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PubMed1962

OXIDATIVE METABOLISM AND THE GLYOXYLATE CYCLE IN PSEUDOMONAS INDIGOFERA.

McFadden, Bruce A. (Washington State University, Pullman, Wash.) and William V. Howes. Oxidative metabolism and the glyoxylate cycle in Pseudomonas indigofera. J. Bacteriol. 84:72-76. 1962.-Oxidative patterns of Pseudomonas indigofera have been investigated. Intact cells oxidize acetate, ethanol, fumarate, glyoxylate, alpha-ketoglutarate, malate, oxaloacetate, pyruvate, and succinate to greater than 35% of completion. Isocitrate is oxidized to 21% of completion. Citrate is not oxidized by whole cells but is oxidized by cell-free preparations, as are fumarate, isocitrate, malate, and succinate. These patterns are suggestive of the operation of the tricarboxylic acid cycle. Investigations of levels of isocitrate lyase and malate synthase as functions of growth substrate have been conducted. Assays for these enzymes in "soluble" preparations were performed under ostensibly optimal conditions for catalysis. Growth substrates used at 0.3% were: (i) ethanol, (ii) glucose, (iii) succinic acid, and (iv) yeast extract. Specific activities of isocitrate lyase were: for (i) 3.80, (ii) 0.61, (iii) 1.47, and (iv) 1.33; activities of malate synthase were: for (i) 0.18, (ii) 0.032, (iii) 0.021, and (iv) 0.029. Additionally, the isocitrate lyase level from butyrate-grown cells was similar to that for ethanol-grown cells; the specific activity of malate synthase was about 60% as high. Specific activities of these enzymes were reproducible when conditions of sonic disruption were standardized. Longer durations of disruption decreased both activities.

Journal Article↗

PubMed2003

Efficacy and safety of ketotifen eye drops in the treatment of seasonal allergic conjunctivitis.

BACKGROUND: Ketotifen blocks histamine H(1) receptors, stabilises mast cells, and prevents eosinophil accumulation. These multiple, pharmacological mechanisms provided the rationale for assessing the efficacy and safety of ketotifen 0.025% eye drops in subjects with seasonal allergic conjunctivitis (SAC) in an environmental setting. METHODS: This was a double masked, randomised, multicentre trial conducted in Australia. Subjects were randomly assigned to ketotifen fumarate 0.025% ophthalmic solution, placebo (as vehicle), or levocabastine hydrochloride 0.05% ophthalmic suspension, twice daily in each eye for a 4 week period. Subjects were assessed at follow up (days 5-8) and termination (days 25-31) visits. The primary efficacy variable was the responder rate, based on the subjects' assessment of global efficacy at the follow up visit. RESULTS: 519 subjects were randomised to treatment. At the follow up visit, the responder rate, based on subjects' assessment of global efficacy, was significantly greater in the ketotifen group (49.5%) than in the placebo group (33.0%) for subjects with a positive diagnostic test for pollen allergy (p = 0.02). The investigators' assessment of responder rates also showed that ketotifen was superior to placebo (p = 0.001). Ketotifen produced a significantly better outcome than levocabastine (p<0.05) for relief of signs and symptoms of SAC, at both the follow up and the termination visit. The type and frequency of adverse events were similar across treatment groups. CONCLUSIONS: In an environmental setting, ketotifen fumarate 0.025% ophthalmic solution was well tolerated and effective in reducing the signs and symptoms of SAC, and in preventing their recurrence. Ketotifen consistently showed the best efficacy in comparison with both placebo and levocabastine. These results indicate that ketotifen eye drops are a valuable treatment option for this condition.

Anti-Allergic Agents↗

PubMed1971

Drug-induced pulmonary hypertension?

Of 40 patients with obstructive pulmonary hypertension studied in Basle, Switzerland, during the period 1966-68, 32 had been taking an anorectic drug, aminorex fumarate. Rapidly progressing exertional dyspnoea, central chest pain, and syncope on effort were characteristic features. The absence of the usual causes of pulmonary vascular disease seems to suggest the possibility of drug-induced pulmonary hypertension. Further studies are necessary, however, to clarify the role of aminorex fumarate in this condition.

