Association of lopinavir concentrations with plasma lipid or glucose concentrations in HIV-infected South Africans: a cross sectional study
© Sinxadi et al.; licensee BioMed Central Ltd. 2012
Received: 15 May 2012
Accepted: 23 October 2012
Published: 26 October 2012
Dyslipidaemia and dysglycaemia have been associated with exposure to ritonavir-boosted protease inhibitors. Lopinavir/ritonavir, the most commonly used protease inhibitor in resource-limited settings, often causes dyslipidaemia. There are contradictory data regarding the association between lopinavir concentrations and changes in lipids.
To investigate associations between plasma lopinavir concentrations and lipid and glucose concentrations in HIV-infected South African adults.
Participants stable on lopinavir-based antiretroviral therapy were enrolled into a cross-sectional study. After an overnight fast, total cholesterol, triglycerides, and lopinavir concentrations were measured and an oral glucose tolerance test was performed. Regression analyses were used to determine associations between plasma lopinavir concentrations and fasting and 2 hour plasma glucose, fasting cholesterol, and triglycerides concentrations.
There were 84 participants (72 women) with a median age of 36 years. The median blood pressure, body mass index and waist: hip ratio were 108/72 mmHg, 26 kg/m2 and 0.89 respectively. The median CD4 count was 478 cells/mm3. Median duration on lopinavir was 18.5 months. The median (interquartile range) lopinavir concentration was 8.0 (5.2 to 12.8) μg/mL. Regression analyses showed no significant association between lopinavir pre-dose concentrations and fasting cholesterol (β-coefficient −0.04 (95% CI −0.07 to 0.00)), triglycerides (β-coefficient −0.01 (95% CI −0.04 to 0.02)), fasting glucose (β-coefficient −0.01 (95% CI −0.04 to 0.02)), or 2-hour glucose concentrations (β-coefficient −0.02 (95% CI −0.09 to 0.06)). Lopinavir concentrations above the median were not associated with presence of dyslipidaemia or dysglycaemia.
There was no association between lopinavir plasma concentrations and plasma lipid and glucose concentrations.
KeywordsLopinavir Hypercholesterolaemia Hypertriglyceridaemia Impaired glucose metabolism Antiretroviral therapy Pharmacokinetics
Ritonavir-boosted lopinavir (LPV/r) is a potent protease inhibitor (PI) widely used in a second-line antiretroviral regimens in low and middle-income countries . Treatment with LPV/r has been associated with the development of dyslipidaemia [2, 3], which is a known risk factor for cardiovascular complications. The Women’s Interagency HIV study showed that dyslipidaemia was more severe in HIV infected women on ritonavir-boosted PI containing antiretroviral therapy (ART), compared with untreated HIV infected women or non-PI based ART . There are conflicting results regarding an association between LPV/r use and the development of insulin resistance and new onset diabetes [5–9]. Furthermore, there are contradictory data as to whether the metabolic toxicity is associated with higher plasma concentrations of either lopinavir or ritonavir [10–12]. Widespread long-term PI use may be limited by these metabolic complications. Data regarding an association between plasma lopinavir and plasma glucose concentration are lacking.
The aim of our study was to investigate whether there is an association between plasma lopinavir and plasma lipids and glucose concentrations. We hypothesized that higher plasma lopinavir concentrations would be associated with higher prevalence of dyslipidaemia and dysglycaemia.
Materials and methods
Study design and participants
We conducted a prospective cross sectional study between February 2007 and January 2008. Consecutive ambulatory HIV infected African adults who presented for a routine follow up visit at primary and tertiary level clinics in Cape Town were recruited. Participants were eligible if they were on lopinavir-based therapy for a minimum of six months. Participants with renal or hepatic disease, active opportunistic infection, diabetes, history of diabetes or dyslipidaemia and self-reported non-adherence were excluded. The study was approved by the University of Cape Town research ethics committee.
Clinical and laboratory evaluations
After obtaining informed consent, we instructed the participants to undergo an overnight fast and to note the time of taking the evening dose of lopinavir on the day proceeding the study day. On the study day, participants underwent an oral glucose tolerance tests (OGTT). Blood was drawn at 0 and 120 minutes after ingestion of 75g glucose in 250ml water, into heparinised or sodium fluoride tubes as appropriate, and kept on ice until centrifugation within 4 hours. Plasma lopinavir concentrations and serum fasting glucose, cholesterol, and triglyceride concentrations were determined from the 0 minute samples of the OGTT. The morning doses of ART were given after 2 hour glucose samples were taken.
