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210 Diabetes Mellitus and Tuberculosis - Double Jeopardy

the increasing prevalence of type 2 DM in less tend to have higher rates of compliance with ATT
developed regions, many patients with TB will medications than do non diabetics. This is per-
have concomitant DM. Presently, little is known haps attributed to the fact that they are tuned to
about the effect of DM on the clinical presenta- a regular medication regimen than non diabetics.
tion and treatment outcome of TB.\nMETHODS: Thus the physician must be aware that the phar-
In an urban setting in Indonesia, 737 patients macology of ATT and diabetes is prone to im-
with pulmonary TB were screened for DM and portant interactions and practical considerations
were followed up prospectively during TB treat- including dose readjustment, toxicity monitoring
ment. Clinical characteristics and outcome were and higher chance of treatment failure. Future
compared between patients with TB who had DM research is required to establish whether thera-
and patients with TB who did not have DM.\nRE- peutic drug monitoring is required routinely and
SULTS: DM was diagnosed in 14.8% of patients feasible in such patients.
with TB and was associated with older age and
a greater body weight. On presentation, diabet- 9. Conclusion:
ic patients with TB had more symptoms but had Diabetes Mellitus and Tuberculosis are common dis-
no evidence of more-severe TB. After 2 months, eases that physicians will encounter in their lifetime
results of sputum microscopic examination was of practice. But the deleterious relationship that they
more often positive in diabetic patients (18.1% vs. share to jeopardize the human host is often under
10.0%
recognised. It is rational to screen every patient with
B. Influence of diabetes on anti tubercular drugs: tuberculosis for diabetes and if detected, engage in
strict glycemic control. Atypical presentations of tu-
Diabetes can cause altered pharmacokinetics berculosis in diabetics must be borne in mind despite
of anti-tubercular drugs especially Rifampicin. conflicting evidence on such an association. Therapy
Rifampicin levels were demonstrated to be 53% for TB and diabetes must consider drug interactions,
lower in diabetics than non-diabetics in one study. combined toxicities of the diseases and medications
This could be perhaps explained by altered gut and adequate precautions taken. Future research
absorption, protein binding in serum and altered must be encouraged in elucidating the patho-biolo-
metabolism of the drug in diabetics. This is of crit- gy behind the immune dysfunction in the diabetics’
icality because low levels of the backbone drug of response to TB infection.
ATT (Rifampicin) raises concerns of development
of drug resistance and treatment failure. Drug
toxicity is also of significance in diabetics with 10. Highlights:
nephropathy and impaired drug clearance in pa- Diabetes and Tuberculosis are common diseases
tients with fatty liver. Diabetics with nephropathy that can occur concurrently with mutual influence
will need dose re-adjustment of Ethambutol and and doubly jeopardise patients.
Pyrazinamide in the setting of a low glomerular Diabetes blunts the immune response to Mycobac-
filtration rate. In fact, studies from India and else- terium tuberculosis infections and results in a higher
where have shown a higher incidence of adverse incidence of disease in diabetics with varying clinical
drug reactions in diabetic patient with tuberculosis presentations and poorer outcomes.
than with patients with TB alone.
The patho-biology of this association has been de-
C. Enhanced toxicity of drugs and disease: scribed in limited studies and needs more research
Overlapping toxicities are also important to keep for better understanding.
in mind. Peripheral neuropathy of diabetes can It is prudent to screen all patients with tuberculosis
be worsened by the one caused by Isoniazid and for diabetes and engage in strict glycemic control, if
requires prophylactic pyridoxine therapy. Macular identified.
toxicity caused by Ethambutol may develop in a
pre existing diabetic retinopathy and worsen vi- Screening of diabetics for tuberculosis can be of
sion in a patient. Considering that a diabetic is public health significance and lead to earlier identifi-
usually on several medications, an add on diag- cation and treatment.
nosis of tuberculosis is bound to increase the pill In patients with co-existence of both diseases, poten-
burden for the patient. This raises concerns on tial drug interactions and overlapping toxicities must
compliance and adherence to medications. How- be taken into consideration by the treating physician.
ever studies from India have shown that diabetics

GCDC 2017