Adult↗

PubMedDate not supplied

Physiological role of GlpB of anaerobic glycerol-3-phosphate dehydrogenase of Escherichia coli.

Anaerobic sn-glycerol-3-phosphate dehydrogenase of Escherichia coli is encoded by an operon of three genes, glpACB. The promoter distal gene, glpB, encodes a 44-kilodalton polypeptide that is not part of the purified soluble dehydrogenase. By recombinant plasmid complementation, in a strain harboring a chromosomal deletion of glpACB, we found that all three genes were essential for anaerobic growth on glycerol-3-phosphate (G3P). By isolation of inner membrane preparations we confirmed the cytoplasmic membrane localization of GlpB. GlpB displayed an electron paramagnetic resonance spectrum that suggested the presence of iron-sulfur center(s) within GlpB. We used this spectrum to show that the center(s) were reduced by the artificial reductant dithionite and by the physiological substrate G3P but not by lactate or formate. The center(s) were oxidized by fumarate. These data indicated that GlpB mediates electron transfer from the soluble GlpAC dimer to the terminal electron acceptor fumarate via the membrane-bound menaquinone pool.

Electron Spin Resonance Spectroscopy↗

PubMed1979

Effect of Krebs cycle intermediates and inhibitors on toad gastric mucosa.

An attempt to increase the permeability of gastric mucosa to exogenous Krebs cycle intermediates seemed advisable for a better understanding their relationship with acid secretion. At pH 7.4, citrate, oxoglutarate, fumarate, and malate had no significant effect on oxygen uptake (QO2) nor on acid secretion (QH+) by toad gastric mucosa; succinate increased QO2 slightly and had no effect on QH+; but at pH 5.0, oxoglutarate and succinate increased QO2 by 18 and 21%, respectively. 14CO2 evolved by gastric mucosa incubated with [14C]oxoglutarate, succinate, malate, or citrate was 155, 92, 128, and 353%, respectively, greater at pH 5. Citrate, oxoglutarate, succinate, fumarate, and malate increased QH+ by theophylline-stimulated mucosa at pH 5.0 by 25, 39, 35, 17 and 28%, respectively. Oxoglutarate-dependent respiration was shown to correlate with oxoglutarate oxidation. Malonate and arsenite inhibited QO2 and QH+; malonate inhibition was reversed by washout or by succinate. Arsenite was reversed by washout and accelerated by addition of lipoate immediately after washout. The results suggest that the Krebs cycle has concomitant roles in the regulation of QH+ and oxidative metabolism in the toad gastric mucosa.

Animals↗

PubMed2003

Essential role of complex II of the respiratory chain in hypoxia-induced ROS generation in the pulmonary vasculature.

In the pulmonary vasculature, the mechanisms responsible for oxygen sensing and the initiation of hypoxia-induced vasoconstriction and vascular remodeling are still unclear. Nitric oxide (NO) and reactive oxygen species (ROS) are discussed as early mediators of the hypoxic response. Here, we describe a quantitative analysis of NO- and ROS-producing cells within the vascular walls of murine lung sections cultured at normoxia or hypoxia. Whereas the number of NO-producing cells was not changed by hypoxia, the number of ROS-generating cells was significantly increased. Addition of specific inhibitors revealed that mitochondria were the source of ROS. The participation of the individual mitochondrial complexes differed in normoxic and hypoxic ROS generation. Whereas normoxic ROS production required complexes I and III, hypoxic ROS generation additionally demanded complex II. Histochemically demonstrable succinate dehydrogenase activity of complex II in the arterial wall decreased during hypoxia. Inhibition of the reversed enzymatic reaction, i.e., fumarate reductase, by application of succinate, specifically abolished hypoxic, but not normoxic, ROS generation. Thus complex II plays an essential role in hypoxic ROS production. Presumably, its catalytic activity switches from succinate dehydrogenase to fumarate reductase at reduced oxygen tension, thereby modulating the directionality of the electron flow.

