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Conference
"Matters of the Heart: Insulin resistance and HIV" Dr. Greg Bondy (biography) English - 2006-01-20 - 51 minutes
(68 slides)
Summary : Both insulin resistance and antiretroviral therapy independently contribute to the development of cardiovascular disease. Dr. Bondy reviews the guidelines for treating HIV positive patients newly diagnosed with type 2 diabetes (T2D) while taking into consideration these cardiovascular risk factors.
While diabetes education, and diet and exercise remains the recommended approach to anyone newly diagnosed with T2D, in patients with symptomatic glycemic control problems immediate attention may be required. In addition, it has been shown that diet and exercise often fails in maintaining glycemic control. Dr. Bondy recommends using glyburide with increasing doses of metformin until optimal therapeutic conditions are attained. Long term use would involve gradually removing the glyburide and replacing it by a thiazolidinedione.
Dr. Bondy provides an overview of the advantages and disadvantages of several oral anti-diabetic agents. These include sulfonylureas, biguanides, alpha-glucosidase inhibitors, carbamoylmethyl benzoic acids, and thiazolidinediones.
The Canadian diabetes guidelines (CDA) recommend the use of metformin, a biguanide, as the first line drug due to its cardio protective effects. In support of these cardio protective effects is the UKPDS study, however, Dr. Bondy cautions us that it is important to recognize the small samples sizes used in this study. All aside, due to the possible cardio protective effects and weight loss effects, metformin may be a useful first line approach for HIV patients with T2D.
PPAR receptors are another target for oral anti-diabetic agents. As nuclear transcription factors, they alter gene expression ultimately affecting lipid, protein and carbohydrate metabolism as well as cell differentiation. Thiazolidinediones (TZDs), a PPAR agonist, work on liver, adipose, and muscle, to improve glucose and lipid levels. Moreover, studies have linked TZDs with a reduction in inflammation which is a known driver of atherosclerosis. Dr. Bondy presents studies supporting TZDs in reducing atherosclerosis and improving endothelial function. He further presents the PROactive study which was designed to determine the effects of TZDs on several cardiovascular endpoints.
In HIV patients, the D:A:D study have shown that the risk heart disease increases with the duration of exposure to antiretroviral therapy. Dr. Bondy reviews the cardiovascular disease risks in HIV patients and the clinical implications of TZDs. Finally, he addresses the side effects of TZDs and its possible contribution to congestive heart failure and liver disease.
Learning objectives : After viewing this presentation, participants will be able to discuss:
- Guidelines for treating type 2 diabetes in HIV patients;
- Insulin resistance and vascular disease;
- Thiazolidinediones and vascular protection.
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