FAST TRACK

Impaired glucose tolerance, beta cell function and lipid

metabolism in HIV patients under treatment with
protease inhibitors
Georg Behrensa, Andre Dejama, Hartmut Schmidtb,
Hans-Joachim Balksc, Georg Brabantc, Thorsten Krnera,
Matthias Stolla and Reinhold E. Schmidta
Objectives: To evaluate metabolic abnormalities, beta-cell function, lipid profile and
vascular risk factors in HIV patients on protease inhibitors (PI).
Design: Prospective cross-sectional study.
Methods: Thirty-eight HIV-1-infected patients receiving at least one PI were
compared with 17 PI-naive HIV patients in an oral glucose tolerance test (OGTT).
Serum glucose, insulin, proinsulin, and C-peptide were determined. The fasting lipid
pattern was analysed using electrophoresis and the assessment of apolipoproteins
including lipoprotein (a). Fibrinogen, homocysteine, and anticardiolipin antibodies
were also assessed.
Results: Twenty-seven (71%) of the PI-treated group had detectable hyperlipidaemia.
Isolated hypertriglyceridaemia was present in 12 patients (44%), two (7%) of them had
type V and 10 (37%) subjects had type IV hyperlipidaemia (Frederickson classification).
Type IIb hyperlipidaemia defined as an increase of both very-low-density lipoproteins
(VLDL) and low-density lipoproteins (LDL) was found in 10 (36%) subjects, and five
(18%) patients presented with isolated hypercholesterolaemia (type IIa). PI treatment
was associated with significant higher fasting cholesterol, triglycerides, LDL and VLDL
levels. Apolipoprotein B and E concentrations were significantly increased in patients
receiving PI. Elevated concentrations of lipoprotein (a) (> 30 mg/dl) were detected in
six (16%) of the hyperlipidaemic patients on PI. Eighteen (46%) patients on PI had
impaired oral glucose tolerance and five (13%) had diabetes. Although four (24%) of
the PI-naive patients were glucose intolerant, none had diabetes. Fasting
concentrations and secretion response of insulin, proinsulin, and C-peptide to glucose
ingestion was significantly increased in the PI-treated group suggesting a beta-cell
dysfunction in addition to peripheral insulin resistance. Beta-cell abnormalities were
associated with the abnormal lipid pattern and PI treatment.
Conclusion: Combination drug regimens including PI are accompanied by impaired
glucose tolerance, hyperproinsulinaemia as an indicator for beta-cell dysfunction,
and lipid abnormalities proved to be significant risk factors for coronary heart
disease. Moreover, PI may have an impact on the processing of proinsulin to insulin.
1999 Lippincott Williams & Wilkins

AIDS 1999, 13:F63F70

Keywords: Protease inhibitor, impaired glucose tolerance, hyperlipidemia,
lipid metabolism, diabetes, metabolic abnormalities

From the aDivision for Clinical Immunology, bDivision for Gastroenterology and Hepatology, and cDivision for Clinical
Endocrinology, Department of Medicine, Hannover Medical School, Carl-Neuberg-Strae 1, 30625 Hannover, Germany.
Sponsorship: This work was supported by Bundesministerium fr Gesundheit (RKI 415-4476-09/10).
Correspondence: Georg Behrens, MD, Division for Clinical Immunology, Hannover Medical School, Carl-Neuberg-Strae 1,
30625 Hannover, Germany.
Tel: +49 (0) 511-532-6656; fax: +49 (0) 511-532-9057; e-mail: behrens.georg@mh-hannover.de
Received: 13 January 1999; revised: 11 March 1999; accepted: 8 April 1999.

Lippincott Williams & Wilkins F63

F64 AIDS 1999, Vol 13 No 10
Introduction
The widespread use of antiretroviral combination
regimens including HIV protease inhibitors (PI) has led
to reduced morbidity and mortality in HIV-infected
patients with advanced disease [1,2]. However, the
early enthusiasm of clinicians about the rapid advance
and virological response shown in clinical trials with
highly active antiretroviral therapy (HAART) has
recently been tempered. On one hand, the clinical
manifestation of previously silent infections and
autoimmune diseases caused by immune reconstitution
has occurred, and on the other hand a syndrome of
peripheral lipodystrophy, central adiposity, dyslipi-
daemia, and insulin resistance have been observed in
patients treated with HIV PI [38]. Some patients
developed hyperglycaemia and type 2 diabetes [9], and
recent reports provided evidence for vascular complica-
tions after the initiation of HAART [1012]. Carr et al.
