Comment on Han et al. Comparative Effectiveness of Diabetic Oral Medications Among HIV-Infected and HIV-Uninfected Veterans. Diabetes Care 2017;40:218–225

Regarding the article by Han et al. (1), we would like to add the following comments.

As the article points out, diagnosis, control objectives, and therapy in the patient with HIV and type 2 diabetes are similar to those in the non-HIV patient (2). At present the approach in patients with HIV and type 2 diabetes who are overweight or obese should be treatment with antidiabetic medications that, in addition to improving metabolic control, produce weight loss without increasing the risk of hypoglycemia; the only such drugs available are the glucosuric agents sodium–glucose cotransporter 2 inhibitors (SGLT2Is) and glucagon-like peptide 1 receptor agonists (GLP-1 RAs). During the period described in the study (1999–2010), in which 74% of the HIV patients with diabetes were overweight or obese, there were commercially available GLP-1 RAs whose efficacy in HIV patients has been demonstrated for the control of HbA_1c and weight loss (3). In addition, reduction in cardiovascular mortality was demonstrated with liraglutide in the Liraglutide Effect and Action in Diabetes: Evaluation of Cardiovascular Outcome Results (LEADER) study (4). On the other hand, since 2011 three SGLT2Is—canagliflozin, dapagliflozin, and empagliflozin—have become available that improve HbA_1c between 0.8 and 1%, decrease weight between 2 and 3.5 kg, and reduce systolic blood pressure. We have recently published a series of eight cases of obese patients with HIV and type 2 diabetes showing statistically significant improvement of HbA_1c and weight loss after 24 weeks of treatment with 300 mg/day canagliflozin, without interference with highly active antiretroviral therapy and with no significant undesirable effects (5).

Therefore, we consider that in overweight or obese patients with HIV and type 2 diabetes, as in non-HIV patients, therapy with an SGLT2I and/or a GLP-1 RA should be initiated after metformin because of the efficacy and safety of these drugs.