**4. Treatment of dyslipidemia secondary to antiretroviral therapy**

Hyperlipidemia is a major risk factor for developing of atherosclerosis. Epidemiological studies in adults show a direct association between high levels of total cholesterol and LDL and the incidence of mortality and morbidity in coronary artery disease (CAD) and is LDL-C a predictor of CAD risk at any age, besides low HDL and *diabetes mellitus* (Giddings, 1999).

Dyslipidemia in Patients with Lipodystrophy in the Use of Antiretroviral Therapy 433

The non-pharmacologic therapy should be first applied to all patients with hypertriglyceridemia, through modification of lifestyle; diet should be instituted to reduce fat intake, weight reduction, reduction or elimination of alcohol intake, smoking cessation control of hyperglycemia and diabetes with insulin sensitizers such as metformin. In studies, it has been found that diets associated with exercise and resistance training promotes decrease of 21% and 27%, respectively, TG levels in HIV-infected patients (Henry

Patients who demonstrate extreme elevations in TG level (> 1000 mg / dL) and with a history of pancreatitis should be treated associating pharmacologic and non-pharmacologic

Drug therapy should be instituted in all patients with TG levels greater than 500 mg/dL with the introduction of Gemfibrozil with starting dose of 600 mg half an hour before meals (lunch and dinner) or fibrates at a dose 54 to 160 mg/day (Dube et al., 2003). In a study carried out in patients with TG levels higher than 400 mg/dL using fibrate dose of 200 mg/day was observed 14% and 54% decrease of TC and TG levels, respectively (Palácios et al., 2002). Therefore, in another study, patients with TG levels higher than 266 mg/dL, using Gemfibrozil 600 mg/day

The use of statins in general is not recommended for the treatment of hypertriglyceridemia (TG> 500 mg / dL) alone, is recommended when triglyceride levels are between 200 to 500

**5. Experience of the assistance service of metabolic diseases secondary to** 

Assistance Service of Metabolic Diseases Secondary to Antiretroviral Therapy (HAART) of the João de Barros Barreto University Hospital (HUJBB), Brazilian national reference in transmissible infectious diseases and AIDS, actually, assist about 99 HIV carriers' patients with lipodystrophy syndrome. Into this service, the authors develop a Project titled Lipodystrophy and Antiretroviral Therapy, financed by The State of Pará Research Foundation (FAPESPA), Research Program for the Unified Health System (PPSUS). One of

The HUJBB lipodystrophy ambulatory care works with team composed by an endocrinologist, a nutrition doctoral student, two medicine M.Sc students, four medical undergraduate students. The medical accompaniment is performed once a week. In the first service is diagnosed the clinical form of lipodystrophy and requested the proper tests (total cholesterol, HDL, LDL, triglycerides, fasting glucose test, oral glucose tolerance, insulin, abdominal ultrasonography to hepatic steatosis diagnostic and computed tomography for evaluation of visceral lipohypertrophy and electrocardiogram). The first patient's return is around 45 days and subsequently every three months for medical accompaniment. Each medical consultation is also performed medical history, measurement of blood pressure, heart auscultation, anthropometric evaluation (measurements of weight, height, skin folds) and bioimpedance. In addition, if need be the patient is referred to other professionals of the

associated with diet, evolved with a reduction of TG values in 18% (Miller et al., 2002).

the Project's purposes was the implantation of the lipodystrophy ambulatory care.

mg/dL associated with increased total cholesterol (Dubé et al., 2003).

**antiretroviral therapy for patients with dyslipidemia** 

**4.2 Hypertriglyceridemia** 

**4.2.1 Non-pharmacologic therapy** 

et al., 1998; Yarashesky et al., 2001).

therapy (Dube et al., 2003).

**4.2.2 Pharmacologic therapy** 

multidisciplinary team HUJBB.

Dyslipidemia in HIV infection is related to a multifactorial framework (Sprinz et al., 2010), so treatment should be done with non-pharmacological and pharmacological measures.

### **4.1 Hypercholesterolemia**

#### **4.1.1 Non-pharmacologic therapy**

The HIV-infected patients with dyslipidemia they should be screened before using those drugs as therapy, with the implementation of the change of lifestyle of these patients through diet, exercise, tobacco control, diabetes mellitus and hypertension (Dubé et al., 2003). In one study, the diet associated with exercise in 11% reduced cholesterol levels of patients infected with HIV (Henry et al., 1998). In another study showed that diet accompanied by resistance exercise at least three times a week reduced the cholesterol level by 18% and triglycerides by 25% (Jones et al., 2001).

The first measure to be taken will always be non-pharmacologic therapy, unless there is urgent need for intervention, as patients at high risk for coronary artery disease (obesity, diabetes, family history of cardiovascular disease) and extremely high levels of LDL-C greater than 220 mg / dL (Dubé et al., 2003).