[13] hypothesized that PI treatment may lead to
unspecific interactions with two proteins (cytoplas-
matic-acid binding protein type 1 and low-density
lipoprotein-related protein) that regulate lipid metabo-
lism. The resulting inhibition is proposed to cause
hyperlipidaemia, to contribute to central fat deposition
and insulin resistance. In a recent report by Walli et al.
[6] the association of peripheral insulin resistance and
impaired glucose tolerance resulting from HAART has
been demonstrated, but a detailed characterization of
hyperlipidaemias as well as an assessment of the beta-
cell function have not been provided. The occurrence
of hyperlipidaemia, maturity onset diabetes and lipody-
strophy with the consequences especially of atheroscle-
rosis sheds new light on the use of PI. Interestingly, the
HAART-associated lipodystrophy has striking similari-
ties with the metabolic syndrome, called syndrome X.
The understanding of the metabolic syndrome may
thus have impact on the pathogenesis of lipodystrophy.
At present, the general consensus appears to be that
patients with severe HIV disease should continue PI
therapy where possible. Lipid-lowering therapy with
statins and fibrates has been demonstrated to be success-
ful [14], but the safety and efficacy of these drugs must
be assessed in further studies. Statins are anti-inflamma-
tory, primarily metabolized through cytochrome 3A4,
and may lead to unfavourable drug interactions with
PI. The aim of this study was to determine in detail the
metabolic abnormalities and alterations of glucose
metabolism and to evaluate possible vascular risk factors
in HIV patients treated with HAART.
Methods
Thirty-eight (32 male, six female) HIV-1-infected
patients receiving at least one HIV-1 PI were included
and compared with 17 PI-naive HIV patients (15 men,
two women) in an oral glucose tolerance test (OGTT).
Co-administered antiretroviral therapy consisting of
reverse transcriptase inhibitors (RTI) and/or
non-nucleoside reverse transcriptase inhibitors
(NNRTI) is listed in Table 1. Venous blood was taken
after an overnight fasting for measurements of serum
glucose, insulin, proinsulin, C-peptide, lipids, fibrino-
gen, homocysteine, and anticardiolipin antibodies
(aCL). Plasma glucose, insulin, proinsulin, and
C-peptide concentrations were determined before and
30, 60, 120, and 180 min after oral administration of 75
g glucose (Dextro-OGT; Boehringer, Mannheim,
Germany). Blood glucose concentrations were mea-
sured by the hexokinase-glucose-6-phosphate-dehy-
drogenase method. Plasma concentrations of insulin
and C-peptide were determined using a commercially
available radioimmunoassay. For the measurement of
proinsulin by microplate immunoradiometric assay,
wells were coated with monoclonal mouse anti-human
insulin/proinsulin antibody 3B1 (Biotrend, Kln,
Germany) and incubated with human serum. Tubes
were washed and incubated with monoclonal mouse
anti-human C-peptide/proinsulin antibody PEP 01
(Novo Nordisk, Mainz, Germany) labelled with
125
I. Recombinant human proinsulin was used as
standard. IgG/IgM aCL were determined by a
commercially available test (Pharmacia and Upjohn,
Freiburg, Germany), homocysteine and fibrinogen
levels were determined using commercial standard
assays. CD4 cell counts were calculated by flow cytom-
etry and HIV-RNA copies obtained by quantitative
polymerase chain reaction (Amplicor HIV-1 Monitor
Test; Roche Diagnostic Systems, Branchburg, USA).
Apolipoproteins [apoA-I, apo-AII, apoB, apoE and
lipoprotein (a)] were analysed by nephelometric quan-
tification using rabbit polyclonal antisera. The concen-
trations of lipid electrophoresis of very-low-density
lipoprotein (VLDL), low-density lipoprotein (LDL),
and high-density lipoprotein (HDL) cholesterol were
determined using an electrophoretic and densitometric
method (REP Lipoprotein-Kin; Helena Diagnostics,
Germany). For the triglyceride assay the Peridochrom
Triglyceride GPO-PAP Kit was used (Boehringer,
Mannheim, Germany). For the total cholesterol assay
the CHOD-PAP Kit (Boehringer) was used.
The results are presented as means SD (range). The
statistical significance for lipid profiles and OGTT was
determined by analysis using the non-parametric
MannWhitney-U test. The 2 (Pearson) test was used
for evaluating lipid differences in proportions between
the groups. The areas under the curve (AUC) for the
OGTT parameter were calculated according to the
mathematic model of Thai [15]. P values of < 0.05
were considered to indicate statistical significance.
 Metabolic abnormalities in HIV patients treated with PI Behrens et al.
