Pulmonary Disease in HIV

Estimados colegas ,les comparto otro artículo interesante.
Saludos
Dr. Carlos Erazo

"Both infectious and noninfectious pulmonary diseases were more common among HIV-positive patients than among HIV-negative controls.
Potent combination antiretroviral therapy has substantially reduced the incidence of infectious pulmonary complications of HIV infection. In a recent analysis of U.S. veterans, investigators compared the incidence of infectious and noninfectious respiratory illnesses between HIV-positive and HIV-negative individuals.
The study population consisted of 33,000 HIV-positive patients and 67,000 HIV-negative controls matched for demographic characteristics. The median age in the cohort was 45, and 98% of participants were men. A subset analysis indicated that although most participants were past or current smokers, the proportion was significantly higher among HIV-positive patients (80% vs. 76%). Pulmonary diagnoses were identified using ICD-9 codes.
Bacterial pneumonia was by far the most common infectious illness and occurred about five times more frequently in HIV-positive patients than in HIV-negative controls. Chronic obstructive pulmonary disease (COPD), lung cancer, pulmonary hypertension, and pulmonary fibrosis were also significantly more common among HIV-positive patients. All these differences held after adjustment for smoking status. The incidence of asthma was similar between groups.
Comment: The notable finding here is the increased rate of noninfectious pulmonary diseases — particularly COPD — among HIV-positive patients, even after adjustment for smoking status. Whether this increased risk would still be present in a population with a lower rate of smoking is unknown. Regardless, the authors argue that HIV can be considered one of the many contributors to chronic lung disease, and certainly the results provide additional impetus for emphasizing smoking cessation in clinical care."
— Paul E. Sax, MD
Published in Journal Watch HIV/AIDS Clinical Care February 14, 2011

Citation(s):

Crothers K et al. HIV infection and risk for incident pulmonary diseases in the combination antiretroviral therapy era. Am J Respir Crit Care Med 2011 Feb 1; 183:388.

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Statins Prevent Vascular Events, Independent of Baseline CRP Levels

Estimados colegas , aqui les dejo un estudio sobre las estatinas y la prevención de eventos vasculares, recordando el manejo integral de las personas que viven con el virus de inmunodeficiencia y el artículo anterior en el que disminuye la progresión de la enfermedad.

Saludos
Dr. Carlos Erazo
http://general-medicine.jwatch.org/cgi/content/full/2011/217/5?q=etoc_jwgenmed

"Contrary to some claims, statins benefited high-risk patients with low C-reactive protein levels.
In the 2008 JUPITER trial, healthy adults — with LDL cholesterol levels <130 mg/dL and C-reactive protein (CRP) levels 2 mg/L — who received rosuvastatin (20 mg daily) for 2 years experienced significantly fewer cardiovascular endpoints than those who received placebo (JW Gen Med Nov 18 2008). JUPITER suggested that statins had particular benefits in patients with high baseline CRP levels whose risk was otherwise low, perhaps through an anti-inflammatory effect.
In the industry-supported Heart Protection Study, >20,000 U.K. adults at high risk for vascular events received simvastatin (40 mg) or placebo daily for a mean of 5 years. Overall, patients who received simvastatin had 24% fewer first vascular events (myocardial infarction, stroke, or revascularization) than those who received placebo.
LDL cholesterol and CRP levels were available for 2727 patients. When these patients were stratified into six groups according to baseline CRP levels (from <1.25 to 8.0 mg/L), vascular risk was significantly lower for simvastatin recipients than for placebo recipients in all groups, with no relation to CRP levels. When patients were categorized as having high or low CRP levels and high or low LDL cholesterol levels at baseline, simvastatin recipients with low CRP and LDL cholesterol levels had proportional reductions in vascular risk that were similar to those in participants with high CRP and LDL cholesterol levels.
Comment: Recent evidence suggests that statins produce similar proportional reductions in vascular events regardless of baseline LDL cholesterol levels, and this study suggests that benefits of statins are independent of baseline CRP levels as well, at least in high-risk patients."
— Bruce Soloway, MD
Published in Journal Watch General Medicine February 17, 2011

Citation(s):

Heart Protection Study Collaborative Group. C-reactive protein concentration and the vascular benefits of statin therapy: An analysis of 20 536 patients in the Heart Protection Study. Lancet 2011 Feb 5; 377:469. (http://dx.doi.org/10.1016/S0140-6736(10)62174-5)

Survival after neuroAIDS Association with antiretroviral CNS Penetration-Effectiveness score

Estimados colegas , aquí otro artículo realcionado con VIH.
Saludos
Dr. Carlos Erazo

http://www.neurology.org/content/76/7/644.abstract

Objective: We examined if the CNS Penetration-Effectiveness (CPE) score of antiretroviral drugs was associated with survival after a diagnosis of HIV-related encephalopathy, progressive multifocal leukoencephalopathy (PML), cerebral toxoplasmosis, or cryptococcal meningitis.

