'Prolonged ART use can trigger diabetes among HIV/AIDS patients'

NACO has no clear guidelines to manage the co-morbidity

Doctors have now found that HIV patients are at the risk of becoming diabetics with prolonged exposure to antiretroviral treatment (ART), and there are no clear guidelines as to how to manage diabetes among 24 lakh HIV patients (UNAIDS, 2009) in the country.

There is a greater need in high prevalence states like Karnataka, Tamil Nadu and Andhra Pradesh, to create awareness among endocrinologists and doctors in ART centres about the diabetes risk in HIV patients, said Dr Sanjay Kalra, endocrinologist, Bharti Hospital, Karnal, Haryana. Dr Kalra, along with a group of doctors from India and Sri Lanka, is in the process of formulating the HIV and diabetes guidelines for South Asia, which will be ready by early 2011.

Talking on the sidelines of the 4th National Insulin Summit held at Puducherry recently, Dr Kalra pointed out that the rate of HIV patients developing diabetes was higher in India as the prevalence of diabetes was higher in the background population. Apart from this, HIV/AIDS patients presented with metabolic disorders, which is an adverse effect of ART medicines. With nearly 50 per cent of diabetes cases going undetected in the country, the numbers would roughly be the same even among HIV patients coming for ART.

“During ART, the medicines play the role of restoring the immune system. However, the sudden surge in immunity can nearly lead to diabetes,” said Dr Kalra, who has had about 8-10 HIV patients coming with complications due to diabetes.

Three categories

HIV patients could be segregated in three categories –– diabetic patients with HIV; patients diagnosed with HIV and diabetes simultaneously; and those who develop diabetes after HIV contraction.

Among these patients too, those at high risk are men, those with HIV for a long time, low CD4 count, high viral load and obesity. Complications that could arise if diabetes among such patients is not managed include diarrhoea, hepatitis and neuropathy.

Management guidelines

While the National AIDS Control Organisation (NACO) had excellent guidelines in management of HIV/AIDS, it did not clearly prescribe how to go about treating diabetes among these patients. It also does not clearly mention what drugs to prescribe for HIV/AIDS patients with diabetes.

“NACO guidelines were made to tackle acute effects of HIV. Now, HIV has become a chronic disease and there is a need to tackle it accordingly,” Dr Kalra said. He added that the present guidelines did not ask doctors to check the history of diabetic HIV patients, no blood glucose tests, etc. In addition to this, the course of treatment was prescribed only for patients on second line of ART with the NACO recognising the risk of diabetes among these patients. However, with studies indicating that diabetes can be contracted in first line too, there is now a need to revise the guidelines.

Since people living with HIV were already on a lot of medication, Dr Kalra suggested that insulin in appropriate doses would help the diabetic patient. However, treatment had to be individualised as each patient’s metabolic levels varied.

An alternative to the daily prick

Diabetics, who have to endure the daily prick for their dose of insulin, will have some respite if all goes well with the ‘Monday-Wednesday-Friday insulin’.

Degludec or Monday-Wednesday-Friday insulin, which is currently under two-year follow up after completing phase 3 clinical trial, is predicted to hit the market by 2012. The weekly thrice insulin will see diabetics through the weekends, revealed Dr P V Rao, Professor of endocrinology, Nizam’s Institute of Medical Sciences, Hyderabad, and one of the authors of a paper on degludec that will be published in the medical journal, Lancet, soon.

Elaborating on degludec, Dr Rao said it was a new injectable insulin preparation, which was effective for more than 24 hours. Hence, if a person took insulin on Monday, Wednesday and Friday, the cumulative effect of the insulin will last over weekends. “It’s a great concept. The clinical trials that were held across the world are over, but we need to conduct a two-year follow-up on these patients before the Drug Controller General India gives its approval,” he said.

While there are more than 10,000 patients being administered degludec in around 20 hospitals across the globe, there are only about 100 on this new insulin formulation in India.

So, how does the insulin last for more than a day? “The molecules in the insulin do not get released into the blood directly. The multiple insulin molecules are connected in a complex manner and therefore take time to break into single molecules,” explained Dr Rao.

He added that it would take about 96 hours for the entire complex structure of insulin to get exhausted in the body. “It’s like an insulin reservoir, which will continuously supply insulin in the body,” he said.