Lopinavir drug concentrations were analyzed by fully validated methods using liquid chromatography-tandem mass spectrometry (LC-MS/MS) on an Applied Biosystems MDS Sciex API 4000 tandem mass spectrometer at our ISO17025 compliant and accredited analytical laboratory as previously described . The assay range was 0.05 to 20 μg/mL. Accuracy ranged from 94 to 103%. Any samples with lopinavir concentrations below the limit of quantification (0.05 μg/mL) were fixed to 0.025 μg/mL. Serum glucose and lipid concentrations were determined by standard methods using the ACE Alera Clinical Chemistry System (Alfa Wassermann Diagnostic Technologies, Woerden, Netherlands). Impaired fasting glucose (IFG) and impaired glucose tolerance (IGT) were defined according to the American Diabetes Association criteria . Hypercholesterolaemia and hypertriglyceridaemia were defined according to the NCEP III criteria .
We reviewed medical records to determine duration on antiretroviral therapy, viral load and CD4 counts. Self reported adherence was determined using a validated 4-day adherence questionnaire administered by trained field workers . Basic anthropometric measurements were measured by a biokineticist.
Pharmacokinetic and statistical analysis
The plasma lopinavir concentrations were obtained from 0 minute of the OGTT. For data points below the limit of quantification (0.05 μg/mL), the lopinavir concentrations were fixed to 0.025 μg/mL. The associations between lopinavir concentrations and glucose, triglycerides, and cholesterol were determined using univariate linear regression and multivariate analyses. Logistic regression was used to determine associations between lopinavir concentrations above the median and metabolic complications (hypercholesterolaemia, hypertriglyceridaemia and dysglycaemia).
Sample size calculation
A previous study found a positive correlation (rho) of 0.32 between lopinavir trough levels and triglyceride levels . When the sample size is 50, the linear regression test of rho=0 (alpha= 0.050 two-sided) for normally distributed triglyceride concentrations, will have 80% power to detect a rho of 0.375.
Study population characteristics, N=84
Median (IQR) or n/N(%)
Female n/N (%)
Race n/N (%)
Body mass index (kg/m2)
Waist: hip ratio
Skin fold thickness (mm)
Blood pressure mmHg
CD4 count (cells/ mm3)
Current viral load
Proportion with <400 copies/mL (%)*
Duration on lopinavir (months)
Concurrent ART n/N (%)
Metabolic parameters (mmol/L)
4.3 (3.7 to 5.3)
1.3 (0.9 to 1.8)
5.2 (4.7 to 5.7)
2 hour glucose
6.3 (5.4 to 8.1)
Association between lopinavir trough concentrations and lipid and glucose concentrations
Beta coefficient (95%CI)
Beta coefficient (95% CI)
−0.04 (−0.07 to 0.00)
−0.02 (−0.06 to 0.01)
−0.01 (−0.04 to 0.02)
−0.00 (−0.03 to 0.02)
−0.01 (−0.04 to 0.02)
−0.00 (−0.03 to 0.02)
2 hour glucose
−0.02 (−0.09 to 0.06)
0.00 (−0.05 to 0.06)
To our knowledge, this is the first study to investigate the association between lopinavir concentrations and serum glucose concentrations, and the first to investigate associations between lopinavir concentrations and serum lipids in a South African population. Despite a high prevalence of dyslipidaemia (29%) and dysglycaemia (42%) in 84 black South African HIV-infected adults treated with ritonavir-boosted lopinavir for a median duration of 19 months, we found no association between plasma lopinavir concentrations and lipid or glucose concentrations. There was also no significant association between the lopinavir concentrations above the median, and hypercholesterolaemia, hypertriglyceridaemia or dysglycaemia.
We found the median lopinavir concentration was 8 μg/mL, which is higher than reported elsewhere [17, 18], but comparable to the trough concentrations after observed doses in a study conducted by our group from the same community . Lopinavir pharmacokinetics demonstrate considerable interindividual variability, which may affect treatment outcomes. At least part of this variability may be explained by host genetic factors. Associations between human genetic variants and lopinavir exposure are incompletely understood and need to be explored.
