Updates
by Carol A. Kemper, MD, FACP
HIV and Cardiac Risk
Source: Hadigan C, et al. Clin Infect Dis. 2003;36(7):909-916.
HIV-infected patients are at increased risk of cardiovascular disease, although longitudinal data are limited. Hadigan and associates compared the 10-year coronary heart disease (CHD) risk estimates for 91 HIV-infected men and women with lipodystrophy and fat redistribution and 30 HIV-infected patients without fat redistribution with that of 273 subjects from the Framingham Offspring Study. Fat redistribution was based on a BMI result and circumferences of the waist, hip, midarm, and midthigh. The HIV-infected subjects had an average duration of HIV infection of 7.2 years and had received an average of 4.7 years of antiretroviral therapy. Ten-year CHD estimates were significantly increased among HIV-infected patients with fat redistribution, compared with that of the control subjects (7.4% vs 5.3%, P = .002), although the risk was especially greatest for HIV-infected men. Comparing the percentage of HIV-infected subjects with a 10-year CHD risk of > 10% to Framingham controls, the relative percentages were 39% vs 17% for men (P = .001) and 4% vs 1% for women (P = .37).
However, when HIV-infected subjects were matched to Framingham control subjects based on age, sex, BMI, and waist-to-hip ratio, their 10-year CHD risk was not significantly greater than controls. A subanalysis of HIV-infected patients with fat redistribution suggested that patients with primary lipodystrophy significantly increased the risk for CHD, while abdominal lipohypertrophy and mixed lipodystrophy were associated with a somewhat lower risk, and protease inhibitor treatment had no apparent effect. While HIV-infected patients appear to be at increased risk for CHD, this risk is not significantly greater than that for non-HIV-infected people with similar central fat redistribution. As many of us feared, this study suggests that nearly 40% of HIV-infected men have > 10% risk of CHD during the next 10 years.
New FDA-Approved Agent for Cryptosporidiosis
Sources: The Medical Letter. 2003;45:29-31; Leav BA, et al. Clin Infect Dis. 2003;36:903-908.
Cryptosporidium are protozoal parasites that cause spectacular and sometimes life-threatening diarrhea in immunosuppressed patients, as well as generally self-limited intestinal disease in normal human hosts and animals. Up until a few weeks ago, there was no FDA-approved treatment for cryptosporidiosis, although paromomycin and azithromycin (especially at higher dosages) were of some benefit in uncontrolled trials in HIV. Nitazoxanide (Alinia, Romark Labs) has just been approved by the FDA for the treatment of cryptosporidiosis and the treatment of giardia in children 1-11 years old. Nitazoxanide is a nitrothiazolyl-salicylamide derivative, which is active against a variety of parasites, including C parvum, G lamblia, Isospora, Entamoeba histolytica, as well as some of the helminths, such as Ascaris, Taenia spp., and Fasciola hepatica.
Cure rates of 80-88% were found in adults and children infected with C parvum when administered 100-200 mg twice daily (for children) and 500 mg twice daily (for adults) for 7 days. A 3-day regimen in children was somewhat less effective, with a clinical response of 56% in those without HIV infection, but a 3-day course of the drug was no more effective in HIV-infected children than placebo. A placebo-controlled clinical trial performed in patients with AIDS and cryptosporidiosis in Mexico found cure rates of 67% and 63% in patients receiving either 500 or 1000 mg twice daily, respectively, for 14 days compared with 25% for placebo recipients. Three- and 5-day regimens were similarly effective (80-85%) in HIV-negative Peruvian children with giardiasis. Other smaller studies have shown efficacy in other parasitic diseases, including a case of metronidazole-resistant giardia in a patient with AIDS.
The drug is well tolerated and is available as a liquid formation (with a strawberry flavor), a tremendous advantage when administering the drug to small children. The most common side effects were diarrhea, abdominal pain, vomiting, and headache. Yellow sclerae can occur due to deposition of the drug during use, but this resolves when the drug is discontinued. The manufacturer recommends that children receive 100 mg twice daily for 3 days with food, although higher dosages and a longer duration of treatment may be necessary for patients with immune suppression.
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