Animals↗

PubMed2005

Differential effects of heptanoate and hexanoate on myocardial citric acid cycle intermediates following ischemia-reperfusion.

In the normal heart, there is loss of citric acid cycle (CAC) intermediates that is matched by the entry of intermediates from outside the cycle, a process termed anaplerosis. Previous in vitro studies suggest that supplementation with anaplerotic substrates improves cardiac function during myocardial ischemia and/or reperfusion. The present investigation assessed whether treatment with the anaplerotic medium-chain fatty acid heptanoate improves contractile function during ischemia and reperfusion. The left anterior descending coronary artery of anesthetized pigs was subjected to 60 min of 60% flow reduction and 30 min of reperfusion. Three treatment groups were studied: saline control, heptanoate (0.4 mM), or hexanoate as a negative control (0.4 mM). Treatment was initiated after 30 min of ischemia and continued through reperfusion. Myocardial CAC intermediate content was not affected by ischemia-reperfusion; however, treatment with heptanoate resulted in a more than twofold increase in fumarate and malate, with no change in citrate and succinate, while treatment with hexanoate did not increase fumarate or malate but increased succinate by 1.8-fold. There were no differences among groups in lactate exchange, glucose oxidation, oxygen consumption, and contractile power. In conclusion, despite a significant increase in the content of carbon-4 CAC intermediates, treatment with heptanoate did not result in improved mechanical function of the heart in this model of reversible ischemia-reperfusion. This suggests that reduced anaplerosis and CAC dysfunction do not play a major role in contractile and metabolic derangements observed with a 60% decrease in coronary flow followed by reperfusion.

Animals↗

PubMed1992

Quantitative analysis of amino acid oxidation and related gluconeogenesis in humans.

Significant gaps remain in our knowledge of the pathways of amino acid catabolism in humans. Further quantitative data describing amino acid metabolism in the kidney are especially needed as are further details concerning the pathways utilized for certain amino acids in liver. Sufficient data do exist to allow a broad picture of the overall process of amino acid oxidation to be developed along with approximate quantitative assessments of the role played by liver, muscle, kidney, and small intestine. Our analysis indicates that amino acids are the major fuel of liver, i.e., their oxidative conversion to glucose accounts for about one-half of the daily oxygen consumption of the liver, and no other fuel contributes nearly so importantly. The daily supply of amino acids provided in the diet cannot be totally oxidized to CO2 in the liver because such a process would provide far more ATP than the liver could utilize. Instead, most amino acids are oxidatively converted to glucose. This results in an overall ATP production during amino acid oxidation very nearly equal to the ATP required to convert amino acid carbon to glucose. Thus gluconeogenesis occurs without either a need for ATP from other fuels or an excessive ATP production that could limit the maximal rate of the process. The net effect of the oxidation of amino acids to glucose in the liver is to make nearly two-thirds of the total energy available from the oxidation of amino acids accessible to peripheral tissues, without necessitating that peripheral tissues synthesize the complex array of enzymes needed to support direct amino acid oxidation. As a balanced mixture of amino acids is oxidized in the liver, nearly all carbon from glucogenic amino acids flows into the mitochondrial aspartate pool and is actively transported out of the mitochondria via the aspartate-glutamate antiport linked to proton entry. In the cytoplasm the aspartate is converted to fumarate utilizing urea cycle enzymes; the fumarate flows via oxaloacetate to PEP and on to glucose. Thus carbon flow through the urea cycle is normally interlinked with gluconeogenic carbon flow because these metabolic pathways share a common step. Liver mitochondria experience a severe nonvolatile acid load during amino acid oxidation. It is suggested that this acid load is alleviated mainly by the respiratory chain proton pump in a form of uncoupled respiration.(ABSTRACT TRUNCATED AT 400 WORDS)

Amino Acids↗

PubMed1987

A somatic cell hybrid with a single human chromosome 22 corrects the defect in the CHO mutant (Ade-I) lacking adenylosuccinase activity.

