CASE 3 55 yo man HIV positive 2008 CD4 320/23% Viral load 123,557 c/ml Genotype clear TDF/FTC/EFV initiated

CASE 3 Further history: Hypertensive Bp 150/95 x 2 in office…home monitoring revealed average of 155/95 over a few weeks(cuff calibrated) Smoker 45 pack years/ Fam. hx of early CAD Impaired glucose tolerance.. FBS 6.6 mmol/l HBA1C 6.2% BMI 30.7 Waist circumference 113cm

CASE 3 Baseline lipids: Chol mmol/l TG mmol/l HDL 0.77 mmol/l LDL 4.01 mmol/l Chol/Hdl 7.78 Apo B 1.34 Alb/creat ratio (no disease) ….15

CASE 3 Diagnosis: Metabolic syndrome Framingham 33% +++/10 yrs Lifestyle modification: Weight loss/Exercise as per Canadian guidelines ETOH/Salt restriction…Dash diet Smoking cessation…counseling/ Varenicline

CASE 3 3 month Follow up: Exercising 6 days/week BMI down from 30.7 to 27.9 Waist circumference 113cm to 108cm Bp 150/90 on average via home monitoring despite Dash diet/weight loss Quit smoking x 8 weeks CD4 390 HIV viral load<40

CASE 3 3 month Follow up: Chol mmole/l TG 2.90 mmole/l HDL 0.74 mmole/l LDL 4.11 mmole/l Chol/Hdl 8.26 Apo B 1.39 g/l

CASE 3 3 month Follow up: Trandolapril 2 mg/day initiated for hypertension Rosuvastatin 20mg/day initiated for hyperlipidemia

CASE 3 4 month Follow up: BMI 27.9 and waist circumference 107cm…stable BP at home via home monitoring on average 130/80 and none >140/90 Quit smoking x 14 weeks and off Varenicline

CASE 3 4 month Follow up: Rosuvastatin 20 mg/day…muscle aches and stiffness tolerable but bothersome…normal liver enzymes and ck Disturbed sleep with poor quality and suboptimal time

CASE 3 4 month Follow up: Chol 4.32 mmole/l TG 2.40 mmole/l HDL 0.85 mmole/l LDL 2.39 mmole/l Chol/HDL 4.96 Apo B 0.97 g/l

CASE 3 4 month Follow up: We discussed suboptimal sleep / slowing of weight loss /waist size reduction Unwilling to increase Rosuvastatin further or add another lipid agent

CASE 3 What would you do: a.Convince him to increase Rosuvastatin dose b.Add Lorazepam to his treatment regime c.Increase his exercise regime d.Switch his antiretroviral regime e.Switch his antiretroviral regime and stop Rosuvastatin

CASE 3 Which Antiretroviral regime would you choose: a.ABC/3TC/RTV/DRV b.TDF/FTC/RGV c.TDF/FTC/ATZ d.TDF/FTC/RPV e.b or d

CASE 3 4 month Follow up: We switched his ARV regime from TDF/FTC/EFV to TDF/FTC/Raltegravir to improve sleep issues and to attempt to optimize lipids

CASE 3 6 month Follow up: Sleep normalized BMI 26.4 (was 30.7) waist size 100 cm (was 113cm) Bp 125/80 Quit smoking x 22 weeks Adherent with Rosuvastatin CD4 490 HIV Viral Load <40

CASE 3 6 month Follow up: Chol 3.82 mmol/l TG 1.40 mmol/l HDL 0.95 mmol/l LDL 1.90 mmol/l Chol/HDL 4 Apo B 0.80 g/l FBS 5.8 mmol/l HBA1C 5.8%

Median changes in lipid parameters between baseline and 12 months according to therapy M. Saumoy et. al., CROI 2011, abstract 820 SPIRAL substudy

Median changes in the percentage of LDL-c phenotype in RGV arm and in PI-arm stratified by PI/r used (group 1 versus group 2) at month 12 M. Saumoy et. al., CROI 2011, abstract 820 SPIRAL substudy group 1 included LPR/r and FPR/r group 2 included ATV/r and SQR/r group 3: raltegravir LDL Phenotype A: less atherogenic LDL Phenotype B: more atherogenic