The lack of an association between lopinavir concentrations and lipid or glucose concentrations that we found can be explained as follows: First, like all protease inhibitors, lopinavir exerts its antiviral activity intracellularly, and the plasma and intracellular half-lives are different . However, the positive correlation between lopinavir plasma and intracellular concentrations reported at 4 weeks was not sustained at 24 weeks of treatment . More importantly, the mechanism of toxicity associated with protease inhibitor use, including lopinavir, is still poorly understood, but is thought to be related to interference with some cellular endogenous processes. For example, lopinavir binds to lipoprotein receptor related protein (LPR), impairing hepatic chylomicron uptake and triglyceride clearance by LPR –lipoprotein lipase complex, causing hyperlipidaemia . In susceptible individuals, the resulting hyperlipidaemia may induce diabetes . Second, clinical manifestations of LPV/r toxicity are also influenced by host susceptibility such as age, sex, weight, race, advanced HIV disease, concomitant ART, higher baseline triglyceride or cholesterol concentrations, and genetic susceptibility [2, 22, 23]. Finally, we hypothesize that the if the association between plasma lopinavir concentrations and toxicity exists, it exists in much lower concentrations, as the dose–response curve is likely to be flat at the concentrations found in our study. Therefore, the influence of lopinavir plasma concentrations on lipids at therapeutic doses, is likely to be small and larger studies are needed to detect the small differences. Furthermore, recent data suggests that lopinavir does not impair insulin sensitivity [7, 8], and therefore, the lack of an association between lopinavir and glucose concentrations is not surprising.
Our findings are in contrast with findings from a small study conducted in 19 patients, which reported that lopinavir trough concentrations were higher in three patients experiencing grade 3 or 4 lipid elevations . A second larger study (n=126) found that patients with fasting triglyceride concentrations above the median had higher lopinavir trough concentrations, but no correlation was found between lopinavir and cholesterol concentrations . Four other studies reported findings similar to ours, with no association between lopinavir and lipid concentrations [12, 17, 24, 25]. The older protease inhibitor indinavir is known to cause diabetes . However, after 12 months of treatment with lopinavir, none of the 73 patients included in another study developed diabetes . Studies in healthy volunteers have shown that insulin sensitivity wasn’t altered by lopinavir in healthy HIV negative men [7, 8]. However, a single dose study in healthy volunteers showed that lopinavir could inhibit glucose uptake acutely . Data regarding the association between lopinavir concentrations and glucose metabolism are lacking.
Our study has several limitations. First, it is a cross sectional study and we therefore cannot compare lipid or glucose concentrations prior to lopinavir treatment. Second, patients with known diabetes or dyslipidaemia were excluded from the study, and it is possible that lopinavir may have exacerbated a pre-existing metabolic defect. Third, our sample size is relatively small, however, it is larger than most of the previous studies that have investigated this association [11, 17, 19]. We aimed to examine 50 participants to detect a correlation of 0.375. Our analyses used simple and multivariate regression analyses with various predictors, therefore we continued to slowly recruit eligible participants until the end of the study. Fourth, we investigated associations with pre-dose lopinavir concentrations and metabolic parameters. The pharmacokinetic parameters area under the curve or average steady state would be a better measure of overall drug exposure. Lastly, the last dose of lopinavir was not observed. To minimize recall bias, participants were requested to record the time of last dose on the appointment card for the day before pharmacokinetic sampling.
In conclusion, we did not find an association between lopinavir concentrations and lipid and glucose concentrations. Larger prospective studies are needed to establish whether an association exists between lopinavir concentrations and increasing lipids or glucose metabolism changes.
The authors are grateful to Ms Carmen Delport (study coordinator) and her team, for the help with collecting blood samples; Ms Alicia Evans and pharmacology laboratory team for the sample preparation and analysis; and to the patients for their participation in this study.
This study was funded by the World Diabetes Foundation, South African Department of Health and the South African Medical Research Council, Clinical Infectious Diseases Research Initiative, and Discovery Health. The funding bodies had no role in study design; in collection, analysis and interpretation of the data; in writing of the manuscript; and in the decision to submit the manuscript for publication.
