Increased blood-sugar levels and risk of type-2 diabetes

Glucose and insulin
Type 2 diabetes
Risk of long-term health problems
What can help
Symptoms, risk factors & tests

More about lipodystrophy:

Associated drugs: some protease inhibitors and some nukes

Glucose and insulin

Glucose is type of sugar and your body relies on glucose to provide energy. A hormone called insulin processes the sugar and allows it to enter cells.

Insulin also regulates production of new glucose by the liver, levels of glucose in the blood, and metabolic aspects of fat cells.

Insulin resistance is the term for when this system fails to work properly. Although your body produces more insulin to compensate, if insulin resistance continues, and sugar levels remain high, you can develop diabetes.

Insulin levels are difficult to measure, but glucose levels, usually checked by fasting or non-fasting blood tests, are routinely used for monitoring risk.

Type 2 diabetes

Type-2 diabetes is a adult illness that develops slowly. It can take years or decades for mild insulin resistance to progress to diabetes, but the impact on the risk of heart disease is serious. Some protease inhibitors can increase glucose levels and the risk of Type-2 diabetes.

Type-2 diabetes is different from Type-1, which is a childhood illness caused by low insulin production, and which is managed by insulin injections.

Risk of long-term health problems

High untreated blood-sugar is related to many long-term health problems including the kidneys, nerves, eyes and vision, risk of heart disease and stroke, erectile dysfunction in men and pregnancy complications in women.

Diabetes increases the risk of having a heart attack as much as smoking.

Fat and sugar metabolism are also closely linked and insulin resistance is a complication of HIV therapy that is gets little recognition. It is directly related to some protease inhibitors and possibly indirectly related to nukes through their effect on fat distribution. Changes in blood glucose levels and insulin sensitivity are closely related to other symptoms of lipodystrophy.

What can help

As with HIV-negative people mild insulin resistance can be managed by diet, exercise and stopping smoking. Switching HIV drugs associated with increases in blood-glucose is recommended when appropriate.

Dietary advice involves reducing processed sugars, refined and fast foods, white flour and potatoes as they cause quick sugar ‘highs’. More complex carbohydrates like wholemeal bread and wholemeal and al-dente pasta, porridge and most vegetables provide energy more slowly with less impact on sugar levels.

Metformin may help people with insulin resistance and fat accumulation. Rosiglitazone or pioglitazone may help people with insulin resistance and fat loss. The possibility of interactions with other HIV drugs (PIs and NNRTIs) means that they should also be used with caution, and perhaps with drug-level monitoring (TDM).

Symptoms of high blood-sugar, and diabetes

Feeling thirsty or excessively hungry
Feeling tired
Low concentration
Blurred vision
Unexplained weight loss
Frequent need to urinate
Slow healing of cuts
Tingling in hands or feet (neuropathy)
Nausea and vomiting

Risk factors for abnormal glucose

Liver damage or coinfection with hepatitis C
Family history of diabetes
Overweight (BMI>30)
Lipodystrophy or lipoatrophy
Low exercise
Age over 40
High blood pressure (over 130/85 but this depends on age and other risk for heart disease)
High cholesterol and triglycerides (over 1.7 mmol/L) and low HDL (good) cholesterol (less than 0.9 mmol/L)
History of insulin resistance or high glucose
Other meds, including niacin, glucocorticoids, megestrol and Growth Hormone and some PIs

Tests to diagnose and monitor

Fasting glucose test - measures blood sugar after an 8-hour fast. This should be measured before starting and after switching treatment, and at least anually after this.

Fasting levels over 5.6 mmol/L in plasma indicate insulin resistance, and need follow-up an oral glucose tolerance test (OGTT).

Random glucose test - Unfasted glucose levels are less accurate but are taken shortly after someone has had something to eat or drink. If it is greater than 5.17 mmol/L other tests are run. Diabetes is over 11.1 mmol/L.

Oral glucose tolerance test (OGTT) - Monitors levels of glucose every 30-60 minutes for two hours after fasting for 8-hours and then drinking a measured glucose drink. Healthy glucose on this test should be less than 3.62 mmol/L. If it is greater than 5.17 mmol/L other tests are run. Diabetes is over 11.1 mmol/L.

Haemoglobin A1c - tests how much glucose adheres to red blood cells. It is used to determine average glucose levels over several months. Normal range for someone without diabetes is 4-6% and managed treatment for someone with diabetes should aim to keep this under 7%.

Fasting insulin test - and results used to calculate HOMA-IR score. Measuring glucose is generally preferred to measuring insulin directly.

Insulin tolerance test (also called glycemic clamp) - where insulin in infused by intravenous line, and glucose given until normal blood sugar levels are reached. This is expensive and again is rarely used.

For further information see the European (EACS) metabolic guidelines:
The European AIDS Clinical Society
http://www.eacs.eu