Table 1. Clinical characteristics of the study subjects
Body mass index
Age (years)
Duration of PI treatment (months)
Duration of RTI treatment (months)
CD4 lymphocyte (cells/l)
HIV-RNA copies/ml (log10)
< 50 HIV-RNA copies/ml
< 400 HIV-RNA copies/ml
< 250/250500/> 500
CD4 lymphocyte (cells/l)
Zidovudine + lamivudine
Zidovudine + didanosine
Stavudine + lamivudine
Stavudine + didanosine
Therapy naive
Indinavir
Indinavir + ritonavir
Saquinavir
Ritonavir
Nelfinavir
Ritonavir + saquinavir
Saquinavir + nelfinavir
PI, Protease inhibitor; RTI, reverse transcriptase inhibitor. *P < 0.005. aPlusminus values are means SD (range). bPlus nevirapine.
Results
Characterization of glucose metabolism
Patients without PI had significantly higher CD4 cell
counts, and a lower but not significant decrease in viral
load (mean 0.41 1.69 log10 HIV-RNA copies/ml)
since the initiation of antiretroviral therapy (n = 10)
compared with the PI-treated patients frequently on
second and third-line therapy (mean decrease 1.36
1.32 log10 HIV-RNA copies/ml). A mean increase of
CD4 cell count/l since therapy was 84 197 in the
PI-naive group compared with 122 29 in the PI-
treated group. The other clinical characteristics are
listed in Table 1. Eighteen (46%) patients on PI had
impaired oral glucose tolerance with 2 h post-load
serum glucose levels between 7.8 and 11.1 mmol/l,
and five (13%) had diabetes according to 1985 WHO
guidelines with 2 h post-load serum glucose levels
above 11.1 mmol/l. Although four (24%) of the
PI-naive patients were glucose intolerant, none had
diabetes. Using the 1997 American Diabetes
Association (ADA) fasting criteria [16], three patients
on PI were glucose intolerant and two had diabetes,
whereas all PI-naive patients had normal fasting glucose
concentrations. Thirteen (45%) out of all hyperlipi-
daemic patients had impaired glucose tolerance accord-
ing to the WHO criteria, although eight of the 26
(31%) patients with normal serum lipid levels revealed
impaired glucose tolerance and two normolipidaemic
patients demonstrated diabetes with over 11.1 mmol/l
2 h post-load.
Insulin response was delayed and increased in patients
on PI with a maximum mean plasma insulin concentra-
F65
PI naive (n = 17) PI treated (n = 38)
24.2 2.2 (2128.7)a 24.0 4.0 (16.336.33)
41 12 (2360) 47 13 (3172)
18.3 6.8 (429)
26 21 (265) 27 14 (485)
438 126 (132652) 259 162 (4775)*
3.27 1.07 (1.694.72) 3.33 1.04 (1.695.57)
4 2
7 14
1/10/6 22/13/3
3/1b 19
1b 1
0 8
5b 10
7 0
0 14
0 1
0 8
0 2
0 7
0 4
0 2
tion of 784.5 693.6 (range 36.23294.7) pmol/l
120 min post-glucose load in comparison with PI-naive
patients with a maximum plasma insulin of 540.9
428.6 (range 65.21484.4) pmol/l already 60 min post-
glucose load (Fig. 1B). After the ingestion of glucose,
C-peptide levels increased in PI-naive patients to mean
peak concentrations of 6.6 3.0 (range 1.713.9)
ng/ml already at 60 min and returned to 3.9 2.0
(range 1.79.2) ng/ml at 180 min. However, the
PI-treated subjects presented with significantly higher
mean fasting mean C-peptides of 3.4 2.2 ng/ml
(range 1.111.1, P < 0.003), increasing up to higher
and delayed peak concentrations of 10.7 5.0 (range
4.723.6) ng/ml at 120 min (P < 0.001), and contin-
ued on a markedly elevated level with 8.4 4.8 (range
2.424.9) ng/ml at 180 min post-glucose challenge
(P < 0.0002) (Fig. 1C). In addition, the calculation of
the AUC of the C-peptide curve revealed significant
(P = 0.001) higher total C-peptide release in the PI-
treated group (Table 2).