Adenine-requiring Chinese hamster ovary (CHO-K1) auxotrophs of the complementation group Ade-I were hybridized with various human cells, and hybrids were isolated under selective conditions in which retention of the complementing gene on the human chromosome is necessary for survival. Ade-I cells are deficient in adenylosuccinase activity. This enzyme carries out two independent, but similar, steps of purine biosynthesis: the removal of a fumarate from succinylaminoimidazole carboxamide ribotide to produce aminoimidazole carboxamide ribotide and the removal of fumarate from adenylosuccinate to produce AMP. These are the 9th and 13th steps of adenylate biosynthesis, respectively. Analysis of hybrids by cytogenetics and by Southern blot techniques using chromosome 22-specific DNA probes, one of which encodes an antigen expressed in human fetal brain, indicated that human chromosome 22 was 100% concordant for growth without adenine. One hybrid subclone, isolated after two successive rounds of subcloning, was found to be capable of growth without adenine; the only human chromosome present was 22. In addition, segregants that had lost the ability to grow in adenine-free media had also lost human chromosome 22. These results suggest that the human gene for adenylosuccinase resides on chromosome 22.

Adenylosuccinate Lyase↗

PubMed2000

Tissue responses to molecularly reinforced polylactide-co-glycolide implants.

Plates for internal fixation fabricated from biodegradable polymers degrade via an autocatalytic route. When they are used in bone implants of significant size and thickness, hollowing of the implant may occur while the overall dimensions appear unchanged. We hypothesized that incorporation of a cross-linked polypropylene fumarate matrix into polylactide-co-glycolide bone plates may provide an internal molecular network which prevents implant collapse. Cross-linking reagents of varying hydrophilicity including N-vinylpyrrolidone (VP), hydroxyethylmethacrylate (HEMA), and ethyleneglycol dimethacrylate (EGDMA) were employed. With the objective of determining the most biocompatible and structurally sound composition for molecular reinforcement, we investigated tissue responses in both subcutaneous and orthotopic rodent implantation models in relation to maintenance of implant integrity by histologic, histomorphometric, and stereomicroscopic analysis. Results showed that tissue responses were correlated with dimensional stability of the implants. The most favorable results were seen with the hydrophobic cross-linker EGDMA; this may have been related to the initial reduction of the water uptake by the implant. Cross-linking of polypropylene fumarate with EGDMA within a polylactide-co-glycolide bone plate may offer a means to maintain excellent biocompatibility while improving dimensional stability of biodegradable bone plates.

Animals↗

PubMed1986

Development of pulmonary aneurysm in primary pulmonary hypertension: a case report.

Selected cases of severe primary pulmonary arterial hypertension and associated pulmonary vascular disease have been related to the oral ingestion of aminorex fumarate, an anorexigen obviously responsible for an epidemic of primary pulmonary hypertension in Western Europe between 1967 and 1970. This report describes a fifteen year follow-up of a female patient with aminorex fumarate related pulmonary hypertension and the uncommon finding of the formation of an excessive fusiform pulmonary trunk aneurysm in the late stage of the disease process. The progressive clinical course was followed by serial chest x-ray films and repeat right heart catheterization. The diagnosis of a main stem pulmonary artery aneurysm was noninvasively established by two-dimensional echocardiography and confirmed by contrast-enhanced computed tomography and radionuclide blood pool imaging. The patient is alive, thus no histologic correlate of this entity is available at present.

Aminorex↗

PubMed1987

L-serine enhances the anaerobic lactate metabolism of Veillonella dispar ATCC 17745.

