Tuberculosis And Diabetes. Dr. hanan abuelrus Prof.of internal medicine Assiut University

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1 Tuberculosis And Diabetes Dr. hanan abuelrus Prof.of internal medicine Assiut University

2 TUBERCULOSIS FACTS More than 9 million people fall sick with tuberculosis (TB) every year. Over 1.5 million die from TB every year, which the vast majority of deaths in the developing world. One in three people in the world is infected with latent TB. People infected with latent TB have a lifelong risk of developing and falling sick with active TB.

3 DIABETES FACTS 350 million people have diabetes. Diabetes prevalence is similar in both high- and lowincome countries. Over 80% of diabetes deaths occur in low- and middle income countries. It is predicted that global diabetes prevalence will increase by 50% by 2030.

4 THE LINKS BETWEEN TUBERCULOSIS AND DIABETES People with a weak immune system, as a result of chronic diseases such as diabetes, are at a higher risk of progressing from latent to active TB. People with diabetes have a 2-3 times higher risk of TB compared to people without diabetes. About 10% of TB cases globally are linked to diabetes.

5 A large proportion of people with diabetes as well as TB is not diagnosed, or is diagnosed too late. Early detection can help improve care and control of both but the reverse is not true Many persons with TB who become diabetic are unaware of their condition and they do not respond well to TB drugs

6 When TB relapses, it is a serious threat as these people can transmit the infection.

7 How might diabetes mellitus lead to tuberculosis Poorly controlled diabetes can lead to multiple complications vascular disease, neuropathy, and increased susceptibility to infection The mechanisms include those directly related to hyperglycemia and cellular insulinopenia or indirect effects on macrophage and lymphocyte function leading to diminished ability to contain the organism

8 The most important effector cells for containment of tuberculosis alveolar macrophages and their precursor monocytes and lymphocytes. Diabetes is known to affect chemotaxis, phagocytosis activation, and antigen presentation by phagocytes in response to M tuberculosis. In diabetic patients chemotaxis of monocytes is impaired and this defect does not improve with insulin

9 Does tuberculosis lead to diabetes Some studies suggest that tuberculosis can even cause diabetes in those not previously known to be diabetic. Patients with tuberculosis have higher rates of glucose intolerance which became normal after 3 months of tuberculosis treatment. Impairment of glucose metabolism probably preceded tuberculosis in these patients rather than the reverse

10 Integrating DM and TB Programs Diagnosing TB in DM Cases Diagnosing DM in TB Cases Treating TB in DM Cases Managing DM during TB Treatment

11 Screening for DM in persons with TB Standard 1.0 : Every person with TB over the age of 18 should be screened for DM Guideline 1.1Diabetes : A fasting plasma glucose > 125 mg/dl A random plasma glucose > 200 mg/dl A hemoglobin A1C > 6.5 % Guideline 1.2 : Abnormal glucose values should be verified with a repeat test in patients who have no symptoms of DM

12 Guideline 1.3 : Glucose testing should be repeated after 2-4 weeks of TB treatment. Screening for TB in persons with DM Standard 2.0 : Persons with DM who are determined to be at increased risk of TB should be screened for active TB disease and latent TB infection Guideline 2.1 A tuberculin skin test (TST) or interferon gamma releasing assay(igra) for TB should be done at the time of DM diagnosis Guideline 2.2 Screening should be repeated as often as the local TB epidemiology may warrant

13 Standard 3.0 : Patients identified with suspected or confirmed active TB should be referred to the local TB Program for TB management Standard 4.0 : Persons with DM who are identified with LTBI should be encouraged to take isoniazid preventive therapy for 9 months Guideline 4.1 Prescribe B6to help prevent INH induced neuropathy (10 25 mg/day) Guideline 4.2 Educate patients for the potential side effects of INH therapy. Monthly monitoring for adherence and side effects is recommended