The analysis of proinsulin concentrations revealed
higher mean fasting values of 26.4 37.5 (range 2167)
pmol/l (P = 0.006), and at each time point a signifi-
cantly higher concentration with a peak of 170.0
144.0 (range 15608) pmol/l in the PI-treated group
compared with the mean maximum concentration of
78.8 66.8 (range 2260) pmol/l in PI-naive patients
at 120 min (P = 0.005) (Fig. 1A). Total pro-insulin
secretion during OGTT, calculated as AUC, was also
significantly higher (P = 0.01) in the PI group (Table
2). Analysis of the serum glucose concentration
revealed increased mean fasting glucose (5.5 1.7
mmo/l, range 3.913.4) in PI-treated patients com-
F66 AIDS 1999, Vol 13 No 10

Fig. 1. Mean ( SE) serum proinsulin (A), insulin (B), C-peptide (C) and glucose (D) concentrations during an oral glucose tol-
erance test in protease inhibitor (PI)-naive (n = 17) and protease inhibitor-treated (n = 38) HIV-infected patients. *P < 0.05;
**P 0.005.

pared with 4.8 0.6 (range 3.35.5) mmol/l in PI-
naive patients, but differences were not statistically sig-
nificant. After the ingestion of the glucose, PI-treated
patients reached higher maximum serum glucose levels
and remained on high levels in the second phase at 120
and 180 min (P = 0.006 and P = 0.002, respectively)
(Fig. 1D). The AUC of glucose revealed higher total
glucose levels during the OGTT in patients receiving
PI (P = 0.008) (Table 2).
More importantly, the hyperlipidaemic patients in the
PI-treated group had more than three times the fasting
proinsulin concentrations compared with normolipi-
daemic PI patients (34.9 43.4, range 5167) pmol/l
(P = 0.008). Mean fasting insulin and particular 180
min insulin concentrations were also markedly
increased in hyperlipidaemic patients (136.0 136.3,
range 21.7687.9 mmol/l and 611.0 514.5, range
29.01737.8 mmol/l) in comparison with normolipi-
 Metabolic abnormalities in HIV patients treated with PI Behrens et al. F67

Table 2. Distribution fasting lipid parameters, glucose, insulin, proinsulin, and C-peptide during the oral glucose tolerance test
PI naive (n = 17) PI treated (n = 38)
Fasting proinsulin (pmol/l) 10.2 10.6 (236)a 26.4 37.5 (2167)*
2 h Proinsulin (pmol/l) 78.8 66.8 (2260) 170.1 144.1 (15608)**
Fasting insulin (pmol/l) 72.0 31.7 (29144.8) 111.7 118.4 (21.7687.9)
2 h Insulin (pmol/l) 458.0 329.6 (72.41310.6) 776.0 686.5 (36.23294)*
Fasting C-peptide (ng/ml) 1.9 0.6 (0.92.85) 3.4 2.2 (1.111.1)**
2 h C-peptide (ng/ml) 6.4 3.2 (1.713.4) 10.7 5.0 (4.723.6)**
Fasting glucose (mmol/l) 4.8 0.6 (3.35.5) 5.5 1.8 (3.913.4)
2 h Glucose (mmol/l) 6.8 1.8 (3.810.2) 8.8 3.4 (4.724.2)*
AUC proinsulin (pmol/l/180 min) 5329.5 (1076.013683.5) 10512.2 (1292.036788.5)*
AUC insulin (pmol/l/180 min) 76334.6 (15640.6175087.4) 112739.5 (7711.7360167.3)
AUC C-peptide (ng/ml/180 min) 1022.2 (357.51905.5) 1595.4 (629.83241.8)**
AUC glucose (mmol/l/180 min) 1314.9 (904.51779.0) 1596.0 (961.53903.0)*
Cholesterol (mg/dl) 175.0 45.8 (125307) 257.3 75.1 (99400)**
Triglycerides (mg/dl) 162.0 136.5 (48538) 451.1 475.0 (582130)**
LDL cholesterol (mg/dl) 114.3 38.6 (34188) 163.2 56.8 (66274)**
VLDL cholesterol (mg/dl) 26.3 28.0 (494) 58.3 45.6 (5173)**
HDL cholesterol (mg/dl) 34.8 8.5 (2048) 35.8 14.9 (1891)
Lipoprotein (a) (mg/dl) 18.6 26.5 (2100) 20.0 34.2 (2158)
apo A-I (mg/dl) 127.8 23.1 (95166) 132.0 23.2 (84189)
apo A-II (mg/dl) 30.1 7.5 (2254) 31.1 5.4 (1844)
apo B (mg/dl) 93.0 33.8 (53180) 126.0 39.3 (54226)**
apo E (mg/dl) 4.4 2.4 (210) 7.5 4.9 (225)*
AUC, Area under the curve; HDL, High-density lipoprotein; LDL, low-density lipoprotein; PI, protease inhibitor; VLDL, very low-density
lipoprotein. aPlusminus values are means SD (range). *P < 0.05; **P 0.005.

daemic patients with PI (55.3 15.6, range 36.286.9
mmol/l and 182.3 141.6, range 43.5521.4 mmol/l;
P < 0.05 and P < 0.005).
