Tuberculosis and diabetes
2017; Wiley; Volume: 34; Issue: 5 Linguagem: Inglês
10.1002/pdi.2106
ISSN2047-2900
Autores Tópico(s)Diabetes and associated disorders
ResumoLeaderFree Access Tuberculosis and diabetes Dr Rowan Hillson MBE, Dr Rowan Hillson MBE National Clinical Director for Diabetes, England 2008–2013Search for more papers by this author Dr Rowan Hillson MBE, Dr Rowan Hillson MBE National Clinical Director for Diabetes, England 2008–2013Search for more papers by this author First published: 15 June 2017 https://doi.org/10.1002/pdi.2106Citations: 1AboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Diabetes is fuelling the spread of TB 1 Marie Duplessis, the beautiful 19th century French courtesan, attracted many admirers. Sadly, her fashionably pale complexion and increasing slimness were due to consumption (tuberculosis), from which she died aged 23. She lives on in Dumas' 'La Dame aux Camélias' and 'La Traviata' by Verdi. But tuberculosis is not a beautiful disease; its effects can be devastating. Worldwide, over one in 10 sufferers die from the disease; in 2015, 1.8 million of the 10.4 million people with known tuberculosis died. Sixty percent of people with tuberculosis are in India, Indonesia, China, Nigeria, Pakistan, and South Africa.2 Most tuberculosis goes undetected. It is estimated that one in three of the world's population (about two billion people) has latent tuberculosis, subsequently reactivated in one in 10.1 In England, in 2015, 5758 cases of tuberculosis were reported, 10.5/100 000. Sixty percent of cases occur in people not born in the UK who have lived here for more than six years. 'The rate of tuberculosis in the non-UK born population is still 15 times higher than in the UK born population, and 73% of all tuberculosis cases notified in 2015 (4087) were born abroad.'3 In 2015, there were about 415 million people with diabetes worldwide, 153.2 million in the Western Pacific, 78.3 million in South East Asia,4 and 4.5 million in the UK.5 Internationally, one in 11 adults had diabetes. The numbers are rising inexorably. Diabetes is more common in South Asian and African Caribbean people. Over 20 years, in a UK cohort including Europeans and first-generation migrants, aged 40–69 years without diabetes at baseline, 14% of Europeans, 33% of South Asians, and 30% of African Caribbeans developed new diabetes.6 Diabetes and tuberculosis are common, so many people worldwide will have both. People with diabetes are also more likely to develop tuberculosis. The Persian physician, Avicenna or Ibn Sina (980–1037), noted that having diabetes increased the risk of phthisis (tuberculosis) and that phthisis caused complications in diabetes. A meta-analysis found a relative risk of tuberculosis of 3.11, (95% CI 2.27–4.26) in those with diabetes vs those without.7 Other risk factors for tuberculosis are undernutrition, smoking, alcohol, HIV and indoor air pollution. Should people with diabetes be screened for tuberculosis or vice versa? Screening (usually via symptoms and X-rays) has been used in India and the Pacific Islands, and may be appropriate in other countries with a high prevalence of tuberculosis and diabetes. More evidence is needed. In countries like the UK with a low incidence of tuberculosis, clinicians should consider the diagnosis in patients with symptoms and in those who have had contact with people with tuberculosis. Detecting and treating latent tuberculosis could prevent reactivation, but further research is needed.8 Symptoms of tuberculosis Symptoms include persistent cough with or without blood, worsening breathlessness, poor appetite, weight loss, extreme tiredness and fatigue, and pyrexia. Tuberculosis may present as lymphadenopathy, or with musculoskeletal, gastrointestinal (e.g. abdominal pain), urinary, reproductive, or neurological symptoms, including confusion, headache or fits.9 Seek tuberculosis vigorously in patients with pyrexia of unknown origin. A 73-year-old woman with diabetes was admitted with congestive heart failure and compression fractures of the spine. She had backache, and a fever with weakness, malaise, sweating, and a non-productive cough. She was found to have both pulmonary and spinal tuberculosis.10 A London hospital found 11 patients with tuberculosis among 431 dialysis patients (incidence 1187/100 000 renal patients per year). Four of the 11 had diabetes (36%) vs 19% among the total dialysis population.11 An eight-year-old girl with a three-year history of type 1 diabetes