Double Trouble:

Diabetes and Tuberculosis

Krishna W Sucipto
Endocrine and Metabolic Division of Internal Department
Faculty of Medicine Syiahkuala University dr Zainoel Abidin Hospital
Banda Aceh
Prevalensi TB di Beberapa Provinsi di Indonesia
(Riskesdas, 2013)
Prevalensi DM di Beberapa Provinsi di Indonesia
(Riskesdas, 2013)
 Tuberculosis and Diabetes:
Old Foes

Indian physician Susruta, in 600 A.D.

phthisis frequently complicated diabetes
Autopsy of diabetics in 1883 showed presence
of TB granuloma I 50% of diabetics
Prior to the insulin era: Diagnosis of DM was a
death sentence
Leading cause of death was: Tuberculosis
 Background

Diabetes increases risk for progression from

latent TB infection (LTBI) to active TB disease
and complicates treatment of active TB
Delays in diagnosis for both diabetes and TB
Globally, the number of people with diabetes
is increasing
 Background
Pathophysiology diabetes, especially when
poorly-controlled, causes relative
immunocompromise and increases likelihood
of reactivation of TB
Epidemiology dramatic increase of diabetes
Demographics diabetes disproportionately
affects lower socioeconomic groups and
ethnic minorities that also have higher
prevalence of TB
 Background
Treatment considerations hard to treat TB in
the face of poor glucose control
Hidden epidemic estimated that of people
with diabetes dont know they have it
 Definitions
Latent Tuberculosis Infection (LTBI)
Persons are infected with M. tuberculosis, but do
not have active TB disease.

Active TB Disease
Persons infected with M tuberculosis bacteria that
progress from latent TB infection.
Prevention of TB in persons with DM
Persons with diabetes mellitus (DM) who are at
increased risk of tuberculosis (TB) should be
screened for latent TB infection (LTBI)

Patients with DM who are found to have LTBI should

be encouraged to take INH for 9 months
Patients with DM on INH should receive vitamin
B6 to prevent INH induced neuropathy
 Screening for DM in persons with TB
Every patient with TB over the age of 18 should
be screened for DM
A fasting plasma glucose > 125 mg/dl = DM
A random plasma glucose > 200 mg/dl = DM
A Hemoglobin A1c > 6.5% = DM

Abnormal glucose values should be repeated in

patients who have no symptoms of DM
 Screening for DM in persons with TB
Glucose should be repeated after 2-4 weeks of
TB Rx or if symptoms of hyperglycemia
develop
Rifampin and INH can markedly elevate glucose
levels
Use the same criteria to diagnose DM as at initial
evaluation

Ask about polyuria/polydipsia at TB clinic visits

Management of DM in patients receiving
TB treatment

Use the frequent contact with the patient during

TB treatment to help manage his/her DM in the
TB clinic
There should be a glucose meter in every TB clinic and
blood glucose should be frequently checked in the
clinic for those with DM
All clinical staff should reinforce lifestyle changes at TB
clinic visits
If available, refer persons with diabetes to a diabetes
specialty clinic or clinician comfortable with treating
DM
 Management of DM in patients
receiving TB treatment
DOT workers should encourage lifestyle changes
at every encounter
Dietary changes and physical activity are most
important in this effort
Use available structured diabetes education materials
Consider delivering DM meds with TB meds via DOT
 Treatment of TB in persons with DM
Ensure that TB treatment is appropriately
adjusted in persons with DM
Check creatinine for diabetic nephropathy
May need to adjust frequency of PZA and EMB
administration
Give B6 to prevent INH induced peripheral
neuropathy
 Treatment of TB in persons with DM
Ensure that TB treatment is appropriately
adjusted in persons with DM
Persons with DM have a relative immune suppression
and often a higher burden of disease
Consider extending treatment to 9 months for persons
with DM and caviatary disease OR delayed sputum
clearance.
Upon completion of therapy, obtain smear and culture
Follow up the patient at 6 months and one year after
treatment completion
 Treatment of TB in persons with DM
Observe closely for treatment failure
Be aware of poor absorption of some TB meds in DM
Manage the many interactions between TB and DM
meds
There may be a slight increase in diabetic retinopathy
in persons with DM
 Choice of pharmacologic therapy should be
based on patient-centered approach,
considering
- Efficacy
- Cost
- Potential side effects
- Effects on weight
- Comorbidities
- Hypoglycemia risk
- Patient preferences
Thank You