To evaluate the relative secretion response of
proinsulin and insulin to glucose challenge, the proin-
sulin-to-insulin ratio during OGTT was determined.
PI-naive patients showed a clear decrease of the proin-
sulin-to-insulin ratio (P = 0.01) in the initial phase,
indicating the dominating insulin release in comparison
with proinsulin secretion. In contrast, the proinsulin-
to-insulin ratio was only slightly decreased during the
first phase of the OGTT in patients on PI, revealing
early proinsulin and insulin secretion (Fig. 2).
Re-analysis of the OGTT parameters and proinsulin-
to-insulin ratio by removing the five diabetic subjects
of the PI group still revealed statistically significant
differences except for the 30 min proinsulin level (data
not shown). As the course of the C-peptide-to-insulin
ratio during OGTT was not different in the PI-treated
compared with the PI-naive patients, hepatic insulin
clearance seems not to be affected in the PI group.
Characterization of lipid profiles
The analysis of the lipid pattern revealed that 27 (71%)
of the PI-treated group had detectable hyperlipidaemia
defined as fasting cholesterol > 200 mg/dl and/or
triglycerides > 200 mg/dl. The fasting mean lipid
parameters of both patient groups are demonstrated in
Table 2. We also determined the type of hyperlipopro-
teinaemia using the Frederickson classification. Twelve
patients (44%) presented with isolated hypertriglyceri-
daemia, two (7%) of them had type V, and 10 (37%)
subjects had type IV hyperlipidaemia. Type IIb hyper-
lipidaemia, defined as an increase of both VLDL and
LDL cholesterol, was found in 10 (36%) subjects and in
addition, five (18%) patients presented with isolated
hypercholesterolaemia thus classified as type IIa.

HAART was associated with significantly higher

Fig. 2. Proinsulin-to-insulin ratio during oral glucose toler-
ance test. PI, protease inhibitor. *P < 0.05.
fasting cholesterol, triglycerides, LDL and VLDL levels
(Table 2). Only four (24%) patients without PI
presented with hyperlipidaemia, one with type IIb, one
with type IIa and two with isolated hypertriglyceri-
daemia. These results were confirmed by characteriza-
tion of the dyslipidaemias and assessment of
apolipoprotein concentration (Table 2). An increased
F68 AIDS 1999, Vol 13 No 10

Table 3. Percentages of patients with dyslipidaemia according to
reference values
PI naive PI treated
Hyperlipidemia (n = 17) (n = 39)
Cholesterol (> 200 mg/dl) 2 (12%) 31 (82%)*
Triglycerides (> 200 mg/dl) 3 (18%) 25 (66%)*
LDL cholesterol (> 155 mg/dl) 3 (18%) 18 (46%)*
VLDL cholesterol (> 35 mg/dl) 3 (18%) 22 (58%)*
HDL cholesterol (< 35 mg/dl) 6 (35%) 20 (53%)
Lipoprotein (a) (> 30 mg/dl) 2 (12%) 6 (16%)
apo A-I (< 115 mg/dl) 4 (24%) 10 (26%)
apo B (> 135 mg/dl) 1 (6%) 15 (39%)*
apo E (> 6 mg/dl) 2 (12%) 16 (42%)*
HDL, High-density lipoprotein; LDL, low-density lipoprotein; PI,
protease inhibitor; VLDL, very low-density lipoprotein. *P < 0.05
(2 Pearson).
proportion of patients were found with elevated mean
fasting serum values of apoB and apoE in the PI
treatment group compared with PI-naive patients
(P < 0.005) (Table 3). Interestingly, an elevated
concentration of lipoprotein (a) (> 30 mg/dl) as an
important atherogenic risk factor was detected in six
(16%) of the hyperlipidaemic patients, five of whom
were treated with indinavir.
Assessment of other atherogenic risk factors
Fibrinogen was increased (> 3.5 g/l) in nine out of 26
patients; homocysteine was normal in all 27 and antinu-
clear antibodies (ANA) and anticardiolipin antibodies
(aCL) was negative in all 23 tested patients receiving PI.
Discussion
The aim of the study was to characterize the lipid pro-
file and glucose metabolism with respect to pancreatic
secretion in PI-treated patients and to elucidate possible
risk factors for cardiovascular disease in this group.
Because rare cases of abnormal fat deposition have also
been described in patients receiving only RTI [7], the
clinical body alteration may not be a direct side effect
of PI at all. Elevated serum cortisol levels were
suggested as a possible underlying mechanism in fat
accumulation and metabolic abnormalities, but normal
24 h urine cortisol levels in 25 of the PI-treated
patients refute this explanation (data not shown).