was admitted to a Turkish hospital with a 24-hour history of nausea, vomiting, fever, lethargy, and headache. She was found to have diabetic ketoacidosis so intravenous fluids and insulin were started. She became stuporose and bradycardic. A CT scan showed cerebral oedema which was treated with mannitol and dexamethasone. Diabetes insipidus developed, treated with desmopressin. Her conscious level did not improve. An MRI scan showed probable tuberculomas. A diagnosis of tuberculous meningitis was confirmed by finding acid-fast bacilli in her cerebrospinal fluid. Quadruple therapy was started.12 A 78-year-old Japanese woman with diabetes, atrial fibrillation, hypertension and renal impairment presented with painless swellings in the neck, some of which had ulcerated. She was apyrexial. Radiology showed widespread lymphadenopathy. Despite intensive investigations, including for tuberculosis, it was nine weeks before deep biopsies found Mycobacterium tuberculosis which was treated with quadruple therapy.13 Treatment See Box 1. People with diabetes who have tuberculosis respond less well to treatment than non-diabetic patients. A meta-analysis found that the risk ratio of treatment failure or death was 1.69 (95% CI 1.36–2.12). After adjusting for confounders such as age, the risk of death was 4.95 (2.69–9.10) among people with diabetes vs those without. There was an increased risk of relapse (RR 3.89; 2.43–6.23).14 Box 1. Issues to consider when managing patients with tuberculosis and diabetes. (Adapted from Riza AL, et al. Lancet Diabetes Endocrinol 2014;2:740–53)8 Coordinate care. The tuberculosis team controls the tuberculosis treatment and must liaise with all the medical and health care teams caring for the patient. People with diabetes often attend multiple clinics and health care services, perhaps on different sites with separate records. Clear communication is essential for patient and staff safety Infection control. Non-tuberculosis clinics may be unfamiliar with the infection control requirements and may lack appropriate equipment Tuberculosis treatment may need to be weight-adjusted and longer than usual Diabetes treatment. Maintain good glycaemic control. Remember drug interactions, the hyperglycaemic effect of active infection, and the hypoglycaemic effect of infection resolution Monitor adherence, and the response to tuberculosis and diabetes treatment. There is an increased risk of drug toxicity, tuberculosis treatment failure, and relapse Support and educate patients and families/carers about tuberculosis and diabetes. Encourage healthy lifestyle. Remember the psychological effects of the patient's diagnoses Screen close contacts for tuberculosis. Consider screening relatives with diabetes even if not in such close contact. In people with diabetes with past tuberculosis who are unwell consider screening for recurrence Continuity of care. Establish a follow-up plan tailored to the patient's needs. He or she is at risk of recurrence of tuberculosis, and often has multiple complications of diabetes. Retrieve non-attenders – do not discharge them Improve glycaemic control and increase blood glucose monitoring. The combination of anti-tuberculosis treatment, diabetes self-management and treatment of any complications places a considerable burden on patients and may reduce adherence to treatment. Provide increased support. Standard anti-tuberculous therapy usually combines isoniazid, rifampicin, pyrazinamide and ethambutol.15 Multi-drug-resistant tuberculosis is an increasing and worrying problem. Rifampicin interacts with many drugs, reducing plasma concentrations of sulphonylureas, repaglinide and nateglinide, pioglitazone, saxagliptin, linagliptin, canagliflozin, and dapagliflozin. It may enhance the action of metformin. Rifampicin also interacts with some statins and anti-hypertensive drugs.8 People with diabetes have lower plasma concentrations of rifampicin than expected. In an Indonesian study, rifampicin levels were 50% lower in tuberculosis patients with diabetes vs those without. However, much of this difference vanished after correction for body weight which was greater in patients with diabetes. It is suggested that larger doses may be required in overweight patients.16 Patients with renal impairment may need to reduce the dose of ethambutol and pyrazinamide. Insulin is sometimes advised rather than oral anti-diabetic agents, but this carries a greater risk of hypoglycaemia. Insulin may be useful in patients with severe