Methods: Using data from the FHDH-ANRS CO4, we compared the survival of 9,932 HIV-infected patients diagnosed with a first neurologic AIDS-defining event in the pre–combination antiretroviral therapy (cART) (1992–1995), early cART (1996–1998), or late cART (1999–2004) periods. Follow-up was subdivided (CPE < 1.5 and CPE ≥ 1.5), and relative rates (RR) of death were estimated using multivariable Poisson regression models.

Results: In the pre-cART and early cART periods, regimens with CPE ≥ 1.5 were associated with lower mortality after HIV-related encephalopathy (RR 0.64; 95% confidence interval [CI] 0.47–0.86 and RR 0.45; 95% CI 0.35–0.58) and after PML (RR 0.79; 95% CI 0.55–1.12 and RR 0.45; 95% CI 0.31–0.65), compared to regimens with CPE < 1.5, while in the late cART period there was no association between the CPE score and the mortality. A higher CPE score was also associated with a lower mortality in all periods after cerebral toxoplasmosis (RR 0.68, 95% CI 0.56–0.84) or cryptococcal meningitis (RR 0.50, 95% CI 0.34–0.74). Whatever the neurologic event, these associations were not maintained after adjustment on updated plasma HIV-RNA (missing, <500, ≥500 copies/mL) with RR ranging from 0.82 (95% CI 0.36–1.91) to 1.02 (0.69–1.52).

Conclusion: At the beginning of the cART era, the CPE score was of importance for survival after severe neurologic event, while in the late cART period, the additional effect of CPE score vanished with more powerful antiretroviral regimens associated with plasma viral load control.

Trial suggests statin may affect markers associated with progression of HIV

 Estimados colegas , aquí un resultado muy interesante sobre las estatinas en el progreso de la infección por VIH.


Saludos
Dr. Carlos Erazo

http://jid.oxfordjournals.org/content/early/2011/01/31/infdis.jiq115.full.pdf+html


A recent multicenter clinical trial of atorvastatin, a type of cholesterol-lowering drug, found that although the drug did not inhibit plasma HIV RNA levels, it did inhibit expression of cellular markers of immune activation and inflammation in patients with HIV infection. Since immune activation and inflammation are associated with progression of HIV infection, the implication is that the statin may inhibit disease progression and help in the infection's management. The findings are in a study, available online, published in The Journal of Infectious Diseases.
The investigators, led by Anuradha Ganesan, MD, of the National Naval Medical Center and the Infectious Disease Clinical Research Program in the Department of Preventive Medicine and Biometrics at the Uniformed Services University of the Health Sciences in Bethesda, Md., randomized 22 HIV-1-infected patients not on antiretroviral therapy and with cholesterol levels lower than those requiring statin therapy in a double-blind protocol of high-dose drug or placebo for eight weeks. After a four-to-six-week washout phase, each group was switched to the other treatment for another eight weeks.
The primary objective was to study the effect of atorvastatin on plasma HIV-1 RNA levels, as previous studies had shown conflicting results. The effect on cellular markers of immune activation was a secondary objective. HIV-1 RNA levels were not significantly affected by the drug, but levels of such immune activation markers as CD38 and HLA-DR on CD4 and CD8 T cells were reduced.
The researchers noted that their findings with atorvastatin suggest that understanding the mechanism by which statins affect immune markers may identify new approaches for the management of HIV infection. They point out, however, that their trial was not designed to demonstrate clinical benefits, for which larger studies of longer duration are needed.
In an accompanying editorial, Andrew Carr, MD, of St. Vincent's Hospital in Sydney, Australia, agreed, noting that "a very large study would probably be required to determine whether potentially positive effects of statin therapy on inflammatory biomarkers will translate into less HIV disease progression."

Fast Facts:

1. Statins show potential to alter the chronic immune activation observed in HIV-1 infected patients.
2. In the study, investigators randomized 22 HIV-1-infected patients not on antiretroviral therapy and with cholesterol levels lower than those requiring statin therapy in a double-blind protocol of high-dose atorvastatin or placebo for eight weeks. After a four-to-six-week washout phase, each group was switched to the other treatment for another eight weeks.
3. HIV-1 RNA levels were not significantly affected by the drug, but levels of such immune activation markers as CD38 and HLA-DR on CD4 and CD8 T cells were reduced.