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CASE 3

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)

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CASE 3

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

  2. 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

  3. CASE 3 Baseline lipids: Chol. 5.99 mmol/l TG. 2.20 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

  4. 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

  5. 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

  6. CASE 3 3 month Follow up: • Chol. 6.11 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

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

  8. 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

  9. 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

  10. 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

  11. 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

  12. CASE 3 What would you do: • Convince him to increase Rosuvastatin dose • Add Lorazepam to his treatment regime • Increase his exercise regime • Switch his antiretroviral regime • Switch his antiretroviral regime and stop Rosuvastatin

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

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

  15. 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

  16. 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%

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

  18. 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 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 M. Saumoy et. al., CROI 2011, abstract 820

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