These data were presented in part at the 12th International Workshop on Adverse Drug Reactions and Co-morbidities in HIV, London, UK, 5 November 2010 (Abstract ADRLH-48). The abstract was also published in Antiviral Therapy 2010; 15 Suppl 4: A61 (abstract no P32).
- World Health Organization : Rapid advice antiretroviral therapy for HIV infection in adults and adolescents. 2009, downloaded from http://www.who.int/hiv/pub/arv/rapid_advice_art.pdf on 03 August 2011, World Health Organization, downloaded from on 03 August 2011
- De Wit S, Sabin CA, Weber R, Worm SW, Reiss P, Cazanave C, El-Sadr C, Monforte W, Fontas A, Law E, Friis-Møller MG, Phillips N: Incidence and risk factors for new onset diabetes in HIV-infected patients. The data collection on adverse events of anti-HIV drugs (D: A: D) study. Diabetes Care. 2008, 31: 1224-1229. 10.2337/dc07-2013PubMed CentralView ArticlePubMed
- Montes ML, Pulido F, Barros C, Condes E, Rubio R, Cepeda C, Dronda F, Antela A, Sanz J, Navas E, Miralles P, Berenguer J, Pérez S, Zapata A, González-García JJ, Peña JM, Vázquez JJ, Arribas JR: Lipid disorders in antiretroviral-naive patients treated with lopinavir/ritonavir-based HAART: frequency, characterization and risk factors. JAC. 2005, 55: 800-804.PubMed
- Anastos K, Lu D, Shi Q, Tien PC, Kaplan RC, Hessol NA, Cole S, Vigen C, Cohen M, Young M, Justman J: Association of serum lipid levels with HIV serostatus, specific antiretroviral agents, and treatment regimens. J Acquir Immune Defic Syndr. 2007, 45: 34-42. 10.1097/QAI.0b013e318042d5feView ArticlePubMed
- Carr A, Samaras K, Thorisdottir A, Kaufmann GR, Chisholm DJ, Cooper DA: Diagnosis, prediction and natural course of HIV-1 protease-inhibitor associated lipodystrophy hyperlipidaemia, and diabetes mellitus: a cohort study. Lancet. 1999, 353: 2093-2099. 10.1016/S0140-6736(98)08468-2View ArticlePubMed
- Galindo MJ, Verdejo J, Gonzalez-Mun M, Ferrer A, Polo R: Metabolic changes in protease inhibitor-naïve patients with lopinavir/ritonavir. J Acquir Immune Defic Syndr. 2008, 48: 628-629. 10.1097/QAI.0b013e31816d9cf8View ArticlePubMed
- Dube’ MP, Shen C, Greenwald M, Mather KJ: No impairment of endothelial function or insulin sensitivity with 4 weeks of the HIV protease inhibitors atazanavir or lopinavir-ritonavir in healthy subjects without HIV infection: A placebo-controlled trial. Clinical Infectious Disease. 2008, 47: 567-574. 10.1086/590154.View Article
- Pao VY, Lee GA, Taylor S, Aweeka FT, Schwarz JM, Mulligan K, Schambelan M, Grunfeld C: The protease inhibitor combination lopinavir/ritonavir does not decrease insulin secretion in healthy, HIV-seronegative volunteers. AIDS. 2010, 24: 265-270. 10.1097/QAD.0b013e328333af1cView ArticlePubMed
- Lee GA, Lo JC, Aweeka F, Schwarz JM, Mulligan K, Schambelan M, Grunfeld C: Single-dose lopinavir acutely inhibits insulin-mediated glucose disposal in healthy volunteers. Clin Infect Dis. 2006, 43: 658-660. 10.1086/505974PubMed CentralView ArticlePubMed
- de González Requena D, Blanco F, Garcia-Benayas T: Correlation between lopinavir plasma levels and lipid abnormalities in patients taking Lopinavir/ritonavir. AIDS Patient Care STDS. 2003, 17: 443-445. 10.1089/108729103322395465View Article
- Gutiérrez F, Padilla S, Navarro A, Masiá M, Hernández I, Ramos J, Esteban A, Martin-Hidalgo A: Lopinavir plasma concentrations and changes in lipid levels during salvage therapy with lopinavir/ritonavir-containing regimens. J Acquir Immune Defic Syndr. 2003, 33: 594-600. 10.1097/00126334-200308150-00007View ArticlePubMed
