The new importance of taking a statin

The new importance of taking a statin

The new importance of taking a statin

There has been a lot of talk about the benefits of taking statins since the results of the REPRIEVE study were presented at IAS Brisbane in 2023. The study found that statin medication reduced the chance of cardiovascular disease in people with HIV and prevented adverse incidents even in those at low and medium risk. This is probably the most important HIV revelation in many years, and why everyone with HIV over 40 should now be considering statins.

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Continued advances in HIV research, treatment and care mean that people with HIV are living longer and healthier. Starting treatment soon after diagnosis and receiving good medical care means a near normal life expectancy. However, even on effective HIV treatment, people with HIV experience twice the risk of cardiovascular disease (CVD) than the general population, and experience CVD earlier than the general population.

Although the reasons are not fully understood, there is thought to be an overlap between traditional risk CVD factors (e.g. smoking, weight, diet, diabetes, and family history) and HIV-related factors (chronic immune activation, leaky gut, and even some of the medication used to treat HIV). Experts have known for many years that HIV increases chronic, systemic inflammation, which also contributes to CVD.

HIV and cholesterol

On average, people with HIV have higher levels of ‘bad’ cholesterol (LDL) than the general population. LDL causes atherosclerosis (disease and damage including build-up of fatty deposits of plaques on the blood vessels), known to contribute to CVD. Elevated LDL cholesterol is asymptomatic, and often silently causes damage to the heart and blood vessels, contributing to CVD risk. Elevated LDL is caused directly by HIV, certain HIV medications, as well as traditional risk factors.

Statin medications are highly effective at reducing ‘bad’ cholesterol, and it has long been theorised that statins may have anti-inflammatory properties as well. Up until now there were no large studies with people with HIV that tested these theories or showed a clear benefit.  Many of these questions have been answered by the REPRIEVE study.

The REPRIEVE Study

The REPRIEVE study began in 2015 and enrolled nearly 8000 people with HIV who had an average age of 50. 31% of participants were women, which is important as studies looking at statin use often exclude women.  Also, 41% of study participants identified as Black, 35% as White, 15% as Asian, and 9% as another race. The participants were divided into two groups. One group was given a statin and the other group a placebo (sugar pill), and nobody in the study knew which pill they were taking. As it was an international multi-centred study, a range of ethnicities participated.

It is important to note that participants were recruited based on their HIV status and having a low-to-moderate risk of CVD over ten years. This risk was calculated using the American AtheroSclerotic Cardiovascular Disease (ASCVD) tool. The Australian CVD risk calculator is similar and can be found here. You will need your latest blood pressure measurement and results of blood tests for cholesterol.

It is important to note that in the REPRIVE study people assessed with low to moderate risk using this assessment tool would not usually be prescribed statins. Therefore, the results of the REPRIEVE study are important to know, as this study observed people with HIV taking a statin who would not otherwise usually be prescribed a statin. The results are new and groundbreaking.

An interim (part way through) review of results showed that people taking the statin had a 35% lower risk of experiencing CVD, and up to 21% lower risk of CVD related premature death. The results were so dramatic that the study was stopped, and everyone was recommended to take a statin. This study used pitavastatin owing to the minimal risk of interaction with HIV medication. Pitavastatin is not available in Australia or the UK, but there are many other statins (Rosuvastatin and Atorvastatin are commonly used) which are thought to have a similar benefit.

What is cholesterol?

Cholesterol is a waxy fatty substance made in the liver and obtained through the diet. It can be found in the fats (lipids) in your blood. Cholesterol is essential for your body to continue building healthy cells, however having high cholesterol can increase your risk of heart disease.

High cholesterol levels cause a build-up of fatty deposits (plaques) on the walls of your blood vessels, which can make it difficult for enough blood to flow through your arteries, also increasing your risk of heart disease.

Your body produces enough cholesterol for your body’s needs in the liver. A diet high in bad fats and sugar results in too much cholesterol that leads to cardiovascular disease. Other causes of high cholesterol are genetic (inherited) high cholesterol, HIV, liver disease and certain medications. The best way to control high cholesterol is through a healthy diet, regular exercise, and medication, usually statins.

What are statins?

Statins are a group of prescription medications that were initially developed to reduce LDL (bad) cholesterol. They work by preventing cholesterol formation in the liver, where about 75% of total cholesterol is made. The remaining 25% comes from diet. As well as reducing LDL statins have been found to increase level of HDL, the so-called good cholesterol.

HDL transports bad cholesterol from the bloodstream to the liver where it is processed and excreted from the body. HDL also acts as an antioxidant, anti-inflammatory and anti-clotting agent, offering multiple health benefits. Statins are a class of medication that prevent the development of heart disease.

