Problematic HIV patients benefit from comprehensive team approach to care
Problematic HIV patients benefit from comprehensive team approach to care
Glucose intolerance higher in HIV patients
HIV clinicians need to screen and monitor patients for lipid abnormalities and cardiovascular illness before and during antiretroviral treatment (ART), an expert advises.
Dietary consultations, as well as a multidisciplinary team approach that includes a pharmacist, are important to HIV care, says May C. Mak, PharmD, CDE, an assistant professor in the department of pharmacy at the University of Southern California in Los Angeles, CA.
"At this clinic, providers refer to pharmacists the problematic patients," Mak says. "We see the people who are out of metabolic and virus control and who have diabetes and high triglycerides."
After receiving many referrals, investigators wanted to find out how common the problems are among HIV patients, Mak notes.
"We wanted to identify whether the virus or highly active antiretroviral therapy (HAART) was the culprit," Mak says. "None of the published data show directly that protease inhibitors (PIs) are the problem, but they've been implicated."
So investigators reviewed data among HIV patients receiving PIs and those without PIs, and they found significantly higher glycosylated hemoglobin (A1c) levels among the PI group, which represented an overall loss of control over glucose, Mak says.
"This doesn't mean PI regimens produce more cardiovascular risk, although they are specifically associated with higher A1c levels," Mak adds. "And PI regimens are associated with higher triglyceride levels, although that correlation wasn't statistically significant."
The study showed that obesity was present in 26 percent of the patients, while hypertension was present in 48 percent, and hypertriglyceridemia was present in 86 percent. Also, 37 percent of the patients had low HDL levels.1
The treatment most commonly associated with metabolic abnormalities was Kaletra, which is the preferred PI in many regimens, Mak says.
"What's unique in my population is we're dealing with a high Hispanic population, whose ethnicity raises the risk of diabetes and hyperlipidemia and obesity," Mak says. "Overall, 63 to 64 percent of our study population fit into the definition of metabolic syndrome, which is having three or more of the abnormalities of hypertension, glucose intolerance, obesity, etc."
About 90 percent of the study population had glucose intolerance, but then another 63 percent fit the metabolic syndrome criteria, Mak clarifies.
This percentage is much higher than the other HIV data reported, so it's question of whether this finding is related to the ethnicity of the clinic's HIV population, Mak notes.
"There are some patients who have triglyceride levels in the thousands, and those have risen because they suffer from pancreatitis," Mak says.
HIV patients with metabolic syndrome need a comprehensive, team approach to their HIV care, but this is sometimes difficult for HIV clinics to provide.
"For a brief period of time, we had a metabolic clinic day within our HIV clinic," Mak says. "But staffing problems came up, and we couldn't do that anymore."
Now the monitoring of metabolic parameters is the responsibility of the pharmacist, she adds.
HIV specialists increasingly are becoming primary care providers, who have to look at a variety of health issues in order to improve patients' overall care, Mak notes.
"We also rely heavily on dietitian consultations to help us evaluate a patient's diet and to see if there could be any adjustment to diet," Mak says.
This consultation often turns up striking examples of problematic foods.
For example, many of the Hispanic patients consider Ramon noodles a dietary staple because they're inexpensive and taste good, Mak says.
"These are high in salt and fat, and we've come across several Hispanic patients who like to eat those on a routine basis and sprinkle cheese on them," she says. "So that's an example of how terrible those diets can be because of economical and ethnic preference."
However, it's very difficult to convince patients to change their dietary habits unless they've suffered a major health problem, such as a heart attack or pancreatitis, Mak says.
"A lot of these patients also want to maintain their quality of life, and they think they're suffering enough from being on all of these medications," Mak says.
The other treatment is to put the patients on triglyceride-lowering agents like Lopid and Tricor because their primary lipid problems are with high triglycerides, and high LDLs is a secondary problem, Mak adds.
"A few individuals have needed insulin, but it comes down to how late we catch these people, because they usually begin with some glucose intolerance in the early stage, and insulin is not needed if they're willing to adopt a healthier diet and exercise," Mak says. "If they do not adopt healthy behaviors, then we begin with insulin sensitizers like Avandia, Aptos, Netforman, which do not lower blood sugar, but help the body handle glucose more effectively."
Mak says she joined the clinic about seven years ago, and at that time the major problems involved virus control and resistance to ART.
"So we were dealing with a lot of interpreting genotype and phenotype and HAART medicine to overcome resistance," Mak explains. "Now, more and more, we're dealing with metabolic abnormalities, and the referrals have been for that problem."
Reference:
- Mak M. Incidence of Abnormal Metabolic Parameters in Patients Receiving HAART. Presented at the Treatment and Management of HIV Infection in the United States Conference, held Sept. 15-18, 2005, in Atlanta, GA.
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