Under anaerobic conditions, the rate of metabolism of lactate by starved resting cells of Veillonella dispar ATCC 17745 was very low. Because pyruvate was metabolized well by the starved cells, oxidation of lactate to pyruvate, which is the first step of the lactate metabolism, must have been limited in the cells. In the starved cells, the levels of the metabolic intermediates, oxalacetate or fumarate, of which reductions to malate or to succinate could be coupled with lactate oxidation to pyruvate and initiate lactate metabolism, were quite low, suggesting that these had been reduced during the starvation steps under strictly anaerobic conditions. Thus, the starved cells were unable to start the anaerobic lactate metabolism because of shortage of such reducible substrates. L-serine greatly enhanced anaerobic lactate metabolism of the starved cells. This enhancement may have been due to metabolism of L-serine itself and conversion to oxalacetate and fumarate, which made it possible to begin lactate oxidation.

Amino Acids↗

PubMed2002

Iodine stability in salt double-fortified with iron and iodine.

Deficiencies in small quantities of micronutrients, especially iodine and iron, severely affect more than a third of the world's population, resulting in serious public health consequences, especially for women and young children. Salt is an ideal carrier of micronutrients. The double fortification of salt with both iodine and iron is an attractive approach to the reduction of both anemia and iodine-deficiency disorders. Because iodine is unstable under the storage conditions found during the manufacturing, distribution, and sale of salt in most developing countries, the effects of packaging materials and environmental conditions on the stability of salt double-fortified with iron and iodine were investigated. Salt was double-fortified with potassium iodide or potassium iodate and with ferrous sulfate or ferrous fumarate. The effects of stabilizers on the stability of iodine and iron were followed by storing the salt under three conditions that represent the extremes of normal distribution and sale for salt in developing countries: room temperature (25 degrees C) with 50%-70% relative humidity, 40 degrees C with 60% relative humidity, and 40 degrees C with 100% relative humidity. The effects of stabilizers, such as sodium hexametaphosphate (SHMP), calcium carbonate, calcium silicate, and dextrose were investigated. None of the combinations of iron and iodine compounds was stable at elevated temperatures. Essentially all of the iodine was lost over a period of six months. SHMP effectively slowed down the iodine loss, whereas magnesium chloride, a typical hygroscopic impurity, greatly accelerated this process. Calcium carbonate did not have a sparing effect on iodine, despite contrary indications in the literature. Ferrous sulfate-fortified salts generally turned yellow and developed an unpleasant rusty flavor. Salt fortified with ferrous fumarate and potassium, iodide was reasonably stable and maintained its organoleptic properties, making it more likely to be acceptable to consumers. We confirmed that application of the iodine compounds as solutions resulted in a more even distribution of the iodine throughout the sample. The effect of the packaging materials was overshadowed by the other variables. None of the packaging materials was clearly better than any other. This may have been due to the fact that the polymer bags were not heat sealed, and thus some moisture penetration was possible. The results indicate that with careful control of processing, packaging, and storage conditions, a double-fortified salt could be stabilized for the six-month period required for distribution and consumption. Unfortunately, the processing and storage required are difficult to attain under typical conditions in developing countries.

Biological Availability↗

PubMed2006

A tale of two ferredoxins: sequence similarity and structural differences.

BACKGROUND: Sequence similarity between proteins is usually considered a reliable indicator of homology. Pyruvate-ferredoxin oxidoreductase and quinol-fumarate reductase contain ferredoxin domains that bind [Fe-S] clusters and are involved in electron transport. Profile-based methods for sequence comparison, such as PSI-BLAST and HMMer, suggest statistically significant similarity between these domains. RESULTS: The sequence similarity between these ferredoxin domains resides in the area of the [Fe-S] cluster-binding sites. Although overall folds of these ferredoxins bear no obvious similarity, the regions of sequence similarity display a remarkable local structural similarity. These short regions with pronounced sequence motifs are incorporated in completely different structural environments. In pyruvate-ferredoxin oxidoreductase (bacterial ferredoxin), the hydrophobic core of the domain is completed by two beta-hairpins, whereas in quinol-fumarate reductase (alpha-helical ferredoxin), the cluster-binding motifs are part of a larger all-alpha-helical globin-like fold core. CONCLUSION: Functionally meaningful sequence similarity may sometimes be reflected only in local structural similarity, but not in global fold similarity. If detected and used naively, such similarities may lead to incorrect fold predictions.

