AACTG recommendations for metabolic problems

Guide covers insulin resistance and diabetes

The Adult AIDS Clinical Trials Group (AACTG) has responded to research showing a link between HIV antiretroviral treatment and metabolic disorders with guidelines that offer recommendations for assessing, monitoring, and treating the problem.

According to the AACTG guides, up to 40% of HIV patients on a protease inhibitor (PI)-containing regimen will have impaired glucose tolerance caused by significant insulin resistance, which can lead to increased risk of cardiovascular complications. Here’s a brief look at the guidelines, which were published Aug. 13, 2002:

• Clinicians should assess HIV patients’ fasting glucose before and during PI treatment, at intervals of three to six weeks after initiating therapy, and annually after that.

• All HIV patients should be educated about following a healthy, balanced diet with regular exercise as a way to prevent diabetes mellitus, and clinicians should recommend weight loss to patients who are obese and at a higher risk of developing diabetes.

• HIV patients who need diabetes drug therapy might first be prescribed metformin or thiazolidinedione, while oral sulfonylureas, meglitinides, and insulin may be appropriate for patients who have severe fasting hyperglycemia.

• Clinicians also might consider not starting HIV patients on a PI therapy in cases where patients have pre-existing abnormalities of glucose metabolism or diabetes risk factors.

• Patients should be carefully monitored for potential adverse effects, including hepatic dysfunction and lactic acidemia, both of which may be caused by the diabetes drugs. Likewise, liver enzymes need to be monitored every two months for the first year of thiazolidinedione treatment.

• HIV clinicians should perform a fasting lipid profile prior to starting antiretroviral therapy, including an assessment of total cholesterol, HDL cholesterol, triglycerides, and a calculated LDL cholesterol. Every three months after starting a new antiretroviral regimen, clinicians should repeat this fasting lipid profile, and if the results are normal, then the profile should be assessed annually.

• When considering interventions for dyslipidemia, clinicians should evaluate and intervene for hypogonadism, hypothyroidism, liver disease, and alcohol abuse.

• It’s also advisable to perform a complete cardiovascular risk assessment and to encourage patients to make lifestyle changes, including stopping smoking, adhering to a lipid-lowering diet, and engaging in regular aerobic exercise.

• When an HIV patient is at significant risk for cardiovascular disease, a clinician might consider substituting a non-PI-containing regimen and/or using a lipid-lowering drug.