Diabetes Mellitus and HIV

1. Diabetes Mellitus and HIV Medical Case Management Clinical Conference September 3 2010

2. Name that DM

3. Diabetes is due to problems with which hormone? • TSH • Leutinizing Hormone • Insulin • Growth Hormone • Follicle Stimulating Hormone

4. Sugar Response • Insulin is produced by islet cells in the pancreas in response to sugar levels in the blood • Insulin causes the blood glucose to go into the cells to be either stored or used for energy

5. Insulin Production

6. Insulin Activity

7. Diabetes Mellitus • Two types: • Insulin deficient • Insulin resistant

8. Diabetes Mellitus • Two types: • Insulin deficient

9. Diabetes Mellitus • Two types: • Insulin resistant

10. DM and HIV • Associations • ART • Hepatitis C • Acidosis • Kidney Problems • Peripheral Neuropathy • Ocular Problems

11. Which class of HIV drugs has been associated with causing a worsening of diabetes? • Nucleoside RT Inhibitors • Nucleotide RT Inhibitors • Non-Nucleoside RT Inhibitors • Integrase Inhibitors • Protease Inhibitors

12. The PIs increase blood glucose by: • Insulin deficiency alone • Insulin resistance alone • Insulin resistance and insulin deficiency • Increased secretion of glucose from the liver • Sugar in the tablets/capsules themselves

13. ART and DM • PIs cause apoptosis of insulin – producing cells AND • PIs cause cells to become insulin resistant • Pancreatitis • PIs cause increase of triglyceride (fat) levels • Along with stavudine (d4T), and efavirenz • Didanosine • Pentamidine (PCP medicine)

14. DM and HIV • Associations • ART • Hepatitis C • Acidosis • Kidney Problems • Peripheral Neuropathy • Ocular Problems

15. Name that DM

16. DM and HIV • Associations • ART • Hepatitis C • Acidosis • Kidney Problems • Peripheral Neuropathy • Ocular Problems

17. Which class of ART is associated with the production of lactic acidosis? • Nucleoside RT Inhibitors • Nucleotide RT Inhibitors • Non-Nucleoside RT Inhibitors • Integrase Inhibitors • Protease Inhibitors

18. The production of acid by the NRTIs is caused by: • toxicity to the mitochondria • toxicity to the DNA of the cells • toxicity to the RNA of the cells • blockage of release of base by the fat cells • blockage of secretion of acid from the kidney cells

19. Lactic Acidosis • In HIV: • Build-up of lactic acid due to toxicity to the mitochondria of the cells • Most commonly associated with d4T, ddI • In diabetes: • Diabetic ketoacidosis • Glucophage (metformin) F F F

20. Lactic Acidosis • In HIV: • Build-up of lactic acid due to toxicity to the mitochondria of the cells • Most commonly associated with d4T, ddI • In diabetes: • Diabetic ketoacidosis • Glucophage (metformin) Fat F F

21. Lactic Acidosis • In HIV: • Build-up of lactic acid due to toxicity to the mitochondria of the cells • Most commonly associated with d4T, ddI • In diabetes: • Diabetic ketoacidosis • Glucophage (metformin) Fat Fertile F

22. Lactic Acidosis • In HIV: • Build-up of lactic acid due to toxicity to the mitochondria of the cells • Most commonly associated with d4T, ddI • In diabetes: • Diabetic ketoacidosis • Glucophage (metformin) Fat Fertile Female

23. DM and HIV • Associations • ART • Hepatitis C • Acidosis • Kidney Problems • Peripheral Neuropathy • Ocular Problems

24. Medication used to treat HIV that has been associated with causing kidney problems: • Stavudine (d4T) • Tenofovir (TDF) • Emtricitabine (FTC) • Raltegravir (RTG) • Maraviroc (MRV)

25. HIV Medication-induced Tenofovir HIV-induced Focal Segmental Glomerulo-Sclerosis (FSGS) Screen by urine for protein Tx: ACE-Inhibitors and ARB; ART DM Sclerosing of the tubules of the kidneys Screen by looking for microalbumin in the urine Tx: ACE-I and ARB Renal Disease

26. Name that DM

27. DM and HIV • Associations • ART • Hepatitis C • Acidosis • Kidney Problems • Peripheral Neuropathy • Ocular Problems

28. Peripheral neuropathy is: • Numbness and tingling of the genitals • Numbness and tingling of the ears and nose • Numbness and tingling of the tongue and eyes • Numbness and tingling of the fingers and toes • Numbness and tingling of the corpus callosum and the hippocampus

29. Peripheral Neuropathy

30. Peripheral Neuropathy • Physical examination • depressed or absent ankle reflexes • impaired vibratory sensation • impaired pain sensation • impaired temperature sensation

31. Peripheral Neuropathy • Toxic neuropathies • “ d drugs” • didanosine (ddI): 13-34% • stavudine (d4T): 12-21% • zalcitabine (ddC): 12-46% • risk increased when neurotoxic agents used together • use of hydroxyurea potentiates

32. Effective Treatment: Lamotrigine (anticonvulsant) Gabapentin / pregabalin (neurontin/ lyrica) HAART Long-acting opiates L-carnitine – 2 studies without controls showed effect Ineffective treatment: Peptide T (entry inhibitor) Amitriptyline (depression) Acupuncture topical 5% lidocaine gel (per Lidoderm-HIV Neuropathy Group – 2004) Peripheral Neuropathy

33. DM and HIV • Associations • ART • Hepatitis C • Acidosis • Kidney Problems • Peripheral Neuropathy • Ocular Problems

34. HIV CMV retinitis Retinal detachment Bleeding to retina Diabetes Diabetic retinopathy Ocular Problems

35. Name That DM

36. Summation • Diabetes • Increased/worsened when patient takes PIs • Have to use metformin cautiously when on nRTIs because of the potential of acidosis • Causes renal, ocular, and nerve problems similar to those from HIV • Increased in patients with hepatitis C

37. In regards to today’s presentation, please choose which statement best reflects your viewpoint: • I learned nothing new • Christina is too silly and I was distracted • I knew most of the material • I learned a lot but see little use for the information • I learned a lot and will be able to use this information with my clients