Feingold Kenneth R.
Emeritus Professor of Medicine, University of California, San Francisco
Numerous studies have observed a decrease in total cholesterol, LDL-C, HDL-C, apolipoprotein B and A-I levels in patients with COVID-19 infections, similar to what is observed with other infections. In most studies the decrease in LDL-C and/or HDL-C was more profound the greater the severity of the illness. LDL-C and HDL-C levels were inversely correlated with C-reactive protein (CRP) levels i.e., the lower the LDL-C or HDL-C level the higher the CRP levels. Patients with low HDL-C and/or LDL-C levels at admission to the hospital were at an increased risk of developing severe disease compared to patients with high levels. With recovery from COVID-19 infections the serum lipid levels return towards levels present prior to infection. In patients that failed to survive, total cholesterol, LDL-C, and HDL-C levels were lower at admission to the hospital and continued to decline during the hospitalization. In patients with COVID-19 infections the serum triglyceride levels were variable. Lipoprotein (a) levels increase during COVID-19 infections. Several studies using the UK Biobank and other databases have shown that low HDL-C and apolipoprotein A-I levels measured many years prior to COVID-19 infections were associated with an increased risk of COVID-19 infections and death from infection while LDL-C, apolipoprotein B, lipoprotein (a), and triglyceride levels were not consistently found to be significantly associated with an increased risk. A 10 mg/dl increase in HDL-C or apolipoprotein A1 levels was associated with ∼10% reduced risk of COVID-19 infection. It should be noted that these observations are subject to the caveats of confounding variables and reverse causation affecting the results. Several studies have found that homozygosity for apolipoprotein E4/4 is associated with a 2-3- fold increased risk of COVID-19 infections and this increase was not due to dementia or Alzheimer’s disease. During the COVID-19 pandemic, diet, exercise, and lipid lowering therapy should be continued. For those who become symptomatic, lipid lowering therapy, if feasible, should also be continued throughout the duration of the illness. Individuals who are naïve to treatment but for whom lipid lowering therapy is indicated should be started on treatment. Randomized controlled studies have shown no benefits from statin therapy but small studies have suggested that PCSK9 inhibitors and omega-3 fatty acids may be beneficial. In patients with severe symptoms of COVID-19 who are too ill to take oral medications, lipid lowering medications may be temporarily suspended. Medications should be re-started when the patient has recovered and is able to take oral medications. One needs to be aware that certain drugs that are used to treat COVID-19 infections may interact with lipid lowering drugs. Remdesivir and Paxlovid (nirmatrelvir and ritonavir) are metabolized by the Cyp3A4 pathway and statins that are also metabolized by this pathway should be avoided (atorvastatin, simvastatin, and lovastatin). For complete coverage of all related areas of Endocrinology, please visit our on-line FREE web-text, WWW.ENDOTEXT.ORG.
多项研究观察到，新冠病毒感染患者的总胆固醇、低密度脂蛋白胆固醇（LDL-C）、高密度脂蛋白胆固醇（HDL-C）以及载脂蛋白B和A-I水平下降，这与其他感染的情况类似。在大多数研究中，疾病越严重，LDL-C和/或HDL-C的下降就越明显。LDL-C和HDL-C水平与C反应蛋白（CRP）水平呈负相关，即LDL-C或HDL-C水平越低，CRP水平越高。与HDL-C和/或LDL-C水平高的患者相比，入院时HDL-C和/或LDL-C水平低的患者发生重症的风险增加。随着新冠病毒感染的康复，血清脂质水平会恢复到感染前的水平。在未能存活的患者中，入院时总胆固醇、LDL-C和HDL-C水平较低，且在住院期间持续下降。新冠病毒感染患者的血清甘油三酯水平各不相同。新冠病毒感染期间脂蛋白（a）水平会升高。几项使用英国生物银行和其他数据库的研究表明，在新冠病毒感染前多年测得的低HDL-C和载脂蛋白A-I水平与新冠病毒感染及感染死亡风险增加有关，而LDL-C、载脂蛋白B、脂蛋白（a）和甘油三酯水平并未始终被发现与风险增加显著相关。HDL-C或载脂蛋白A1水平每升高10mg/dl，新冠病毒感染风险约降低10%。应当指出，这些观察结果受到混杂变量和反向因果关系影响结果的限制。几项研究发现，载脂蛋白E4/4纯合子与新冠病毒感染风险增加2至3倍有关，且这种增加并非由痴呆或阿尔茨海默病所致。在新冠疫情期间，应继续进行饮食、运动和降脂治疗。对于出现症状的患者，如果可行，在整个病程中也应继续进行降脂治疗。对于未接受过治疗但需要进行降脂治疗的患者，应开始治疗。在新冠病毒感染之前或期间给予降脂药物是否有益尚不确定，但随机对照研究正在进行中。对于新冠病毒感染症状严重、无法口服药物的患者，降脂药物可能需要暂时停用。当患者康复并能够口服药物时，应重新开始用药。需要注意的是，某些用于治疗新冠病毒感染的药物可能与降脂药物相互作用。瑞德西韦和帕罗韦德（奈玛特韦和利托那韦）通过Cyp3A4途径代谢，应避免使用同样通过该途径代谢的他汀类药物（阿托伐他汀、辛伐他汀和洛伐他汀）。由于针对新冠病毒感染患者的药物治疗迅速发展，需要警惕潜在的药物相互作用。欲全面涵盖内分泌学的所有相关领域，请访问我们的在线免费网络文本，网址为WWW.ENDOTEXT.ORG。