tuberculosis, in those needing a high-calorie, high-protein diet or requiring an anabolic effect, in tuberculous pancreatitis, in patients with liver dysfunction, and in those in whom interactions between anti-tuberculosis drugs and non-insulin diabetes drugs are an issue.17 The management of patients with tuberculosis, diabetes and HIV, with greater possibility of multiple complications and drug interactions, is even more complex. Like other infections, tuberculosis may cause hyperglycaemia in patients without known diabetes. In some cases, the glucose will return to normal when the tuberculosis has been treated successfully. Summary People with diabetes are three times more likely to develop tuberculosis than people without diabetes. Suspect tuberculosis in patients with: persistent cough (haemoptysis), breathlessness, anorexia, weight loss, fatigue and pyrexia; unexplained lymphadenopathy; or unexplained symptoms in a patient with a past history of tuberculosis. Tuberculosis can affect most parts of the body, as can diabetes. Tuberculosis is harder to treat successfully, and is more likely to recur in people with diabetes than in those without diabetes. Beware drug interactions, and the need to adjust both anti-tuberculosis treatment and hypoglycaemic treatment. Rifampicin interacts with most oral diabetes drugs. Be alert to the hyperglycaemic effect of infection, and the hypoglycaemic effect of recovery. Support the patient and family/carers to enhance adherence to treatment. Ensure good communication between all teams caring for the patient. All teams must know that the patient has tuberculosis and how to manage infection control, as well as the medication and monitoring issues. Remember tuberculosis. It is a disease of the present, not just the past. References 1The International Union against Tuberculosis and Lung disease and World Diabetes Federation. The looming co-epidemic of TB-diabetes: a call to action. www.theunion.org/what-we-do/publications/technical/english/EMBARGOED-DMTB-REPORT-Oct-22.pdf. 2 World Health Organisation. Global Tuberculosis Report 2016. http://apps.who.int/iris/bitstream/10665/250441/1/9789241565394-eng.pdf?ua=1 [accessed 30 April 2017]. 3 Public Health England. Tuberculosis in England 2016 report. https://www.gov.uk/government/publications/tuberculosis-in-england-annual-report [accessed 29 April 2017]. 4 Diabetes UK. https://www.diabetes.org.uk/Professionals/Position-statements-reports/Statistics/ [accessed 29 April 2017]. 5 International Diabetes Federation. www.idf.org/about-diabetes/facts-figures [accessed 29 April 2017]. 6Tillin T, et al. Insulin resistance and truncal obesity as important determinants of the greater incidence of diabetes in Indian Asians and African Caribbeans compared with Europeans. Diabetes Care 2013; 36(2): 383– 93. 7Jeon CY, et al. Diabetes mellitus increases the risk of active tuberculosis: a systematic review of 13 observational studies. PLoS Med 2008 Jul 15; 5(7):e152. https://doi.org/10.1371/journal.pmed.0050152 [accessed 29 April 2017]. 8Riza AL, et al. Clinical management of concurrent diabetes and tuberculosis and the implications for patient services. Lancet Diabetes Endocrinol 2014; 2: 740– 53. 9 NHS Choices. www.nhs.uk/Conditions/Tuberculosis/Pages/Symptoms.aspx [accessed 29 April 2017]. 10Dass B, et al. Tuberculosis of the spine (Pott's disease) presenting as 'compression fractures'. Spinal Cord 2002; 40: 604– 8. 11Moore D, et al. High rates of tuberculosis in end-stage renal failure: the impact of international migration. Emerg Infect Dis 2002; 8(1): 77– 8. 12Elmas ON, et al. Tuberculous meningitis associated with diabetic ketoacidosis. J Clin Res Pediatr Endocrinol 2011; 3(4): 222– 4. 13Minakawa S, et al. A diagnostically challenging case of tuberculous lymphadenitis. Dermatologica Sinica 2016; 34(4): 217– 8. 14Baker MA, et al. The impact of diabetes on tuberculosis treatment outcomes: a systematic review. BMC Med 2011; 9: 81. 15British National Formulary April 2017. https://www.medicinescomplete.com/mc/bnf/current/index.htm [accessed 30 April 2017]. 16Nijland HMJ, et al. Exposure to rifampicin is strongly reduced in patients with tuberculosis and type 2 diabetes. Clin Infect Dis 2006; 43: 848– 54. 17Niazi AK, et al. Diabetes and tuberculosis: a review of the role of optimal glycemic control. J Diabetes Metab Disord 2012; 11(1): 28. Citing Literature Volume34, Issue5June 2017Pages 149-150 ReferencesRelatedInformation
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