They work by lowering levels of LDL cholesterol, the ‘bad’ form of fat which accumulates in arteries and leads to blockages that cause heart attacks and strokes. Statins also influence cardiovascular health by reducing inflammation and oxidative stress, as well as limiting the formation of dangerous blood clots and stabilising artery-blocking masses of fatty debris called plaques.

What about side effects and drug interactions?

Some people taking pitavastatin in the trial experienced muscle ache, cramping and muscle pain in the legs. These side effects are often associated with all statins; however, the numbers were very small and is recognised as a potential side effect of all statins. This side effect usually settles down after a few weeks.  There was also a minimal risk of developing insulin dependent diabetes, and again this can be associated with all statins, and again the numbers were very small.

When a doctor recommends statins, they will want to talk to you about which statin will best work for you. Getting a side effect from one statin does not mean you will get the same side effect from another, and people can change their statin easily, a bit like HIV medication. If people cannot tolerate statins there are other medications that offer similar health benefits.

Some statins can interact with medications including HIV treatment although generally not with the newer HIV treatments we have available. Thus, it’s always best to make sure your GP and your HIV prescriber know what medications you are on.

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Extra benefits for liver health

A recent study also suggests that there are benefits to liver health for people living with HIV. The study of over 200,000 people set out to examine the incidence of non-alcoholic fatty liver disease, or liver disease not caused by alcohol.

People living with HIV can have up to double the risk of developing liver disease, which is associated with traditional risk factors including metabolic syndrome, obesity, insulin-resistance, unhealthy diet, alcohol, low physical activity, high cholesterol, high triglycerides, and high blood pressure.

Women and statins

Research shows that world-wide, millions of people refuse to take a statin when prescribed and often stop taking statins without talking to their prescriber. Research suggests that women are more reluctant than men to take statins. The reasons are varied and often include concerns about side effects and potential impacts on pregnancy and symptoms of menopause.

During the REPRIEVE study the side effects reported were similar for both men and women, and there was a very low incidence of people withdrawing from the study because of side effects.

Pregnancy

While it is thought that some statins can cause complications to the baby (foetus) during pregnancy, some research suggests that they are safe to use during pregnancy. Women of child-bearing age should adopt at least one strategy to prevent pregnancy. Otherwise, it is recommended that women who want to become pregnant should stop taking a statin at least three months before conceiving and breastfeeding. Women living with HIV should review all medications, including over the counter (OTC) medications and supplements they are taking with their medical team at least six months before conceiving. More information can be found here.

Menopause

Women of menopausal age and older may be at risk of developing diabetes if they take a statin. However, the risk is statistically low and depends on other risk factors, especially lifestyle, family history, and weight. Women should discuss the overall benefit of taking a statin versus the risk of developing diabetes.

Overall, women have a lower risk of heart disease than men, and these numbers are similar among people living with HIV. Also, heart disease often presents differently for women living with HIV and it is important for women to be aware of the signs of heart disease and the early warning signs of a heart attack. Follow this link for more information.

Should I take a statin?

Since the results of the REPRIEVE study were published, the UK, European, and US guidelines have been updated to recommend that all people with HIV over the age of forty should take a statin, regardless of their risk of CVD. This is how much of an impact the benefits of this study have had. Those under 40 may still be advised to take a statin depending on their overall risk of developing CVD. Anyone with a family history of high cholesterol and/or other risk factors for CVD are usually recommended to take a statin. Talk to your GP and/or HIV prescriber about whether you should be taking a statin and if you are, whether a higher dose is a good idea.

What else can I do?

  • Know your risk using the Australian CVD risk calculator.
  • Ask your doctor for a Medicare-funded Heart Health Check, you will need to know you most recent fasting blood results of your cholesterol levels as well as your blood pressure.
  • Review your HIV medications with your HIV specialist doctor, as certain HIV meds have a higher risk of heart disease.
  • Exercise regularly, according to Heart Research Australia.
  • Know and maintain your ideal weight.
  • Review your diet with an HIV specialist dietitian. You can consult an HIV specialist dietitian for free through some sexual health clinics, hospitals and HIV Community Health Teams.  Medicare, private health insurance, NDIS and My Aged Care can pay for some or all the cost of seeing a dietitian.
  • Quit smoking. It is hard to quit, but the rewards are amazing. Check out quit.org.au.
  • Maintain a healthy blood pressure. High blood pressure can be asymptomatic and cause damage to your kidneys and heart without you knowing.
  • Manage stress. Your doctor may be able to recommend a counsellor or psychologist who understands HIV and mental health. Your local HIV organisation may know of free or affordable counselling services.
  • Take a good quality omega 3 and 6 supplement.
  • Monitor your drug and alcohol consumption and if you need help, call the National Drug and Alcohol support line on 1800 250 015. If you have private health insurance, you might be eligible for treatment in a private clinic. Check with your health fund.