Moreover, excellent viral suppression under HAART
regimens (below the limit of detection) has been pro-
posed as a likely mechanism for lipodystrophy, but no
correlation to absolute viral load nor to the decline of
mean HIV-RNA levels in the PI-treated group were
found. Recent data support a major role for PI in the
pathogenesis of metabolic abnormalities since the
replacement of a PI by an NNRTI (nevirapine)
resulted in a partial improvement of serum lipids and fat
distribution without a relapse of viral suppression or a
decline in CD4 lymphocyte counts [17,18]. New-onset
diabetes mellitus has been described with several PI
commonly used to manage HIV disease [9]. Walli et al.
[6] proposed a stepwise model of a HAART-induced
decrease in insulin sensitivity leading first to impaired
P-value glucose tolerance and finally in some cases to the mani-
0.0001 festation of diabetes mellitus. The data demonstrate that
0.001 patients on PI had a higher and prolonged output of
0.049
0.007
insulin during the OGTT with delayed peak concen-
0.271 trations in the second phase of the test. In contrast, PI-
0.759 naive patients respond with rapid insulin release in the
0.831 first phase of OGTT after glucose ingestion.
0.037
0.028
More interestingly, proinsulin levels in the PI-treated
group were significantly increased in comparison with
untreated patients. The proinsulin-to-insulin ratio in
this group was found to be relatively consistent during
the first phase of the OGTT, suggesting the early secre-
tion of immature proinsulin-rich granula. Increased
secretion of proinsulin has been suggested as an indica-
tor of beta-cell dysfunction, either in absolute terms in
relation to insulin [19,20]. Hyperproinsulinaemia may
have several explanations: as a secondary reaction to
external factors, beta-cell distress, the increase of beta-
cell secretory demand due to insulin resistance, the
impaired maturation of proinsulin to insulin or com-
promised insulin secretion. Hyperglycaemia in individ-
uals with impaired glucose tolerance and NIDDM
might be associated with an increase of the proportion
of proinsulin relative to insulin. It has also been sug-
gested that beta-cell dysfunction rather than insulin
resistance plays an important role in the future
development of NIDDM in Caucasians with impaired
glucose tolerance [21]. These data partly support the
two-step model for the development of diabetes pro-
posed by Saad et al. [22]. In the first step, the transition
from normal to impaired glucose tolerance would
depend mainly on the presence of insulin resistance.
The second step, the worsening from impaired glucose
resistance to diabetes, although accompanied by some
further worsening of insulin resistance, is assumed to be
primarily dependent on the development of beta-cell
dysfunction. To support this hypothesis further, more
direct measurements of beta-cell function need to be
performed. It has recently been demonstrated that in
elderly prediabetic individuals increased proinsulin con-
centration as an indicator of defective insulin secretion
is associated with conversion to diabetes over a short
time period [23,24]. The processing of proinsulin to
insulin in beta cells is catalysed by proprotein conver-
tases PC2 and PC3. It may be possible that PI for HIV-1
interact with enzymes required for the processing of
proinsulin to insulin, resulting in an accumulation of
proinsulin, and/or directly induce the secretion of
immature proinsulin-rich granula of beta cells.
Interestingly, in one HIV-1-infected patient, who
developed diabetes while taking PI, there was no
increase in insulin, C-peptide, and proinsulin secretion
during OGTT (data not shown). After the discontinua-
tion of PI, the patient resolved and became normogly-
 Metabolic abnormalities in HIV patients treated with PI Behrens et al.
caemic within a few weeks, indicating a direct role of
PI in the pathogenesis of HAART-induced diabetes.
These data confirm conclusively that a complex alter-
ation in glucose and insulin metabolism exists in HIV
patients on HAART. PI treatment was associated with
a higher rate of diabetes mellitus, impaired glucose tol-
erance, hyperinsulinaemia, and early hypersecretion of
proinsulin. This is important, because HIV infection
itself was shown to cause an increase in insulin sensitiv-
ity of peripheral tissue and insulin clearance compared
with control subjects [25]. Significantly higher rates of
the disproportional secretion of proinsulin and delayed
insulin secretion were dominant in hyperlipidaemic
HIV-patients receiving PI in comparison with nor-
molipidaemic PI-treated patients. However, impaired
glucose tolerance may exist without dyslipidaemia,
although hyperproinsulinaemia is one of the main char-
acteristics in patients with lipid abnormalities induced
by HAART. The relationship between fasting hyperin-
sulinaemia and certain cardiovascular risk factors, such
as blood pressure, obesity, raised triglycerides, and low
concentrations of HDL cholesterol, has been demon-
strated in both diabetic and non-diabetic individuals
[26]. It has been demonstrated that young, non-
diabetic, male survivors of myocardial infarction are
truly hyperinsulinaemic during an OGTT, and there is
evidence for a close association between impaired
glucose tolerance and proinsulin and coronary athero-
sclerosis [27,28].
