Question:

Dear Ask the Doc:
I have been on a cocktail combination of Sustiva and Combivir for about 3 years now. As a result, the HIV is non-detectable and my CD-4 cells are trending upward.

However, the caveat is my cholesterol and most alarmingly, my triglycerides are skyrocketing. A year ago my cholesterol went up to 350 and my triglycerides soared to 930. My doctor prescribed Lipitor (40mg.) and a strict diabetic diet. My numbers came down almost overnight to normal ranges.

Over the past 6 months, I've gone back to normal eating and I've gained 20 pounds. I received a worried phone call from my doctor yesterday who informed me my last labs showed my cholesterol was back up to 350, but my triglycerides had climbed to a shocking 1,832!

My question is, is it true that anti-retro viral cocktail can cause this sort of lipid insanity? In order to keep my cholesterol and triglycerides within normal ranges, will I have to spend the remainder of my life eating like a fashion model? Please say it isn't so.

Thank you for any information you might pass on to me regarding this matter.

Answer provided by:

Mark H. Katz, M.D.
Regional HIV/AIDS Physician Coordinator
Kaiser Permanente of Southern California

Dear Christopher:
You bring up several interesting points, and thank you for contacting "Ask the Doc."

First of all, we accept that along with the major benefits of HAART therapy, one of the potential downsides is the elevation of serum lipids (cholesterol and/or triglycerides). If indeed we now have, as you call it, "lipid insanity," think back to the days prior to 1996, when persons living with HIV had many fewer treatment options and were dying at much greater rates, and with more debilitating opportunistic conditions.

It is not yet definitively known if the lipid elevations contribute to the perceived increased incidence of cardiovascular complications in persons living with HIV, but pretty much everyone agrees that it should be addressed.

I see a couple of possible paths for you to take right now--and of course, in consultation with your provider;

First, some drugs are known to elevated lipids more than others. There is evidence than nevirapine (Viramune) can improve lipid profiles (as presented at the 8th European Conference on Clinical Aspects and Treatment of HIV Infection, or ECCATH, see www.pslgroup.com/dg/20c0c2.htm). At last year's International AIDS Conference in Barcelona, Fisac et al presented evidence that the HDL, or "good cholesterol," rises statistically significantly in persons treated with nevirapine as compared to efavirenz (Sustiva) or abacavir (Ziagen) (see www.aegis.org/conferences/14wac/thpeb7354.html)

Next, weight loss, especially if it involves reduction or elimination of animal fats, may result in decreased serum lipids.

But, do remember, most of all, that elevated lipids can be treated! The Lipitor you took, at 40 mg, might need to be restarted, and/or even bumped up to 80 mg. And indeed, HIV-positive or not, you are far from alone: Lipitor was the number-one selling drug in the US in 2001 (and may well be for 2002 as well). There are also specific medications which work against the elevated triglycerides, such as gemfibrozil (Lopid), a safe and effective medication.

I suggest you discuss these options with your provider, and good luck!

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