Patients with HIV are more likely to have diabetes. And like any high-risk group, HIV patients need special attention.
“Persistent inflammation appears to be a driver for diabetes and cardiovascular disease in people living with HIV,” said Phyllis Tien, MD, Professor of Medicine and Clinical Pharmacy at the University of California, San Francisco. “Even when the virus is successfully suppressed, there is residual inflammation that can play a role in other inflammatory conditions.”
Dr. Tien opened Saturday morning’s symposium HIV and Diabetes—The Double Whammy. The session’s speakers reviewed the inflammatory and metabolic changes in HIV patients that can favor diabetes. They also discussed how some of the agents used to treat HIV can also affect metabolism, and how HIV patients are living longer and developing more chronic comorbidities.
“HIV, like diabetes, is now a chronic disease,” said Priscilla Hsue, MD, Professor of Medicine at the University of California, San Francisco. “As the HIV population ages, the prevalence of cardiovascular disease will continue to increase.”
European guidelines recommend statin therapy for all HIV patients. European guidelines also acknowledge that cardiovascular disease risk calculators perform poorly in HIV patients, particularly in the intermediate and high-risk groups.
“U.S. guidelines fail to recognize the cardiovascular risk conferred by HIV,” Dr. Hsue said.
One of the first diabetes-related changes noted in HIV patients in the 1980s was the distribution of adipose tissue. HIV patients tend to lose adipose tissue in the hips and legs and gain fat in the upper torso.
The concern is overblown, but not entirely misplaced, said Carl Grunfeld, MD, PhD, Professor of Medicine at the University of California, San Francisco. Much of the shift in adiposity is the result of successful treatment, he said.
“Don’t just look at the belly,” Dr. Grunfeld advised. “Look at the difference between upper trunk fat and fat in the legs and buttocks. Those are the problem patients.”
The ADA has long recommended that all HIV-infected individuals be screened for diabetes before starting antiretroviral therapy, and also four to six weeks after therapy begins and every six to 12 months thereafter.
“I would do a fasting plasma glucose before antiretroviral therapy and then annually,” said Todd T. Brown, MD, PhD, Professor of Endocrinology, Diabetes and Metabolism at The Johns Hopkins Bloomberg School of Public Health. “Every six months is probably overkill.”
Lifestyle changes are particularly helpful in HIV patients and metformin remains the first-line treatment, Dr. Brown said. The most important caveat is an interaction with dolutegravir, which can increase circulating levels of metformin. Patients taking dolutegravir should take no more than 1,000 mg metformin daily.
The overall diabetes management strategy is familiar: antiplatelet therapy, blood pressure management, cholesterol management, glucose management, and smoking cessation. The biggest difference is statin use.
Simvastatin and lovastatin are contraindicated in HIV. Atorvastatin and rosuvastatin are the most commonly used statins in HIV, but Dr. Brown advised starting low and titrating up to minimize interactions.
“Follow diabetes management guidelines for the general population, but watch for interactions between dolutegravir and metformin, which are quite common,” he advised.