In this context, the assessment of lipid metabolism in
HIV-1-infected patients under HAART is of particular
importance. Hypertriglyceridaemia and low plasma
HDL cholesterol concentrations are the most common
lipid abnormalities associated with both NIDDM and
insulin resistance syndrome. Similarly, the treatment of
HIV-1 infection with PI was associated with striking
abnormalities in the lipid profiles compared with
PI-naive HIV-1-infected patients. Significant higher
fasting total cholesterol and triglyceride levels, and in a
more comprehensive analysis higher LDL cholesterol
and VLDL cholesterol levels, were characteristic for the
patients receiving PI. Interestingly, hypertriglyceri-
daemia, especially in the late phase of the disease and to
a lesser extent, has been seen in HIV-infected individu-
als since the early 1980s. The major causes of hyper-
triglyceridaemia were shown to be elevated rates of
de-novo lipogenesis and the delayed clearance of
triglycerides in the postprandial period [29]. HAART
had no significant influence on HDL cholesterol con-
centrations, and low plasma contents of HDL are
already known to occur early in the disease [29].
According to the described characteristic lipid profile
associated with PI, evaluation of the apolipoproteins
confirmed these results. HAART is thus accompanied
by lipid abnormalities, which have been proved to be a
significant risk factor for coronary heart disease, such as
F69
high total cholesterol and LDL cholesterol and low
HDL cholesterol levels in a significant proportion of
patients receiving PI. This is supported by a high
percentage (6070%) of HIV patients with elevated
serum lipids and increased levels of lipoprotein (a)
(> 30 mg/dl). In addition to other cardiovascular
abnormalities common in HIV infection [30], this may
contribute to severe cardiovascular events. Despite the
fact that PI-naive patients partly received antiretroviral
treatment (RTI, NNRTI), they demonstrate significant
differences in glucose and lipid metabolism in compari-
son to patients on PI. Therefore we suggest that these
effects are caused by PI, as supported by other studies
[5,6,17,18]. Consequently, we recommend a compre-
hensive analysis of lipid profile and an OGTT before
starting patients on PI treatment along with close
monitoring during therapy. Furthermore, evaluation of
current trials comparing PI-sparing drug regimens with
treatment combinations including PI (e.g. the
ATLANTIC Study [31]) will provide further informa-
tion on the clinical relevance of the described meta-
bolic abnormalities.
References
1. Mocroft A, Vella S, Benfield TL, et al. Changing patterns of
mortality across Europe in patients infected with HIV-1.
Lancet 1998, 352:17251730.
2. Palella FJ, Delaney KM, Moorman AC, et al. Declining morbidi-
tiy and mortality among patients with advanced human
immunodeficiency virus infection. N Engl J Med 1998,
338:853860.
3. Race EM, Adelson-Mitty J, Kriegel GR, et al. Focal mycobacterial
lymphadenitis following initiation of protease-inhibitor ther-
apy in patients with advanced HIV-1 disease. Lancet 1998,
351:252255.
4. Behrens G, Knuth C, Schedel I, Mendila M, Schmidt RE. Highly
active antiretroviral therapy. Lancet 1998, 351:10571058.
5. Carr A, Samaras K, Burton S, Law M, Freund J, Chisholm DJ,
Cooper DA. A syndrome of peripheral lipodystrophy, hyper-
lipidaemia and insulin resistance in patients receiving HIV
protease inhibitors. AIDS 1998, 12:F51F58.
6. Walli R, Herford O, Michl GM, et al. Treatment with protease
inhibitors associated with peripheral insulin resistance and
impaired glucose tolerance in HIV-1 infected patients. AIDS
1998, 12:F167F173.
7. Lo JC, Mulligan K, Tai VW, Algren H, Schambelan M. Buffalo
hump in men with HIV infection. Lancet 1998, 351:867870.
8. Miller KD, Jones E, Yanovski JA, Shankar R, Feuerstein I, Fallon J.
Visceral abdominal-fat accumulation associated with use of
indinavir. Lancet 1998, 351:871875.
9. Dube MP, Johnson DL, Currier JS, Leedom JM. Protease
inhibitor-associated hyperglycemia. Lancet 1997,
350:713714.
10. Henry K, Melroe H, Huebsch J, et al. Severe premature coro-
nary artery disease with protease inhibitors. Lancet 1998,
351:1328.
11. Behrens G, Schmidt H, Meyer D, Stoll M, Schmidt RE. Vascular
complications associated with the use of HIV protease
inhibitors. Lancet 1998, 351:1958.
