Clinical Manual for Management of the HIV-Infected ... - myCME.com

Insulin Resistance and Hyperglycemia
on Antiretroviral Therapy
Background
Patients taking antiretroviral therapy (ART),
particularly certain regimens containing a protease
inhibitor (PI), appear to have an increased risk of
hyperglycemia and diabetes mellitus. Hyperglycemia
with or without diabetes has been reported in 3-17% of
patients and has occurred at a median of about 60 days,
with a range of 2 days to more than a year, after starting
therapy. Disorders of glucose metabolism may present as
the following:
♦
♦
♦
♦
Insulin resistance, in which higher concentrations
of insulin are required to exert normal effects; blood
glucose levels may be normal but fasting insulin
levels will be high because of compensatory insulin
secretion by the pancreas
Impaired glucose tolerance (ie, a glucose level of
140-199 mg/dL 2 hours after a 75-g oral glucose
load)
Impaired fasting glucose (ie, 110-125 mg/dL)
Diabetes mellitus, which is diagnosed when the
fasting blood sugar is >126 mg/dL, or the confirmed
2-hour glucose level is >200 mg/dL during glucose
tolerance testing
The incidence of new-onset hyperglycemia in HIVinfected
patients taking ART has been reported as
about 5%, on average. Even if fasting glucose levels
remain normal in patients taking ART, up to 40% of
those on a PI-containing regimen will show impaired
glucose tolerance. The etiology of insulin resistance and
hyperglycemia in HIV-infected patients is probably
multifactorial, with varying contributions from
traditional risk factors (eg, obesity, family history),
comorbid conditions (eg, hepatitis C virus infection),
and antiretroviral-related factors (eg, direct effects of
PIs, hepatic steatosis, and fat redistribution).
Patients who have preexisting diabetes must be
monitored closely when starting ART; some experts
would consider a PI-sparing regimen for these patients.
Alternatively, PIs with favorable metabolic profiles (eg,
atazanavir) may be preferred for such patients. Those
with no history of diabetes should be advised about the
warning signs of hyperglycemia (polydipsia, polyuria,
and polyphagia) and the need to use diet and exercise to
maintain an ideal body weight.
Section 4—Complications of Antiretroviral Therapy | 4–13
S: Subjective
The patient is about to begin ART, has been on an
antiretroviral (ARV) regimen that includes a PI, or
is overweight, has central fat accumulation, or has
lipoatrophy. Although most patients with hyperglycemia
are asymptomatic, some may report polydipsia, polyuria,
and polyphagia.
History
Include the following in the patient’s history:
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
♦
Fat redistribution on ART (see chapter
Abnormalities of Body Fat Distribution)
Family history of diabetes
Obesity, or habitual physical inactivity
Racial or ethnic heritages at higher risk: African,
Hispanic, Native American, Asian-Pacific Islander
Hypertension
History of low level of high-density lipoprotein
History of elevated triglycerides
Gestational diabetes or delivery of infant weighing
>9 lbs
Current pregnancy
Hepatitis C virus coinfection
Polycystic ovary syndrome
O: Objective
Review previous or baseline blood glucose levels.
Document weight and any weight changes or fat
redistribution.
A: Assessment
Determine whether the patient has normal blood
glucose, impaired fasting glucose, or diabetes (see
laboratory recommendations and definitions below).