- León A, Martinez E, Sarasa M, López Y, Mallolas J, De Lazzari E, Laguno M, Milincovic A, Blanco JL, Larrousse M, Lonca M, Gatell JM: Impact of steady-state lopinavir plasma levels on plasma lipids and body composition after 24 weeks of Lopinavir containing therapy free of thymidine analogues. J Antimicrob Chemother. 2007, 60: 824-830. 10.1093/jac/dkm285View ArticlePubMed
- Ren Y, Nuttall JJ, Egbers C, Eley BS, Meyers TM, Smith PJ, Maartens G, McIlleron HM: Effect of rifampicin on lopinavir pharmacokinetics in HIV-infected children with tuberculosis. J Acquir Immune Defic Syndr. 2008, 47: 566-569. 10.1097/QAI.0b013e3181642257View ArticlePubMed
- American Diabetes Association : Diagnosis and classification of diabetes mellitus. Diabetes Care. 2008, 31: S55-S60.View Article
- Grundy SM, Cleeman JI, Merz CN, Brewer HB, Clark LT, Hunninghake DB, Pasternak RC, Smith SC, Stone NJ: Implications of recent clinical trials for the National Cholesterol Education Program Adult Treatment Panel III guidelines. Circulation. 2004, 110: 227-239. 10.1161/01.CIR.0000133317.49796.0EView ArticlePubMed
- ACTG adherence follow-up questionnaire : 2006, http://www.caps.ucsf.edu/tools/surveys/pdf/2098.4188.pdf, on the 22 December 2006,
- Hurst M, Faulds D: Lopinavir. Drugs. 2000, 60: 1371-1379. 10.2165/00003495-200060060-00009View ArticlePubMed
- Bierman WF, van Vonderen MG, Veldkamp AI, Burger DM, Danner SA, Reiss P, van Agtmael MA: The lopinavir/ritonavir-associated rise in lipids is not related to lopinavir or ritonavir plasma concentration. Antivir Ther. 2011, 16: 647-655. 10.3851/IMP1824View ArticlePubMed
- Decloedt EH, McIlleron H, Smith P, Merry C, Orrell C, Maartens G: Pharmacokinetics of lopinavir in HIV-infected adults receiving rifampicin with adjusted doses of lopinavir-ritonavir tablets. AAC. 2011, 55: 3195-3200.View Article
- Bazzoli C, Jullien V, Le Tiec C, Rey E, Taburet AM: Intracellular pharmacokinetics of antiretroviral drugs in HIV infected patients, and their correlation with drug action. Clin Pharmacokinet. 2010, 49: 17-45. 10.2165/11318110-000000000-00000View ArticlePubMed
- Carr A, Samaras K, Chisholm DJ, Cooper D: Pathogenesis of HIV-1-protease inhibitor associated peripheral lipodystrophy, hyperlipidaemia and insulin resistance. Lancet. 1998, 351: 1881-1883. 10.1016/S0140-6736(98)03391-1View ArticlePubMed
- Bongiovanni M, Bini T, Cicconi P, Landonio S, Meraviglia P, Testa L, Di Biagio A, Chiesa E, Tordato F, Biasi P, Adorni F, Monforte AD: Predictive factors of hyperlipidemia in HIV-infected subjects receiving lopinavir/ritonavir. AIDS Res Hum Retroviruses. 2006, 22: 132-138. 10.1089/aid.2006.22.132View ArticlePubMed
- Tarr P, Telenti A: Toxigenetics of antiretroviral therapy: genetic factors that contribute to metabolic complications. Antivir Ther. 2007, 12: 999-1013.PubMed
- Rhee MS, Hellinger JA, Sheble-Hall S, Cohen CJ, Greenblatt DJ: Relationship between plasma protease inhibitor concentrations and lipid elevations in HIV patients on a double-boosted protease inhibitor regimen (saquinavir/lopinavir/ritonavir). J Clin Pharmacol. 2010, 50: 392-400. 10.1177/0091270009339739View ArticlePubMed
- Ter Hostede HJM, Koopmans PP, Burger DM, Sprenger HG, Napel CT, Vriesendorp V, Richter C: Lopinavir plasma concentrations and serum lipids in therapy naïve HIV-patients: A sub- analysis of the FREE study. Pharmacology & Pharmacy. 2012, 3: 90-96. 10.4236/pp.2012.31013View Article
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