Amino Acid Sequence↗

PubMed2000

Oral, intraperitoneal and intravenous pharmacokinetics of deramciclane and its N-desmethyl metabolite in the rat.

The pharmacokinetic properties of deramciclane fumarate (EGIS-3886), a new potential anxiolitic agent, and its N-desmethyl metabolite have been investigated in Wistar rats after 10 mgkg(-1) deramciclane fumarate was administered orally, intraperitoneally or intravenously. A highly sensitive, validated and optimized gas chromatographic method with nitrogen selective detection (GC-NPD) using a solid-phase extraction technique was used to determine plasma levels of the parent compound and its N-desmethyl metabolite. After oral administration the absorption of the parent compound was very fast (t(max) 0.5h). The maximum plasma concentration (C(max)) was detected at 44.9, > or =177.8 and > or =2643.0 ngmL(-1) after oral, intraperitoneal and intravenous administration of deramciclane, respectively. For the metabolite the respective Cmax values were 32.0, > or =25.4 and 51.0 ngmL(-1). The pharmacokinetic curves of both the parent compound and its metabolite showed enterohepatic recirculation for all administration routes. The biological half-life (tbeta 1/2) for deramciclane ranged from 3.42 to 5.44 h and for the N-desmethyl metabolite the range was 2.90-5.44 h, after administration of the drug by the three different routes. After intravenous administration AUC0-infinity, of deramciclane was 29.2- and 5.4-times higher than that observed after oral and intraperitoneal treatment, respectively. These AUC0-infinity ratios were only 2.1- and 1.5-times higher for the metabolite. The absolute bioavailability of deramciclane in rats was 3.42% after oral and 18.49% after intraperitoneal administration. The comparative pharmacokinetic study of deramciclane in rat after the different administration routes showed fast absorption. Furthermore, plasma levels were found to be administration route-dependent, low bioavailability of the parent compound indicated an extremely fast and strong first-pass metabolism. The apparent volume of distribution suggested strong tissue binding after administration of the drug by any of the three routes studied.

Administration, Oral↗

PubMed1997

Change of mechanical activity to contraction from the relaxation induced by the intracellular Ca2+ antagonist KT-362; effects of alkylation of side chain, and substitution of 2,3,4,5-tetrahydro-1,5-benzothiazepine derivatives.

KT-362 (5-[3-[2-(3,4-Dimethoxyphenyl)ethyl]aminopropionyl]-2,3,4, 5-tetrahydro-1,5-benzothiazepine fumarate) is an intracellular Ca2+ antagonist. The compound obtained by introducing methyl groups onto the nitrogen (R2) of the side chain of KT-362 showed vasoconstrictive activity. Therefore we synthesized various derivatives, and examined their activities. Substitution at position R2 of the side chain resulted in potent contractile activity, and the optimal alkyl length was two or three carbons. The potency was further increased by the introduction of a chloro group at the R1 position of 2,3,4,5-tetrahydro-1,5-benzothiazepines. One of the synthesized compounds, 8-chloro-5-¿N-ethyl-N-[2-(3,4-dimethoxyphenyl)ethyl]aminopropionyl¿-2,3,4, 5-tetrahydro-1,5-benzothiazepine fumarate (9b), showed an EC50 value of 3.47 x 10(-8) M for contraction of rabbit iliac artery. The action of compound 9b was antagonized competitively by an H1-histamine receptor antagonist, diphenhydramine, and the pA2 value was 7.82. The maximum constriction was inhibited by a Ca2+ entry blocker, nicardipine, but not by an alpha 1-adrenoreceptor antagonist, prazosin. In a Ca(2+)-free medium, tonic constriction induced by 9b disappeared, and only a phasic constriction was observed. Though this phasic constriction was inhibited by diphenhydramine, it was not inhibited by prazosin or nicardipine.

