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

4–14 | Clinical Manual for Management of the HIV-Infected Adult/2006
P: Plan
Laboratory
Most experts (eg, the International AIDS Society-
USA) recommend monitoring routine fasting blood
glucose levels at baseline and 3-6 months after starting
therapy if baseline results are normal. Some recommend
2-hour postprandial measurements or a 75-g oral
glucose tolerance test within the first 3-4 months
of starting therapy and every 3-4 months thereafter.
Monitoring should be more frequent if abnormalities
are detected, or any additional risk factors exist, as
noted earlier. Patients with these risk factors must be
counseled about prevention of hyperglycemia before
starting ART.
Treatment
Patients with insulin resistance
For patients with insulin resistance (impaired glucose
tolerance) and normal blood glucose levels, current
evidence is inadequate to recommend drug treatment.
However, lifestyle modifications can be recommended,
including exercise, weight loss, and diet changes.
Weight loss is strongly recommended if the patient
is overweight. Refer the patient to a dietitian. Some
studies of insulin resistance in HIV-infected individuals
are under way, and patients with access to clinical trials
may be interested in these studies.
Patients with hyperglycemia and insulin resistance
require treatment. A trial of lifestyle modifications may
be attempted, including weight loss (if indicated), diet
changes, and exercise. When drug treatment is required,
because patients meet the diagnosis of diabetes and
lifestyle changes are not adequate, the insulin sensitizers
metformin or thiazolidinediones (pioglitazone or
rosiglitazone) should be considered. Oral antidiabetic
agents may increase the risk of hepatic and renal
abnormalities, so patients should be monitored for
hepatic toxicity (thiazolidinediones) and lactic acidosis
(metformin). Thiazolidinediones should be avoided
in patients with significant liver disease. Patients with
elevated serum creatinine (>1.5 mg/dL in men or >1.4
mg/dL in women), hepatic impairment, or metabolic
acidosis should not take metformin. In some cases,
insulin may be the safest drug therapy for symptomatic
hyperglycemia, although episodes of hypoglycemia
are much more common with insulin than with most
oral agents. For hyperglycemia that is associated with
the use of PIs, switching to an alternative agent (eg,
a nonnucleoside reverse transcriptase inhibitor or a
different PI) may be effective if the HIV treatment
history and resistance profile permit.
Patients with diabetes
Treatment should be instituted to control blood sugar
and to modify other cardiovascular risk factors, with the
aim of preventing heart disease and other end-organ
disease.
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Control glucose: maintain the glycosylated
hemoglobin (HbA1c) level at