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New Cholesterol-Lowering Drug Improves Care for People with HIV

A new class of cholesterol-lowering medication called PCSK9 inhibitors is able to bring down LDL (bad cholesterol) to levels that until now have never been achievable with other drugs, a recent analysis found.

A new subgroup analysis of the FOURIER study, published last week in Circulation, found that taking Amgen’s PCSK9 inhibitor evolocumab (Repatha®) slashed LDL levels by 59% in patients with peripheral artery disease. Among other high-risk groups, evolocumab reduced the risk of heart attack by 27%.

Numerous studies in past decades agree that lowering LDL reduces the risk for heart attacks and cardiovascular disease. Traditionally, physicians have prescribed statins – along with diet and exercise – to lower LDL in high-risk patients. There is a growing recognition that HIV-positive individuals are one such risk group.

People living with HIV have a 1.5 to 2 times higher risk of developing atherosclerosis (the buildup of cholesterol plaques in the arteries) than the general population. Terry Ferguson, the U.S. Cardiovascular Therapeutic Head at Amgen, points to the biology of HIV to explain this heightened risk.

“The HIV-positive population is in a pro-inflammatory state, much in the same way as people with rheumatoid arthritis,” said Ferguson. “I think that there’s more appreciation that this inflammation predisposes people to more rapid progression and higher risk of atherosclerotic disease.”

Due to their underlying cardiovascular risk, people living with HIV can benefit from more aggressive cholesterol-lowering therapy. Unfortunately, HIV medications, particularly protease inhibitors, increase the side effects of statins. These side effects sometimes include debilitating muscle pain, which makes it more difficult for people with HIV to use statins.

Robert Rosenson, a cardiologist at Icahn School of Medicine at Mount Sinai, presented a study last week to the American Heart Association on the prevalence of statin use among people with HIV. His data revealed that HIV-positive people with diabetes or cardiovascular disease – despite their heightened risk for heart attacks – were less likely to take statins between 2007 and 2015 compared to people without HIV. The aggravated side effects from dual use of statins and HIV medication may help explain this disparity.

On a positive note, Rosenson’s study also found that HIV-positive people without diabetes or cardiovascular disease were more likely to take statins than their HIV-negative peers. This good news suggests that many HIV-positive people recognize the cardiovascular risk that comes along with HIV and are working to minimize that risk.

Evolocumab presents an opportunity to improve the cardiovascular care of people living with HIV. With fewer side effects than statins and more effective LDL reduction, evolocumab “shows how far the standard of care for HIV-positive patients has come,” added Ferguson.

Although evolocumab vastly improves our ability to lower LDL and prevent cardiovascular disease, it is not necessarily the right fit for everybody. Evolocumab is more expensive than statins and must be administered as a subcutaneous injection at 2- or 4-week intervals. In light of these drawbacks, it is the task of physicians to identify the patients in whom statins are not good enough.

As a monoclonal antibody, evolocumab is one of many new clinical applications of immunotherapy to treat a growing list of healthcare needs. Earlier this year, researchers at ID Week in San Diego presented promising data on the effectiveness of monoclonal antibodies in the treatment of HIV.

While new and improved LDL-lowering drugs will surely benefit those living with HIV, it’s also possible to improve cardiovascular health through lifestyle changes. Quitting smoking, controlling high blood pressure, and engaging in regular exercise are all ways to reduce one’s risk for cardiovascular disease. Managing these risk factors – in combination with taking medications to reduce LDL – will become increasingly important as the HIV-positive population in the U.S. continues to age.