Volume 1, Issue 2

 

Evaluating the Management of Diabetes Mellitus Type-2 in HIV-Infected Patients

August 2, 2010

BACKGROUND

  • Diabetes mellitus (DM) and impaired glucose tolerance in HIV-infected patients are common
  • Insulin resistance is an important cardiovascular disease risk factor in HIV-infected patients
  • Hemoglobin A1c (HbA1c) used to monitor glucose control 
  • Literature suggests HbA1c overestimates glucose control
  • Fructosamine measures glycosylated proteins in the serum or plasma over previous 2-3 weeks
  • Fructosamine may be more reliable marker of glucose control in HIV patients
  • If treatment is necessary, preferred option is insulin-sensitizers

OBJECTIVES

Primary 

  • Determine if discrepancy exists between fructosamine-estimated average glucose and HbA1c-estimated average glucose (eAG)

Secondary 

  • If discrepancy exists, which is more accurate compared to self-monitor blood glucose readings
  • Assess management of diabetes

       -Percentage of subjects well-controlled

       -Determine if insulin-sensitizing agents result in better glucose control

METHODS

  • Observational cohort study of HIV-infected patients with DM2
  • Study period October 2009- April 2010 (IRB approved)
  • n=26 subjects (α = 0.5, Power of 80%)
  • Inclusion Criteria:

       -Diagnosed with HIV, treated with diabetic medications, >18 years of age

  • Exclusion Criteria:

       -Hemoglobinopathies, anemias, G6PD-deficiency, pregnancy, DM-Type1,

        ESRD, on medications: dapsone,  ribavirin, primaquine, oral  cortico-

        steroids in past 3 months, changes in diabetic agents within past 3months

  • After consenting, HbA1c and fructosamine levels were obtained 
  • Estimated average glucose (eAG) was calculated from HbA1c levels:                           
  • HbA1c-eAG = (28.7xA1c) - 46.7
  • Estimated average glucose was derived from fructosamine measurements:

FR-eAG = {[(0.017xfructosamine)+1.61]x28.7} -46.7

RESULTS

 

LIMITATIONS

  • Small number of home glucometer averages obtained

       -Frequency and time of self-testing varied

  • Fructosamine level obtained only once per subject

       -Only estimates an average for previous 2-3 weeks

  • Subjects may adhere to diet and/or medications during period prior to clinic visit
  • Fructosamine sent to Quest vs. HbA1c measured in-house
  • 33% patients were on both insulin-sensitizing agents and insulin/sulfonylurea

       -Cannot determine efficacy of agents in these subjects

   -Unknown if prior regimens were not tolerated

 

DISCUSSION

  • 52.8% had >28mg/dL discrepancy (=1.0% HbA1c)

–         Not statistically significant, but clinically significant

  • Cannot conclude which laboratory test is a more accurate
  • measure of glucose control
  • Fructosamine estimates glucose control over shorter period of time compared to HbA1c

–        3 weeks vs. 3 months

  • Good adherence may explain lower FR-eAG vs HbA1c-eAG

–        Opposite results compared to previous studies where HbA1c underestimated glucose by 29mg/dL but fructosamine did not underestimate glucose

  • Diabetes well-controlled in 42% of subjects (15/36)

–        80% were treated with insulin-sensitizers

CONCLUSION

  • Discrepancy does exists between fructosamine-estimated average glucose and HbA1c-estimated average glucose  -(r =0.7;  r2 = 0.52)
  • Recommend fructosamine for adjunct monitoring when random glucose does not correspond with HbA1c
  • Metformin or pioglitazone may be more efficacious when  treating HIV-infected diabetic patients
  • Essential to encourage patient self-testing with home glucometers and bring to clinic visits to compare
  • More studies are needed to evaluate optimal management of DM in HIV patients

Disclosure

The authors of this presentation have the following to disclose concerning possible financial or personal relationships with commercial entities:

A. Cha: Nothing to disclose

E. Berrios-Colon: Nothing to disclose

L. Berkowitz: Nothing to disclose

J. Huang: Nothing to disclose

R. DiGregorio: Nothing to disclose