Treatment Overview

Prevention

  1. People with either impaired glucose tolerance (IGT) or impaired fasting glucose (IFG) are at increased risk of cardiovascular disease, and increased risk of developing diabetes.1

In patients with pre-existing abnormalities of glucose homeostasis, or with first-degree relatives with diabetes mellitus, IAS guidelines from 2002 suggest that consideration should be given to avoiding use of certain PI-based regimens as initial therapy.3 However more recent guidelines do not provide specific recommendations on the selection of first antiretroviral regimens in patients at high risk of developing diabetes.

Assessments

Find out about assessments recommended at diabetes diagnosis and regular follow-up visits.

  • EACS recommend that people living with HIV diagnosed with diabetes should receive a consultation with a specialist in diabetology2

Treatment goals

EACS2 recommend that the treatment goals for diabetes in people living with HIV are:

  • glucose control (HbA1c <6.5–7.0% without hypoglycemia; fasting plasma glucose 4–6 mmol/L [73–110 mg/dL])
  • normal blood lipids:
    • optimal, total cholesterol ≤4mmol/L = [155mg/dL], low density lipoprotein cholesterol = ≤2mmol/L = [80mg/dL]
    • standard, total cholesterol ≤5mmol/L = [190mg/dL], low density lipoprotein cholesterol = ≤3mmol/L = [115mg/dL]
       
  • blood pressure < 130/80 mmHg
     

In their recommendations for the general population, ADA suggests that older adults who are functional and cognitively intact should receive diabetes care using the same goals as younger adults.

Interventions for treatment of diabetes

Patients with HIV disease and diabetes require individualized medical and nutritional therapy and exercise counseling to improve glycogenic control and reduce cardiometabolic risk.4

  • Oral anti-diabetic agents may be tried if lifestyle measures do not provide sufficient glucose control
    • drug-drug interactions and potential adverse effects should be considered
    • some guidelines recommend that metformin should be avoided in lipoatrophic patients,5 as it may worsen this condition2
    • other oral hypoglycemic agents should be used with caution;5 there are currently limited data on these drugs in HIV-infected patients2,5
      • there is some evidence that thiazolidinediones improve insulin sensitivity in HIV-1-infected patients with insulin resistance and lipodystrophy;3  however the clinical use of pioglitazone is questioned due to its side effects3
         
  • It has been suggested that although it may be unwise to discontinue efficacious antiretroviral agents because of hyperglycemia,4 substituting certain antiretrovirals with alternatives may be considered and has been associated with short-term improvements in insulin resistance3
    • the relative risks and benefits of switching antiretroviral agents compared with initiation of lipid-lowering or insulin-sensitizing treatment are currently unknown
       

Figure 1. Interventions for the treatment of diabetes

i. Very limited data for incretins (e.g. liraglutide, saxagliptine, sitagliptine, vildagliptine) and exenatide in HIV patients; no clinically significant drug-drug interaction expected; clinical use of pioglitazone questioned by its side effects.

Reproduced with permission from the European AIDS Clinical Society Guidelines Version 6.0.



Download further information on treatment considerations in diabetic patients living with HIV.

Further details on diabetes management and interventions are available from the IDF and from the ADA. Treatment considerations for patients with diabetes and other comorbidities, such as hypertension and dyslipidaemia, are summarized in guidelines from the American Association of Clinical Endocrinologists (2007). 




References

  1. American Diabetes Association. Standards of Medical Care in Diabetes 2011. Diabetes Care. 2011;34;Suppl 1: S11–S61.  
  2. European AIDS Clinical Society (EACS). Guidelines. Version 6.0. Accessed 3 July 2012. 
  3. Schambelan M, Benson C, Carr A, et al. Management of metabolic complications associated with antiretroviral therapy for HIV-1 infection: Recommendations of an International AIDS Society USA Panel. J Acquir Immune Defic Syndr. 2002;31:257–275.  
  4. Mullen MP and Caplivski D. HIV and comorbidities: A case based approach to diagnosis and management. Oxford American Infectious Disease Library. Oxford University Press 2008.
  5. Gazzard BG on behalf of the BHIVA Treatment Guidelines Writing Group. British HIV Association Guidelines for the Treatment of HIV-1-Infected Adults with Antiretroviral Therapy 2008. HIV Medicine. 2008;9:563–608.