (cells/mm3) Viral load (copies/ml)
46 38 43 15 50 141 142
32% 27% 30% 11% 35% 228 (81– 373) 52 000 (8350–230 000)
Dyslipidemia Total cholesterol $6.2 mmol l21 HDL-c #1 mmol l21 Triglycerides $2.3 mmol l21 TC/HDL-c ratio $6.5
23 72 69 29
17% 63% 49% 25%
Previous antiretroviral treatment Naı¨ve Previous ritonavir Previous PI Previous NNRTI
6 91 126 101
4% 64% 89% 71%
Treatments associated with LPV/r PI NNRTI
10 33
7% 23%
232
L. Valerio et al.
had elevated serum triglycerides and 63% had low HDL-c. LPV/r was associated with nucleoside reverse transcriptase inhibitors (NRTI) in 94% of patients, with non-nucleoside reverse transcriptase inhibitors (NNRTI) in 23% of patients, and with another PI in 7% of patients. Treatment was discontinued because of adverse events in 15 patients (due to dyslipidemia associated with a pre-existing cardiovascular risk in three patients and with isolated serum hyper-triglyceridemia in two other cases).
Virological and immmunological impact At M3 VL had significantly diminished ðp , 0:001Þ below detection limit (400, IQR ¼ 40 – 1900) (Fig. 1). It remained undetectable until M12 in 50% of patients. The CD4 T-cell count had increased significantly as early as M3 ðp , 0:001Þ and up to M12. The median CD4 T-cell count reached 338/ml (IQR ¼ 181 – 553) at M12, with a mean increase of 168 ^ 205/ml.
Trends in lipid profile The proportion of patients with elevated triglycerides or TC increased from M3 (respectively 66% vs 49%, p ¼ 0:003; 36% vs 17%, p , 0:001) and up to M12 (respectively 72%, p ¼ 0:001; 35%, p ¼ 0:003). Regarding the TC/HDL-c ratio, a rise was observed from M6 (37% vs 25%, p ¼ 0:056) and up to M12 (41%, p ¼ 0:019). On the other hand, the proportion of patients with HDL-c # 1 mmol/l did not overall vary significantly between M0 and M12 (53% vs 63%, NS), although it had decreased till M9 (48%, p ¼ 0:03).
During the whole study period, 11 patients (8%) had serum triglycerides above 11.2 mmol/l. Fig. 2 shows trends in serum lipid concentrations. A significant increase in mean concentrations was observed from M3 for triglycerides, TC and HDL-c, and from M6 for the TC/HDL-c ratio. At M12, mean values for the four lipid variables were significantly higher than at inclusion. For those patients for whom laboratory data were available at M0 and M3, the mean increase in triglycerides and TC over the period was respectively 0.92 ^ 2.33 mmol/l (71%; p , 0:001; n ¼ 132) and 0.96 ^ 1.20 mmol/l (23%; p , 0:001; n ¼ 121). At M12, it was 1.5 ^ 6.39 mmol/l for triglycerides (132%; p ¼ 0:042; n ¼ 78) and 1.27 ^ 2.15 mmol/l for TC (30%; p , 0:001; n ¼ 71). HDL-c increased by 0.07 ^ 0.27 mmol/l on average at M3 (17%; p ¼ 0:007; n ¼ 101) then levelled off until M12. The average rise in HDL-c over the duration of the study was 0.13 ^ 0.29 mmol/l (21%; p ¼ 0:001; n ¼ 59). Lastly, the mean increase in CT/HDL-c ratio at M12 was 0.5 ^ 1.8 (14%; p ¼ 0:033; n ¼ 59). There was no difference in TC/HDL-c ratio whether the patients had been exposed to ritonavir or not in the previous 3 months. However, patients not exposed to ritonavir experienced an increase in TC/HDL-c ratio by 0.66 ^ 1.74 at M6 (n ¼ 68; p ¼ 0:003) and by 0.56 ^ 1.83 at M12 (n ¼ 46; p ¼ 0:04), while no change was observed in patients exposed to ritonavir. The proportion of patients with an elevated ratio increased, significantly over the study period only among non exposed patients (24% at M0, 44% at M12; p , 0:001) (Fig. 3).
Figure 2 Evolution of mean lipid levels (mmol/l).
Lopinavir/ritonavir in real life
233
Figure 3 Percentage of patients with TC/HDL-c ratio > 6.5 depending on prior ritonavir exposure in the 3 months before M0.
In univariate analysis, factors associated with a ratio $ 6.5 among the 75 patients for whom laboratory data were available at M12 were male gender (OR ¼ 7.5 [1.4 – 52.3], p ¼ 0:005) and a ratio already $ 6.5 at inclusion (OR ¼ 10.8 [2.7 – 43.8], p ¼ 0:02). At the 5% level of significance, age, BMI, mode of contamination, lipodystrophy, HIV disease stage, CD4 T-cell count and VL at M0, and prior treatment with ritonavir during the 3 months before inclusion were not associated with an elevated ratio at M12 (data not shown). After adjusting with a logistic regression model, age (continuous), gender and a high ratio at treatment initiation were, significantly and independently associated with an increased ratio at M12. (p ¼ 0:04; p ¼ 0:03; p ¼ 0:001; respectively).
Pharmacological measurements Among the 30 patients for whom LPV/r plasma measurements were available at M3, those with elevated triglycerides had a higher mean residual serum concentration of lopinavir (6.73 ^ 2.1 vs
4.41 ^ 3.63 mg/l; p ¼ 0:05) (Table 2). At M6, 19 measurements were available and the patient group with a ratio $ 6.5 also had an elevated mean residual serum concentration of lopinavir (8.07 ^ 3.61 vs 2.00 ^ 2.78; p ¼ 0:02).
