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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.

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:

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