Wierzbicki is a lipid and cardiovascular risk specialist at St
Thomas’s Hospital in London.
He expects to see a lot more type 2 diabetes in people with HIV in the future.
people had AIDS-defining illnesses they lost a lot of weight, which protected
them. But we’re now seeing increasing levels of diabetes. We see ddI-induced
pancreatitis like George’s and d4T-caused insulin resistance, but anyone with
VAT is pushed up the diabetes risk scale.”
form of diabetes treatment is prevention. “You can reduce your risk of type 2 diabetes
by two-thirds if you work on being fit and not being overweight, and 50% of
people with early diabetes can reverse it back to a pre-diabetic stage.13,14
Smoking contributes to insulin resistance,15 so give that up.
Dietary trials have usually been about reducing saturated fat, but the modern
diet problem is now too much sugar rather than too much fat.
however there is a point of no return after which type 2 diabetes will continue
to progress. After this point we can use drugs to control glucose levels. These
can help control the condition for decades before we have to start using insulin.
drugs either reduce the amount of glucose released into the blood (e.g.
metformin), boost insulin production (e.g. gliclazide) or make body cells more
sensitive to insulin (e.g. rosiglitazone).16
is the number one strategy for management. Unfortunately it also causes both
diarrhoea and constipation.17 It also induces fat loss, so if you
have lipoatrophy it could make that look worse.”
second-line therapies are the sulphonylurea drugs like gliclazide. These boost
insulin production but can cause weight gain and hypoglycaemia (‘hypos’, a
condition familiar to insulin users, in which blood sugar falls drastically,
causing fatigue, anxiety and eventually coma).
Wierzbicki says, “Both metformin and sulphonylureas have long-term evidence of
drugs are the thiazolidinedione (TZD) or ‘glitazone’ drugs, which induce the
sluggish cells to be more sensitive to insulin. However they may be associated
with weight gain, fluid retention, possibly heart disease, and fractures.19
are a few new classes. One class is the DPP-4 antagonists which also increase
insulin production.20 The first one, sitagliptin, was licensed in
2007.21 They reduce blood glucose in diabetics but only a handful of
people with HIV have tried them. And there’s a new injectable agent called
exenatide,22 which amplifies the action of any remaining insulin you
have. Unfortunately it can also cause pancreatitis and I’ve seen ten cases of
it being tried in people with HIV.”
Wierzbicki comments, “It feels like the early days of awareness of increased
heart attack risk in people with HIV. Diabetes takes longer to develop, so
we’re only just beginning to recognise that diabetes may be a big problem in
the coming years.
slowly changing, but the average diabetologist knows nothing about HIV and I
think HIV doctors need better training to try and manage patients with
pre-diabetes in their units. We have a cardiovascular risk clinic in the HIV
clinic here now, as do some of the other large London clinics. With complex cases, however,
HIV clinicians will still have to know when to bail out and seek expert help.”