Assessment and Prevention of Diabetes
Clinicians should assess for risk factors for type 2 diabetes in HIV-infected patients at baseline and annually (see Table 1 below).
Clinicians should emphasize appropriate diet, weight control, and exercise as methods to avoid the development of type 2 diabetes.
Clinicians should assess fasting blood glucose before initiating highly active antiretroviral therapy (HAART), 3 to 6 months after initiation, and at least annually thereafter.
Clinicians should administer 75 g of oral glucose (2-hour glucose tolerance test) to distinguish between impaired glucose tolerance (glucose level ≥140 mg/dL 2 hours after oral glucose) and diabetes (glucose level ≥200 mg/dL after oral glucose) in patients with repeated borderline fasting glucose values.
Table 1: Risk Factors for Type 2 Diabetes in HIV-infected Patients*
- PI use
- Severe body fat changes
- Hepatitis C infection
- Age ≥45 years
- Overweight (BMI ≥25 kg/m²)
- Habitual physical inactivity
- First-degree relative with diabetes
- Specific racial or ethnic groups
- African American
- Latino
- Native American
- Asian American
- Pacific Islander
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- Previously identified glucose metabolism disturbance (e.g., IGT or IFG on previous testing)
- History of vascular disease
- Blood pressure ≥140/90 mmHg
- High-density lipoprotein cholesterol (HDL-C) ˂35 mg/dL
- Triglycerides >250 mg/dL
- History of gestational diabetes or delivery of infant >9 lbs
- Polycystic ovary syndrome or acanthosis nigricans
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IFG, impaired fasting glucose; IGT, impaired glucose tolerance; PI, protease inhibitor
*Except for HIV-related risk factors (i.e., PI use, severe body fat changes, and hepatitis C), the information provided is based on criteria established by the American Diabetes Association for diabetes testing in asymptomatic non-HIV-infected adults.
Key Point:
If fasting blood glucose tests are not feasible, random blood glucose values may be used as an alternative screening method. Patients with random glucose consistently <100 mg/dL do not require follow-up testing. A random glucose >140 mg/dL should prompt use of a standardized diagnostic test, such as a glucose tolerance test. A random plasma glucose ≥200 mg/dL, either repeated on a subsequent day or in the presence of unequivocal symptoms of hyperglycemia (e.g., serum glucose >400 mg/dL, lactic acidosis, small to moderate amounts of ketones, serum pH of <7.3, bicarbonate of <15 mEq/L, anion gap >12), meets the threshold for the diagnosis of diabetes.
Prevention of Diabetes Disease Progression
Clinicians who lack experience in treating diabetic patients should refer patients for evaluation by clinicians experienced in managing diabetes.
When possible, clinicians should prescribe alternatives to a protease inhibitor-based HAART regimen in patients with preexisting glucose intolerance or diabetes.
Clinicians should recommend life-style interventions, including diet, exercise, weight management, and smoking cessation, for HIV-infected patients with glucose intolerance or diabetes.
When possible, HIV-infected patients with diabetes should develop and maintain a nutrition plan with a qualified nutrition counselor.
Clinicians should refer diabetic patients who are not responsive to medical intervention or who have symptoms and signs of worsening diabetes to an endocrinologist.
For additional information regarding the management of diabetes in the setting of antiretroviral (ARV) therapy, see the National Guideline Clearinghouse summary of the New York State Department of Health guideline, Long-Term Complications of Antiretroviral Therapy.
