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Diabetes for HIV Care Providers

There are an estimated 16 million persons in the U.S. with diabetes. Approximately half have been diagnosed and half are currently undiagnosed. Most are type 2 Diabetes. The greatest risk factors for developing type 2 diabetes are age > 45 years, obesity, and family history. Many of our HIV positive patients have one or more of these risk factors.

A. The criteria for the diagnosis of diabetes have been changed to reflect the current understanding of the complications of hyperglycemia. The new criteria are:

Symptoms of diabetes plus casual plasma glucose of >or = 200 mg/dl; classic symptoms include polyuria, polydipsia, and unexplained weight loss.

or

8 hour fasting plasma glucose > or = 126 mg/dl

or

2-hour plasma glucose level > or = 200 mg/dl during an oral glucose tolerance test done by using a 75 g of glucose.

Screening your patients periodically every 6 to 12 months, especially if they are on medications known to cause or potentially increase plasma glucose may detect hyperglycemia. Glucose should be checked if the person has symptoms that might be attributed to hyperglycemia.

B. What is the association between Diabetes and HIV?

Various cohort studies show about 1-5 % rate of diabetes in patients on protease inhibitor containing regiments. When compared to those not on treatment there is a small increase, in the range 1% that may be attributable to the PIs. Many patients are now at the age when the incidence of

Medications that are known to cause diabetes are pentamidine, prednisone, nicotinic acid, anabolic steroids, growth hormone, and megestrol (megace).

Ritonavir may increase levels (AUC) of sulfonylureas and potentiate their effect. When starting a sulfonylurea like glyburide or glipizide you should start at lower doses. Metformin (Glucophage) can not be given to patients with abnormal creatinines >1.4 due to the increased risk of lactic acidosis. It should be stopped 72 hours prior to xray contrast studies and not restarted until 48 hours after and when you know that the creatinine is normal. Other conditions known to cause acidosis e.g. severe CHF, hypoxia, sepsis, liver failure are contraindications to mefformin.

Troglitazone (Rezulin) is associated with liver failure. LFTs must be checked every month for the first 8 months then every 2 months for the next 4 months and periodically thereafter. It may cause p450 enzyme induction and may decrease levels of nelfinavir. It is unknown if this is significant.

C. The increased morbidity and mortality seen in persons can be reduced by cardiovascular risk reduction and diabetic health care maintenance procedures. Persons with diabetes are at increased risk of fatal and nonfatal cardiovascular disease. The most crucial areas of intervention are:

D. Diabetes and HIV share many of the same complications. This makes monitoring and prevention very important. It may be difficult to know which disease process caused the

complication. Shared complications are: Neuropathy Nephropathy Retinopathy (31 dysfunction Cardiac disease Dermatologic diseases Weight loss

Increased susceptibility to certain infections

Pregnancy related problems

E. Other areas of special consideration for the diabetic patient

• Home glucose monitoring and glucose of 150%
• Hemoglobin A1C monitoring - Hb Aic of 7% = average blood glucose of 150%. For each 1% change mHgAic. Glucose 30 mg^
• Dental care
• Avoidance of hypoglycemia
• Referral to a nutritionist and a diabetes educator
• Care in prescribing medication that can worsen or potentiate the effects of hypoglycemic agents
• Tight control before and during pregnancy
• Achieving the best level of control safely

III. Epidemiology

• Approximately 16 million diabetics. 8 million are diagnosed, 8 million are undiagnosed.
• Approximately 800,000 type I DM aka IDDM.
• Direct medical cost $45 billion in US 1992
• Indirect cost $47 billion ( disability, work loss, premature mortality)
• Deaths: Diabetes is the 7th leading cause of death listed on death certificates in 1993. In 1992 diabetes contributed to the deaths of more than 169,000 persons.

IV. Incidence

• 1. New cases each year:. NIDDM 595,000; IDDM 30,000.
• 2. Prevalence % of adults with DM

• a)    African-Americans, 9.6%; Mexican-Americans, 9.6%
• b)    White Americans 6.2%; Native Americans, range 5 to 50%
• c)    Japanese Americans aged 45-74 in Kings Co, WA 20% of Men, 16% of Women
• d)    Cumulative incidence by age 74 White, 17%; African-Americans, 26%
• e)    Framingham study, persons >120% IBW have a 2.26X risk of having DM.

V. Risk Factors for Developing DM

• Family history is strong, 60-90% in identical twins. If you have a first-degree relative 20-40% develop N!DDM venus 6% without a relative.
• Obesity especially abdominal, 75% of newly diagnosed NIDDM are obese. If >40% overweight 3X risk of NIDDM
• Poverty, low education
• Increased age :
• Diet, Japanese in Hawaii have a great prevalence than Japanese in Japan. The so called cocacolonization.
• Sedentary lifestyle. Exercise decreases the risk even if there is no weight loss and a +Fhx.
• Hx of abnormal GTr in pregnancy, 30-40% develop NIDDM over 10-20 years

VI. Morbidity and Mortality Associated with NIDDM

• CV disease is 2-4X more common in DM
• CV disease is present in 75% of DM related deaths
• Middle aged people with DM have 2X the mortality and 2-4X the heart disease death rate as non-DM
• Stroke is 2.5X
• Hypertension affects 60-65% of DM
• Blindness: DM is the leading cause of blindness, 12,000 to 24,000 new cases of blindness each year are caused by DM retinopathy.
• Renal Failure: DM is the leading cause of ESRD, 36% of the new cases. 56,059 persons with DM were undergoing dialysis or transplant in 1992.
• Amputations: more than half of all the amputations of the lower extremity are DM, amputations per year in DM 54,000.
• Dental disease: higher rates of periodontal disease and tooth loss.