VOLUME 9 NUMBER 3 • SEPTEMBER 2012
113
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
a good understanding of their diabetes as well as all the other
problems encountered in the metabolic syndrome.
General measures: modify risk factors such as hypertension
•
and dyslipidaemia. Check blood pressure quarterly and do
an annual lipid profile. Self monitoring of sugar levels where
possible. Advise patient to be careful with the sharps they’re
using. Check HbA
1
c
level two to four times per annum. Aim to
keep HbA
1
c
< 7%.
Annual eye examination by an ophthalmologist or optometrist.
Foot care: refer to a podiatrist when necessary. Patients with
diabetes and HIV may be prone to peripheral neuropathy.
This may be compounded by TB treatment and antiretroviral
therapy.
Screen for diabetic nephropathy. These patients may also have
HIV-associated nephropathy.
Lifestyle modification: dietary modification. Refer patients to a
•
dietician to provide adequate nutritional support and dietary
education. Exercise and weight loss (in the patient with a raised
body mass index) have positive effects on metabolic parameters
in HIV-positive patients. It may improve blood pressure and lipid
profile and increase insulin sensitivity. Cessation of smoking as
this is a major risk factor for cardiovascular disease.
7,10,11
Drug management of diabetes mellitus
The aim of treatment is to reduce mortality and morbidity of
diabetes-related complications.
What are the indications for a lipid-lowering agent? The use of
statins should be universal in diabetics. Consider drug interactions
with antiretroviral therapy, particularly protease inhibitors. Fibrates
are the agents of choice with hypertrigyceridaemia and have some
effect against hypercholesterolaemia. They are safe to use with
protease inhibitors. Many statins have significant drug interactions
with protease inhibitors, leading to elevated levels of statins,
resulting in potential toxicity. Pravastatin and low-dose atorvostatin
are safe to use with protease inhibitors.
Other important medications include ACE inhibitors or
angiotensin receptor blockers (ARBs) which are renoprotective,
aspirin
10,12,13
and oral hypoglycaemic agents, such as biguanides,
thiazolidediones and insulin secretagogues.
Biguanides: Metformin improves insulin resistance or glucose
intolerance. There is a possible risk of lactic acidosis, but it is not
contra-indicated in patients on antiretroviral therapy. Patients
receiving nucleotide reverse transcriptase inhibitor (NRTI) therapy
for longer than six months are usually at higher risk for lactic
acidaemia. Stavudine, zidovudine and didanosine are the drugs
most commonly associated with raised lactate levels. Check renal
function first. Educate patients about symptoms of lactic acidosis.
Thiazolidediones increase insulin sensitivity and reduce insulin
resistance. Do liver function tests (LFTs) before using pioglitazone
or rosiglitazone. Avoid these drugs if LFTs are impaired: > 2.5 upper
limit of normal.
Insulin secretagogues such as sulphonylureas may not be
effective in severe insulin resistance.
Change to subcutaneous insulin therapy if diabetes remains
uncontrolled. Insulin does not have any drug interactions with
antiretroviral therapy or other drugs and it is not contra-indicated
in hepatic or renal dysfunction. Insulin is always the safe option if
there is any doubt.
3,4
Type 1 diabetes is usuallymore difficult tomanagewith or without
HIV. Most of these patients are adolescents. Various issues need
to be addressed. These patients need more extensive counselling,
support and the involvement of caregivers. Compliance, substance
abuse and sexual issues are some of the points that need to be
addressed. A multidisciplinary approach is important where the
social worker, caregiver, teachers at school, doctors and many
others need to be involved.
10,14
Conclusion
HIV and diabetes are chronic diseases which significantly impact
on a patient’s lifestyle and wellbeing. It can be overwhelming to
deal with. One has to understand the glucose disturbances that can
occur with antiretroviral therapy, screen patients appropriately for
impaired glucose tolerance and diabetes, altering HIV therapy when
necessary, and take into account all other metabolic disturbances
associated with antiretroviral therapy, which put patients at high
risk of cardiac disease. These modifiable cardiovascular risk factors
will have a significant impact on healthcare and patients in the near
future.
14-16
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