Adrenergic alpha-Antagonists↗

PubMedDate not supplied

A comparative study of the organic acid content of the hemolymph of Schistosoma mansoni-resistant and susceptible strains of Biomphalaria glabrata.

The freshwater snail Biomphalaria glabrata is an intermediate host of the trematode Schistosoma mansoni. However, some strains of B. glabrata are resistant to successful infection by S. mansoni larvae. The present work examines the profile of organic acids present in S. mansoni-resistant and -susceptible strains of B. glabrata, in order to determine whether the type of organic acid present is related to susceptibility. The organic acids were extracted from the hemolymph of two susceptible B. glabrata strains (PR, Puerto Rico and Ba, Jacobina-Bahia from Brazil), and from the resistant strains 13-16-R1 and 10R2, using solid phase extraction procedures followed by high performance liquid chromatography. The organic acids obtained were analyzed and identified by comparison with known standards. Pyruvate, lactate, succinate, malate, fumarate, acetate, propionate, beta-hydroxybutyrate and acetoacetate were detected in all hemolymph samples. Under standard conditions, the concentration of each of these substances varied among the strains tested and appeared to be specific for each strain. An interesting variation was the low concentration of pyruvate in the hemolymph of PR-snails. Only the concentration of fumarate was consistently different (p < or = 0.05) between resistant and susceptible strains.

Animals↗

PubMed2006

Cardiovascular risk in patients with HIV Infection: impact of antiretroviral therapy.

Increased coronary heart disease risk in HIV-positive patients using antiretroviral therapy (ART) has been a controversial topic since 1998 when the dyslipidaemic effect of protease inhibitors (PIs) was recognised. Accumulating evidence suggests an association between ART and increased coronary heart disease risk. In 2003, the large, prospective D:A:D (Data Collection on Adverse Events of Anti-HIV Drugs) study reported a 26% relative increase in the rate of myocardial infarction per year of exposure during the first 4-6 years of use. As the HIV-population grows older, infectious disease specialists have to consider unfamiliar areas of internal medicine such as lipid-lowering therapy and smoking cessation. Moreover, the ART regimen itself may be a modifiable risk factor, as there are both class differences and within-class differences in the tendency to increase lipids. Most nucleoside reverse transcriptase inhibitors (NRTIs), including the newer agents tenofovir disoproxil fumarate and emtricitabine, have little or no effect on lipid levels or glucose metabolism. One exception is the highly effective NRTI stavudine, which has a dyslipidaemic profile and a negative effect on glucose metabolism. In contrast the non-nucleoside reverse transcriptase inhibitor nevirapine may increase the 'good cholesterol' high-density lipoprotein (HDL) cholesterol and thus reduce the total cholesterol : HDL cholesterol index. Most of the PIs have some dyslipidaemic effect, especially ritonavir (alone or in combination with other PIs), fosamprenavir and the novel PI tipranavir. Only atazanavir, and to some extent saquinavir, seem to have little effect on lipid levels and glucose metabolism. Studies on blood pressure in HIV-positive patients have been contradictory. Apart from a recent report from the D:A:D study where lower blood pressure was found in patients receiving NNRTIs, the influence of the individual drugs on blood pressure is unknown. When hypertension is detected in a HIV-positive patient, creatinine clearance (CL(CR)) should be calculated and the urine checked for proteinuria. When CL(CR) is <30 mL/min, tenofovir disoproxil fumarate is not recommended. Many hypertensive HIV-positive patients have proteinuria and an ACE inhibitor or an angiotensin II receptor antagonist is a better choice than a thiazide diuretic or calcium channel antagonist in these patients. In addition, physicians treating patients with ART should be especially aware of the long list of possible interactions between PIs and anti-hypertensive- and lipid-lowering drugs. This review discusses important clinical aspects of treating middle-aged HIV-positive patients who have an increased risk of experiencing a cardiovascular event.

Anti-Retroviral Agents↗