Diabetes mellitus or high blood sugar (glucose) occurs in two forms: type 1 and type 2. Type 1 typically occurs at younger ages and almost always needs insulin injections to control. Type 2 is more common in older persons and usually can be controlled with less aggressive treatment. While there is some variability in research reports, most data show that there is an increase in the frequency of DM in older adults with HIV. For example, one study found that there was a 10% increase in the rate of diabetes in older adults with HIV and a 6% increase in the comparison group (no HIV). More extensive studies that follow large populations over many years find similar increases. These findings have caused physicians managing older adults with HIV to monitor and identify diabetes and treat it to avoid the serious side effects that can occur.
WHAT HAPPENS WHEN DIABETES IS NOT TREATED?
Both forms of diabetes are the result of inadequate amounts of active insulin in the blood stream that normally would control the amount of sugar in our bodies. An excess of sugar can result in various complications in blood vessels. This can cause damage in the eyes, heart, kidneys and feet. The person with HIV experiences the same risk factors that everyone else encounters. Those risk factors are older age, obesity, and maybe genetics. However, for the older person with HIV who has been impacted by the chronic inflammation associated with HIV for many years, together with periods of lower CD4 counts, and possibly the presence of concurrent hepatitis C virus, there is likely an increase in risk for diabetes and its complications. And for those who were treated with the older ART drugs they may have an increased risk for diabetes. These included certain “nukes” and protease inhibitors, most of which are no longer used.
ASK IF YOU SHOULD BE TESTED FOR DIABETES
Besides a history of weight change, frequent urination because of sugar in the urine, and other symptoms, there are two screening blood tests that can be used. The easiest, because it does not require fasting from foods before the test, is the glycated hemoglobin (HbA1c). A value of 6.5% or higher is suggestive of diabetes. But HIV patients may need a more sensitive test that requires fasting before blood sugar levels are assessed. A value of 126 or higher suggests a problem. It is recommended that these tests be done before starting ART and at regular intervals afterwards after therapy is started.
FOLLOW TREATMENT STRATEGIES: MEDICATIONS and LIFE STYLE CHANGES
The general recommendations of the American Diabetes Association should be followed for older persons with HIV and diabetes. Changes in life style are often needed. This should include the needed education and support about diet and exercise. Weight loss for those with obesity can have a major positive effect. Increased physical activity including exercise is a prescription for better health for those with diabetes, and for all. If one of the ART medications is adversely affecting the blood sugar, it should be changed.
The guidelines for diabetes medications should be followed (American Diabetes Foundation http://www.diabetes.org/). A common medication that is used to begin diabetes treatment is metformin, unless there is a kidney problem. HbA1c is monitored to determine if treatments are working, if this does not occur there are several other oral medications that can be used successfully. However, if the patient has numerous other comorbidities and is showing signs of being “frail” it is likely better to avoid polypharmacy issues. It will be very important to check for possible diabetes complications that occur with other comorbidities. This will require coordination among all doctors. Successful management of diabetes should be possible.
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