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Severe hyperglycemia after initiation of long-acting cabotegravir in two antiretroviral treatment-controlled people with HIV
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march 26 2026
Diabetes & Metabolism
Download the PDF here
Download the PDF here
Download the PDF here
We report here two cases of PWH who transitioned ART to injectable CAR-LA and developed severe hyperglycemia within weeks to months after the transition. Both patients had normal glycemic values before starting CAR-LA-based ART but both presented in the preceding year with mildly increased glycemic values suggesting a prediabetic condition.
Our PWH were probably prediabetic (previous mildly elevated glycemia) with limited insulin production capacity. Even mild inhibition of insulin secretion by CAB could result in insulinopenia and consequently hyperglycemia. Indeed, the level of peptide-C was low in Case 2 and the presence of ketoacidosis in case 1 is in line with severe insulinopenia. Both PWH benefited from a treatment with intravenous insulin which reversed hyperglycemia. Interestingly, in case 2, after the acute episode, glycemia was controlled by metformin while CAR-LA was pursued.
Our case reports serve as a warning regarding glycemia after CAB use. Clinicians should closely monitor blood glucose in cabotegravir-treated patients throughout treatment initiation and follow-up, especially PWH with metabolic syndrome features, mildly increased glycemia or with a high BMI.
Recent studies indicate that initiating or switching people with HIV (PWH) to integrase strand transfer inhibitor (INSTI)-based antiretroviral treatment (ART) can result in weight gain or obesity. INSTI initiation has also been associated with an increased risk of type 2 diabetes within the first year of INSTI treatment, which has been related, at least in part, to weight gain [[1], [2], [3], [4], [5]].
Additionally, some rare clinical cases of rapid severe hyperglycemia occurring shortly after initiating an orally given INSTI raltegravir (RAL), evitegravir (EVG), dolutegravir (DTG) or bictegravir (BIC) have been reported [[6], [7], [8], [9], [10], [11], [12], [13]]. To our knowledge, no case of rapidly occurring severe hyperglycemia has been reported after long-acting (LA) cabotegravir (CAB) initiation administered monthly the first two months then every two months via intramuscular injection in association with the non-nucleoside reverse transcriptase inhibitor (NNRTI) rilpivirine (CAR-LA). We report here two cases of ART-controlled PWH, switched to CAR-LA for simplification, who developed severe hyperglycemia a few weeks after receiving the initial CAR-LA injection.
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