Discussion Our study, which was conducted on an observational data base and concerned patients with treatment failure after multiple treatments, confirmed the increase in serum concentrations of TC and triglycerides during antiretroviral treatment including LPV/r. It also showed a moderate increase in mean TC/HDL-c ratio and HDL cholesterol. The increase in TC and triglycerides in patients receiving Kaletraw had already been reported3,4 but in naive patients during clinical trials. In spite of an increase in triglycerides, the proportion of patients with serum triglycerides above 11.3 mmol/l was lower in our study (8%) than that observed among patients receiving full-dose ritonavir for grade III/IV
Table 2 Pharmacokinetic analysis (mg/ml) and dyslipidemia. Values are median (IQR)
M3:
M6:
a
Triglycerides ,2.3 mmol/l Triglycerides $2.3 mmol/l TC/HDL-c ratio ,6.5 TC/HDL-c ratio $6.5 Triglycerides ,2.3 mmol/l Triglycerides $2.3 mmol/l TC/HDL-c ratio ,6.5 TC/HDL-c ratio $6.5
Mann– Whitney U test
Lopinavir Cmin
pa
Ritonavir Cmin
pa
3.02 (1.89 –8.10) 6.78 (4.90 –8.17) 5.05 (3.19 –8.28) 4.85 (2.81 –8.29) 0.81 (0.04 –1.58) 7.21 (3.09 –9.44) 0.96 (0.11 –4.93) 9.19 (5.25 –10.00)
0.05
0.14 (0.08 –0.24) 0.21 (0.04 –0.32) 0.08 (0.04 –0.27) 0.16 (0.04 –0.25) 0.04 (0.04 –0.04) 0.11 (0.05 –0.29) 0.04 (0.04 –0.29) 0.16 (0.06 –0.34)
1
0.91 0.06 0.02
0.93 0.07 0.13
234
hypertriglyceridemia in the studies published by Cameron10 and Di Perri11 (12.9% . 16.9 mmol/l and 15% . 11.3 mmol/l, respectively). During our study, only two patients had to discontinue treatment due to severe hypertriglyceridemia. Our data thus suggest a weaker induction of major hypertriglyceridemia with LPV/r than with full-dose ritonavir. We also observed a significant increase in mean plasma HDL-cholesterol above 1 mmol/l as early as M3, which was sustained up to M12. Similar results were described with other PIs.12 – 14 Despite the increase in HDL-c, the mean progression of the TC/ HDL-c ratio was 14% (0.5 ^ 1.8) between M0 and M12. Berthold reported a more marked increase in the TC/HDL-c ratio with nelfinavir, ritonavir or indinavir (1.2; 95% CI ¼ [0.7 –1.7]) but in PI-naive patients, and with a lower ratio at inclusion (4.8 ^ 1.5).14 In our study, the number of patients with a TC/HDL-c ratio . 6.5 increased significantly only among patients who had not received ritonavir during the 3 months preceding LPV/r initiation. Since full-dose ritonavir is the most potent inductor of dyslipidemia,15,16 our results suggest that patients treated with ritonavir may have reached their peak TC/HDL-c ratio. The switch from ritonavir to LPV/r would thus not further affect the TC/HDL-c ratio. We showed that patients with a TC/HDL-c ratio . 6.5 or triglycerides . 2.3 mmol/l had significantly higher residual lopinavir concentrations, above the recommended Cmin of 5 mg/l.17 Gonzales de Requena has also shown an association between the percentage of increase in triglycerides and the residual lopinavir concentration.18 Our data suggest a specific effect of lopinavir on serum lipids, and conversely no adverse effect for low-dose ritonavir (100 mg £ 2/day). Moreover, while PI residual concentration is usually one to four-fold the EC50,19 that of lopinavir, at the recommended dose for LPV/r of 400/100 mg bid is 75-fold higher,20 in an attempt to reduce the risk of treatment failure and the selection of non-susceptible mutant or resistant strains.21,22 Regular and systematic monitoring of residual lopinavir concentrations could thus be of major interest, not only with the objective of reaching adequate Cmin but also not to exceed it and thus limit the incidence of dyslipidemia. The effectiveness of LPV/r on virological and immunological criteria was observed as early as M3. At M6, viral load was below 400 copies/ml in 50% of patients, which is in line with the 31.7% rate reported by Romano in another observational study on highly treatment-experienced patients.23 Those results are quite different from the 85% at 48 weeks4 and the 79% at 24 weeks3 reported in two
L. Valerio et al.
randomised clinical trials among naive patients. Similarly, the mean increase in CD4 T-cells observed at M12 in our study differs from that reported in these two clinical trials: 168 vs 213 for Murphy and 207 for Walmsley. Our study, which was conducted on a non-selected population, allowed a more adequate assessment of the immune and virological impact of Kaletra w in a real life situation. Those results must be discussed with regard to study limitations. The observational nature of the study and the absence of a control group do not allow us to establish a definitive causal relationship between intake of LPV/r and dyslipidemia. Besides, treatment with Kaletraw was not randomly allocated and therefore our group of patients cannot be considered a representative sample of the overall patient file. Demographic characteristics of our patients are nevertheless comparable to those of the remaining cohort (data not shown). Lastly, it is impossible to ascertain that all lipid measurements were conducted on fasting patients, although this is the recommended procedure. Most previous studies focusing on lipid data during LPV/r treatment were clinical studies conducted on antiretroviral-naive patients and should be considered cautiously because of selection bias.24 It was therefore of interest to confront those initial results with observational data that reflect daily clinical practice.25
Acknowledgements The authors would like to thank Nathalie Oran and Christophe Caissotti for their help in preparing the database and for the preliminary statistical analysis.
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