Study-inclusion criteria were met by 700 patients. Mean (SD) age was 43 (8) years, 86% were men, and mean (SD) CD4+ cell count nadir was 182 (180) cells/μL ().
Clinical and Demographic Characteristics of Study Patients by Type of Initial Statin (N = 700)
The 3 most commonly prescribed statins were atorvastatin (N = 303; 43%), pravastatin (N = 280; 40%), and rosuvastatin (N = 95; 14%). Dose data were not available on all patients, but among the subset of patients with complete dose data (N = 320), the median starting dose was 10 mg for atorvastatin, 20 mg for pravastatin, and between 5 and 10 mg for rosuvastatin. Median doses at study end were 20 mg for atorvastatin, 40 mg for pravastatin, and 10 mg for rosuvastatin. Another 22 patients received other statins: simvastatin (N = 14; 2%), lovastatin (N = 3; <1%), and fluvastatin (N = 5; <1%). Median (interquartile range [IQR]) follow-up while receiving an initial statin was 19 months (7–40 months). The distribution of baseline lipid values, other laboratory values, and BMI stratified by statin is in . Patients who started rosuvastatin were younger, had a higher HIV-1 RNA level () and slightly lower baseline total cholesterol values ().
Baseline Laboratory Values among Patients Starting Commonly Prescribed Statins (N = 678)
Mean total cholesterol, LDL-C, triglyceride, and non-HDL-C levels were lower than baseline values at periods up to 24 months (). HDL-C values did not change significantly over time.
Lipid levels among human immunodeficiency virus (HIV)–infected patients initiating their initial statin medication (N = 700).
We excluded patients receiving simvastatin, lovastatin, or fluvastatin from adjusted analyses due to small numbers. Patients treated with atorvastatin had greater decline in total cholesterol, LDL-C, and non-HDL-C values than patients treated with pravastatin, whereas those receiving rosuvastatin had greater decline in total cholesterol, LDL-C, triglyceride, and non-HDL-C values at 12 months in adjusted analyses (). Findings are similar in models that also adjust for diabetes mellitus. Findings at time points from 3 to 24 months and results of sensitivity analyses including propensity scores were similar to 12 month findings in (data not shown). Findings were similar in sensitivity analyses that did not censor patients who started another lipid-lowering agent.
Decrease in Plasma Lipid Concentrations After 12 Months of Statin Therapy Compared With Baseline by Individual Statin in Adjusted Analyses
National Cholesterol Education Program Goals
Based on the Framingham formula, the estimated mean 10-year coronary heart disease risk at statin initiation was 10% (median, 6%; IQR, 3%–16%) for the study cohort. Lipid goals based on NCEP criteria did not differ among patients by statin. Among patients receiving their initial statin for 12 months, LDL-C goals were met by 374 (71%) of 530 patients who had 12-month LDL-C data, and non-HDL-C goals were met by 292 (62%) of 473 patients who had 12-month non-HDL-C data. Of 700 patients, 53% were receiving the initial statin without other lipid-lowering medications and had an LDL-C level below their NCEP goal at 12 months; 42% were receiving the initial statin and had a non-HDL-C level below their NCEP goal at 12 months. The likelihood of reaching NCEP goals differed by statin. Patients who received rosuvastatin (odds ratio [OR], 2.1; 95% confidence interval [CI], 1.1–3.9; P = .03) or atorvastatin (OR, 2.1; 95% CI, 1.4–3.2; P = .001) were more likely to reach NCEP LDL-C goals at 12 months than patients who received pravastatin in adjusted analyses. Patients who received rosuvastatin were also more likely to reach NCEP non-HDL-C goals at 12 months compared with patients who received pravastatin (OR, 2.3; 95% CI, 1.0–5.0; P = .045). Patients receiving atorvastatin appeared more likely to reach non-HDL-C goals at 12 months, although this was not statistically significant (OR, 1.5; 95% CI, .9–2.4; P = .1).
Toxicity associated with discontinuing statin therapy occurred rarely (in 6.4% of cases), with similar rates across the 3 commonly used statins: 6.1% for pravastatin, 7.3% for atorvastatin, and 5.3% for rosuvastatin. Among the 44 patients who experienced toxicities, 15 (2.2% of all study participants) had potentially serious toxicity and 29 (4.3%) had symptomatic toxicity. An elevation in CPK level (with or without a decline in renal function) was the most common potentially serious toxicity followed by elevations in liver enzymes. Five patients had CPK-level elevations between 1000 and 10,000 U/L (4 on pravastatin, 1 on rosuvastatin), and 1 had an elevation >10,000 U/L (on atorvastatin). Among 29 patients with symptomatic toxicity, the most common symptoms were myalgias/arthralgias (62%), gastrointestinal symptoms (21%), and fatigue (7%). Overall, 49 patients (7.2%) discontinued statins without any laboratory abnormalities or symptoms reported in the medical record. The rate of discontinuation for unknown reasons was similar across the 3 statins.