Liraglutide Treatment in a Patient With HIV and Uncontrolled Insulin-Treated Type 2 Diabetes

C ombination antiretroviral therapy has improved survival in human im-munodeficiency virus (HIV)-infected patients but has become associated with altered body fat distribution, type 2 diabetes , and increased cardiovascular risk (1). Both the protease inhibitors and nucleotide reverse transcriptase inhibitors have been implicated (1). Management of HIV-associated type 2 diabetes may be challenging because of severe insulin resistance, which—in spite of the initial use of insulin sensitizers—often requires a high dose of insulin, causing additional weight gain (1). The glucagon-like peptide-1 receptor ago-nists lower glucose, reduce weight, and improve the cardiovascular risk profile in type 2 diabetes (2,3). Recently, exenatide use in an HIV-associated type 2 diabetic case and in a type 1 diabetic HIV patient was reported (4,5). Here, we report the first successful liraglutide use in an HIV patient with type 2 diabetes. A 57-year-old man regularly visited the outpatient clinic since 2003 because of an HIV infection, which was diagnosed in 1995. Initial treatment consisted of zidovudine, then dual-therapy zidovu-dine and zalcitabine. From 1997–2003 he received zidovudine and lamivudine, then triple-therapy with efavirenz, didan-osine, and lamivudine, which was discontinued because of dizziness, rash, and depression. Then, atazanavir, tenofo-vir, and lamivudine were given. In 2005, because of a progressive abdominal dis-tention, the protease inhibitor atazanavir was replaced by raltegravir, an integrase inhibitor with a better metabolic profile. In 2005, at a weight of 105 kg, compatible with a 15-kg weight gain in 2 years, type 2 diabetes was diagnosed. After lifestyle consultation, metformin (1,000 mg b.i.d.) was initiated. Since A1C rose to 8.8%, NPH insulin was started (November 2007). Body weight increased by 5 kg in 6 months with little glycemic improvement. Insulin treatment was replaced by glimepiride (up to 6 mg q.i.d.), but A1C remained 8.3%. He could be persuaded to start insulin glargine (September 2010), titrated to 60 U/day, while glimepiride was discontinued. Unfortunately, weight increased by 7 kg in 6 months without glycemic improvement. In May 2011, at a weight of 116 kg (BMI 35.1 kg/m 2) and A1C 8.1%, off-label liraglutide was initiated at 0.6 mg/day, and uptitrated to 1.8 mg/day. He consulted a dietitian and diabetes educator and was advised to lower daily insulin dose by 10 U when self-monitored blood glucose was ,5 mmol/L. After 3 weeks of liraglutide therapy, body weight dropped to 110 kg, insulin dose was reduced to 30 U/day, and discontinued altogether after 6 weeks. Fasting glucose decreased …