14 Treating TB in persons with DM Standard 5.0 : Ensure that TB treatment is appropriately adjusted in persons with DM Guideline 5.1 : Ensure that TB medications are properly dosed : Check creatinine for diabetic nephropathy, and adjust the frequency of PZA and EMB : Administer B6 to prevent INH induced peripheral neuropathy (10 25 mg/day ) Guideline 5.2 : Observe closely for TB treatment failure in persons with DM : Be aware of poor absorption of some TB meds in DM :Manage the many interactions between TB and DM meds

15 5.2.3 : Be aware of a possible slight increase in TB drug resistance in persons with DM : Consider extending treatment to 9 months for persons with DM, especially those patients with cavitary disease or delayed sputum clearance : Upon completion of therapy, obtain AFB smear and culture : Evaluate patients at 6 months and one year after treatment for evidence of relapse

16 Managing DM in persons with TB Standard 6.0 :Glucose testing should be repeated in TB Clinic during TB therapy Guideline 6.1 : There should be a glucometer in every TB clinic Guideline 6.2 : Check glucose in TB clinic at least weekly for the first 4 weeks, and less frequently thereafter if the diabetes is well controlled (Monthly blood glucose measurement during TB treatment is recommended.)

17 Standard 7.0 : Use frequent contact in clinic with TB patients to help manage DM Guideline 7.1 : All clinic staff should reinforce lifestyle changes at TB clinic visits. Guideline 7.2 : If available, refer persons with DM to the diabetes Clinic for long-term diabetes care ensure the DM clinician is aware of TB diagnosis and TB medications Standard 8.0 : Use frequent DOT visits with TB patients to help manage DM Guideline 8.1 : DOT workers should encourage lifestyle changes at every patient encounter.

18 8.1.1 : Dietary changes and physical activity are most important in this effort : DOT workers should use structured culturallyappropriate diabetes educational materials. Guideline 8.2 : Consider delivering DM meds with TB meds via DOT for persons with DM who have suspected non-adherence to diabetic medications.

19 Treatment of Tuberculosis Among Diabetic Patient Diabetes medications can interact with tuberculosis treatment Patients with diabetes and TB take longer to respond to anti-tb treatment Patients with tuberculosis and diabetes mellitus showed no response to tuberculosis therapy as patients who do not have diabetes. Tuberculosis infection in diabetes mellitus is usually due to reactivation of an old focus rather than through fresh contact

20 ADVERSE EFFECTS AND DRUG Rifampicin INTERACTIONS Accelerates the metabolism of oral hypoglycemic agents It was also to cause early hyperglycemia in nondiabetic patients with or without T.B. Also to augment intestinal absorption of glucose Chronic rifampicin treatment manifesting hypercortisolism and unstable glycemic control However, after withdrawal of rifampicin, his urinary cortisol excretion returned to normal within two weeks.

21 Malabsorption of rifampicin was also reported in poorly controlled D.M. Isoniazid, or Pyrazinamide It was attributed to the increased insulin requirment peripheral neuropathy caused by treatment with isoniazid Vit B 12 should be given with isoniazid during T.B treatment in diabetic patients

22 Diabetes can also cause changes in oral absorption, decreased protein binding of drugs, renal insufficiency, fatty liver with impaired drug clearance and therapeutic drug monitoring might be considered ACTIVE TUBERCULOSIS SHOULD BE TREATED WITH INSULIN

23 Contraindications for oral antidiabetic drugs sulphonylureas bigunides Tuberculosis, a serious intercurrent illness Pancreatic disease Hepatic disease Loss of appetite Loss of weight Glucose malabsorption

24 Diabetic patients with TB should receive the standard SCC regimen (2HRZE/4HR). a)intensive Phase Ethambutol (E) Ig Isoniazid (H) 300 mg Rifampicin (R) 450 mg Pyrazinamide (Z) 1.5 g 2EHRZ All drugs consumed together, daily, for 2 months (b)continuation phase 4HR Isoniazid (H) 300 mg Rifampicin (R) 450 mg

25 (BCG) vaccine in type 1 diabetes can regenerate insulin-secreting cells in the pancreas Two injections, four weeks apart, of BCG There are preserved islet cells many years out

26

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