| Insulin resistance, asymptomatic hyperglycemia, DMa |
Thymidine analogue NRTIs (d4T, ddI, ZDV)
Some PIs (IDV, LPV/r; perhaps less often ATV, ATV/r, DRV/r, TPV/r) |
Onset:
Weeks to months after beginning therapy; median of 60 days (adult data)
Presentation:
Most commonly:
Asymptomatic fasting hyperglycemia (possibly in the setting of lipodystrophy), metabolic syndrome, or growth delay
Also possible:
Frank DM (polyuria, polydipsia, polyphagia, fatigue, hyperglycemia)
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Impaired fasting glucose:
ARV-treated adults: 3%–25%
ARV-treated children:
0%–7%
Impaired glucose tolerance:
ARV-treated adults: 16%–35%
ARV-treated children:
3%–4%
DM:
ARV-treated adults: 0.6–4.7 per 100 person-years (2- to 4-fold greater than that for HIV-uninfected adults)
ARV-treated children:
Very rare in HIV-infected children
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Risk factors for Type 2 DM:
Lipodystrophy
Metabolic syndrome
Family history of DM
High BMI
Obesity
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Prevention:
Lifestyle modification (see Management ).
Although uncertain, avoiding use of d4T, IDV may reduce risk.
Monitoring:
Monitor for polydipsia, polyuria, polyphagia, change in body habitus, acanthosis nigricans.
Obtain RPG levels at:
Initiation of ARV therapy;
3–6 months after therapy initiation; and once a year thereafter.
For RPG ≥140 mg/dL, obtain FPG performed after 8-hour fast and consider referral to endocrinologist.
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Counsel on lifestyle modification (low-fat diet, exercise, no smoking).
Consider changing from thymidine analogue NRTI (d4T or ZDV)-containing regimen.
For either RPG ≥200 mg/dL plus symptoms of DM or FPG ≥126 mg/dL:
Patient meets diagnostic criteria for DM; consult endocrinologist.
FPG 100–125 mg/dL:
Impaired FPG is suggestive of insulin resistance; consult endocrinologist.
FPG <100 mg/dL: Normal FPG but does not exclude insulin resistance; recheck FPG in 6–12 months.
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