Metformin in an HIV-infected patient with protease inhibitor-induced diabetic ketoacidosis

Identification of novel differentially expressed genes in type 1 diabetes mellitus complications using transcriptomic profiling of UAE patients: a multicenter study

Type 1 diabetes mellitus (T1DM) is a chronic metabolic disorder that mainly affects children and young adults. It is associated with debilitating and long-life complications. Therefore, understanding the factors that lead to the onset and development of these complications is crucial. To our knowledge this is the first study that attempts to identify the common differentially expressed genes (DEGs) in T1DM complications using whole transcriptomic profiling in United Arab Emirates (UAE) patients. The present multicenter study was conducted in different hospitals in UAE including University Hospital Sharjah, Dubai Hospital and Rashid Hospital. A total of fifty-eight Emirati participants aged above 18 years and with a BMI < 25 kg/m² were recruited and forty-five of these participants had a confirmed diagnosis of T1DM. Five groups of complications associated with the latter were identified including hyperlipidemia, neuropathy, ketoacidosis, hypothyroidism and polycystic ovary syndrome (PCOS). A comprehensive whole transcriptomic analysis using NGS was conducted. The outcomes of the study revealed the common DEGs between T1DM without complications and T1DM with different complications. The results revealed seven common candidate DEGs, SPINK9, TRDN, PVRL4, MYO3A, PDLIM1, KIAA1614 and GRP were upregulated in T1DM complications with significant increase in expression of SPINK9 (Fold change: 5.28, 3.79, 5.20, 3.79, 5.20) and MYO3A (Fold change: 4.14, 6.11, 2.60, 4.33, 4.49) in hyperlipidemia, neuropathy, ketoacidosis, hypothyroidism and PCOS, respectively. In addition, functional pathways of ion transport, mineral absorption and cytosolic calcium concentration were involved in regulation of candidate upregulated genes related to neuropathy, ketoacidosis and PCOS, respectively. The findings of this study represent a novel reference warranting further studies to shed light on the causative genetic factors that are involved in the onset and development of T1DM complications.

AUTOIMMUNE DIABETES IN A PATIENT WITH HUMAN IMMUNODEFICIENCY VIRUS ON ANTI-RETROVIRAL THERAPY WITH LITERATURE REVIEW

Objective

Diabetes that develops in human immunodeficiency virus-infected individuals is typically classified as type 2 diabetes mellitus. Although less commonly reported, it has been shown that autoimmune diabetes can also develop in this population.

Methods

We present a case of a patient found to have autoimmune diabetes following initiation of anti-retroviral therapy.

Results

A 68-year-old, African American man with human immunodeficiency virus had a nadir CD4 count of 2 cells/μL, which improved with anti-retroviral therapy. He was subsequently diagnosed with type 2 diabetes mellitus but developed worsening glycemic control. Further investigation demonstrated an elevated glutamic acid decarboxylase antibody level >250 IU/mL and a declining C peptide level from 1.82 ng/mL to 0.56 ng/mL. He was ultimately diagnosed with autoimmune diabetes that was treated with insulin glargine and insulin aspart with improvement in his glycemic control.

Conclusion

Autoimmune diabetes in this case was attributed to immune reconstitution after anti-retroviral therapy led to recovery from a significantly low CD4 count. While this phenomenon has been described in previous case reports, our case was unique in that autoimmune diabetes affected an older African American man, a different demographic than previously reported. Although the true mechanism of this association remains unknown, the recognition of autoimmune diabetes is crucial as it greatly impacts diabetes management.

Metformin effect on gut microbiota: insights for HIV-related inflammation

The gut microbiota is emerging as a prominent player in maintaining health through several metabolic and immune pathways. Dysregulation of gut microbiota composition, also known as dysbiosis, is involved in the clinical outcome of diabetes, inflammatory bowel diseases, cancer, aging and HIV infection. Gut dysbiosis and inflammation persist in people living with HIV (PLWH) despite receiving antiretroviral therapy, further contributing to non-AIDS comorbidities. Metformin, a widely used antidiabetic agent, has been found to benefit microbiota composition, promote gut barrier integrity and reduce inflammation in human and animal models of diabetes. Inspired by the effect of metformin on diabetes-related gut dysbiosis, we herein critically review the relevance of metformin to control inflammation in PLWH. Metformin may improve gut microbiota composition, in turn reducing inflammation and risk of non-AIDS comorbidities. This review will pave the way towards innovative strategies to counteract dysregulated microbiota and improve the lives of PLWH.

Protease inhibitor-induced diabetic complications : incidence, management and prevention

Protease inhibitors (PIs) have become a crucial element in the treatment of patients infected with HIV. However, the widespread use of PI therapy has also been associated with a number of metabolic adverse effects, including fat redistribution and hyperglycaemia. The objective of this review is a discussion of the incidence, pathophysiology, management and prevention of PI-associated hyperglycaemia. Initial case reports have been followed by large cross-sectional and cohort studies, which demonstrate that the incidence of PI-induced impaired glucose tolerance, as well as frank diabetes mellitus, is significant and demands attention. Investigations into the pathophysiology behind PI-associated hyperglycaemia have identified an underlying problem of insulin resistance that is presumably caused by both direct PI-induced mechanisms and lipotoxicity. Given this, clinical trials have explored the use of various classes of oral hypoglycaemic agents in the management of PI-induced diabetic complications, and the use of insulin therapy must be considered as well. Newer PI agents are also under development, with the hope of reducing metabolic adverse effects. In the meantime, prevention, in the form of dietary modification, regular physical activity and periodic screening for impaired glucose tolerance, must receive heightened attention in the care plan of patients receiving long-term PI therapy.

Insulin resistance complicating pregnancy in a human immunodeficiency virus-infected patient treated with protease inhibitors and corticosteroids

BACKGROUND

Protease inhibitor therapy in human immunodeficiency virus (HIV)-infected adults has been associated with onset or aggravation of glucose intolerance. We report a case of a pregnant HIV-infected woman receiving highly active antiretroviral therapy who developed acute onset of severe insulin resistance during treatment for preterm labor.

CASE

A 26-year-old multigravida with HIV infection treated with highly active antiretroviral therapy presented in preterm labor. During treatment, including corticosteroids for fetal lung maturity, severe hyperglycemia and ketonemia suggestive of diabetic ketoacidosis were detected. Aggressive intravenous fluid and insulin therapy was necessary to correct hyperglycemia.

CONCLUSION

We found that HIV-positive pregnant women receiving highly active antiretroviral therapy may be at increased risk for development of glucose intolerance. The use of medications that impair glucose tolerance, for example, corticosteroids, may have a synergistic effect in aggravating insulin resistance. Additional screening for glucose intolerance later in the third trimester should be considered in these patients.