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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.

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 

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 diabetes is increasing in the general population. Now that they are no longer suffer from malnutrition and are on medications that exacerbate diabetes they develop diabetes.

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 metformin.

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:

Cardiovascular risk assessment

Control of hypertension to levels near 130/80

Smoking cessation

Checking cholesterol and getting the LDL to 100- 130 or lower, getting the ItDL to >35 and preferably to >55 o Aspirin

Monitoring renal function, serum creatinine and urine albumin (mg/dl) / urine creatinine (g/l). This ratio is done on a spot urine and should be less than 30. If> 30 do a 24-hour collection to quantify the amount of proteinuria. ACE inhibitors are proven to decrease the risk of progression to end stage renal disease in diabetics with microproteinuria (30 to 300mg/24 hours).

Examining the feet each visit detects diabetic calluses, ulcers, and neuropathy and prompts referral to foot care that prevents infection and amputation.

Annual exams by an ophthalmologist detect early retinal disease and vision may be saved by laser therapy.