12. SoRelle R. Vascular and lipid syndromes in selected HIV-
infected patients. Circulation 1998, 9:829830.
13. Carr A, Samaras K, Chisholm DJ, Cooper DA. Pathogenesis of
HIV-1 protease inhibitor-associated peripheral lipodystrophy,
hyperlipidaemia, and insulin resistance. Lancet 1998,
351:18811883.
F70 AIDS 1999, Vol 13 No 10
14. Henry K, Melroe H, Huebsch J, Hermundson J, Simpson J.
Atorvastatin and gemfibrazol for protease-inhibitor-related
lipid abnormalities. Lancet 1998, 352:10311032.
15. Thai MM. A mathematic model for the determination of total
area under glucose tolerance and other metabolic curves.
Diabetes Care 1994, 17:152154.
16. American Diabetes Association. Report of the Expert
Committee on the diagnosis and classification of diabetes
mellitus. Diabetes Care 1997, 7:11831197.
17. Martinez E, Lozano L, Conget I, Casamitjana R, Gatell JM.
Reversion of lipodystrophy after switching HIV-1 protease
inhibitors to nevirapine. Sixth Conference on Retroviruses and
Opportunistic Infections. Chicago, February 1999 [abstract 670].
18. Ruiz L, Bonjoch A, Paredes R, et al. A multi-center, random-
ized, open-labeled, comparative trail of the clinical benefit of
switching the protease inhibitor (PI) by Nevirapine (NVP) in
HAART-experienced patients suffering lipodystrophy (LD).
Sixth Conference on Retroviruses and Opportunistic Infections.
Chicago, February 1999 [abstract LB14].
19. Williams DR, Byrne C, Clark PM, et al. Raised proinsulin con-
centration as early indicator of cell dysfunction. BMJ 1991,
303:9596.
20. Roder ME, Porte D, Schwartz RS, Kahn SE. Disproportionately
elevated proinsulin levels reflect the degree of impaired cell
secretory capacity in patients with noninsulin-dependent dia-
betes mellitus. J Endocrinol Metab 1998, 83:604608.
21. Nijpels G, Popp-Snyders C, Kostense PJ, Bouter LM, Heine RJ.
Fasting proinsulin and 2-h post-load glucose levels predict
the conversion to NIDDM in subjects with impaired glucose
tolerance: the Hoorn Study. Diabetologica 1996, 39:113118.
22. Saad MF, Knowler WC, Pettitt DJ, Nelson RG, Charles MA,
Bennet PH. A two-step model for the development of non-
insulin-dependent diabetes. Am J Med 1991, 90:229235.
23. Heine RJ, Nijpels G, Mooy JM. New data on the rate of
progression of impaired glucose tolerance to NIDDM and
predicting factors. Diabetes Med 1996, 13:S12S14.
24. Mykknen L, Haffner SM, Kuusisto J, Pyrl K, Laakso M.
Serum proinsulin levels are disproportionately increased in
elderly prediabetic subjects. Diabetologica 1995,
38:11761182.
25. Hommes MJT, Romijn JA, Endert E, Schattenkerk JKME,
Sauerwein HP. Insulin sensitivity and insulin clearance in
human immunodeficiency virus-infected men. Metabolism
1991, 40:651656.
26. Haffner SM, Fong D, Hazuda HP, Pugh JA, Patterson JK.
Hyperinsulinemia, upper body adiposity, and cardiovascular
risk factors in non-diabetes. Metabolism 1988, 37:338345.
27. Jarrett RJ. The cardiovascular risk associated with impaired
glucose tolerance. Diabetic Med 1996, 13:S15S19.
28. Bvenholm P, Karpe F, Proudler A, Tornvall P, Crook D,
Hamsten A. Association of insulin and insulin propeptides
with atherogenic lipoprotein phenotypes. Metabolism 1995,
44:14811488.
29. Grunfeld C, Pang M, Doerrler W, Shigenaga JK, Jensen P,
Feingold KR. Lipids, lipoproteins, triglyceride clearance, and
cytokines in human immunodeficiency virus infection and the
acquired immunodeficiency syndrome. J Clin Endocrinol Metab
1992, 74:10451052.
30. Lipshultz SE. Dilated cardiomyopathy in HIV-infected patients.
N Engl J Med 1998, 339:11531155.
31. Katlama C, Murphy R, Johnson V, et al. The Atlantic Study. A
randomised open-label study comparing two protease
inhibitors (PI)-sparing antiretroviral strategies versus a stan-
dard PI-containing regimen. Sixth Conference on Retroviruses
and Opportunistic Infections. Chicago, February 1999 [abstract
647].