DM and TB in Indonesia,

The Under-recognized Problem

dr Em Yunir
dr. Andra Aswar
 TUBERCULOSIS
www.who.int/tb & DIABETES
COLLABORATIVE FRAMEWORK FOR
CARE AND CONTROL OF TUBERCULOSIS AND DIABETES
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 Estimated
infected with latent TB have a tuberculosis
lifelong risk of developing and incidence,
falling sick with active TB by country,
2009

Prevalence of diabetes in adults aged 25+ DIABETES FACTS:

by WHO region and World Bank Income Group, 2008 350 million people have
diabetes
Diabetes prevalence is similar
in both high- and low-income
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

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
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
All people with TB should be screened for diabetes
Screening for TB in people with diabetes should be
considered, particularly in settings with high TB prevalence
People with diabetes who are diagnosed with TB have a
higher risk of death during TB treatment and of TB relapse
after treatment. WHO-recommended treatments should be
rigorously implemented for people with TB/diabetes
Diabetes is complicated by the presence of infectious
diseases, including TB. It is important that proper care for
diabetes is provided to those that are suffering from
TB/diabetes

WHO Sept 2011 For more information: www.who.int/tb


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
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
WHO Sept 2011
It is predicted that global
diabetes prevalence will
increase by 50% by 2030
All people with TB should be screened for diabetes
Screening for TB in people with diabetes should be
considered, particularly in settings with high TB prevalence
People with diabetes who are diagnosed with TB have a
higher risk of death during TB treatment and of TB relapse
after treatment. WHO-recommended treatments should be
rigorously implemented for people with TB/diabetes
Diabetes is complicated by the presence of infectious
diseases, including TB. It is important that proper care for
diabetes is provided to those that are suffering from
TB/diabetes
For more information: www.who.int/tb
 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
 Mortality Rate and Pattern in Diabetes :
Data from RSCM*
Retrospective Data from Medical Records during 2011
n=1590
Mortality Rate 4.59%

n = 1590, RSCM 2011 Tahapary D, et al (unpublished data). 2013

 Tuberculosis Among Diabetes Patients in
Endocrinology Outpatient Clinic of RSCM*

9.4% of tuberculosis self-reported

cases

Tahapary D, et al. JDM. 2012

Retrospective Data from Medical Records 2003-2004

n=1893 (1255 completed)
 Diabetes and Tuberculosis in Indonesia

Case Control Study, Prevalence of DM (FPG >126 mg/dL) among newly

diagnosed pulmonary TB patients and matched control

TBC + Non TBC

13.2 % 3.2 %
DM +
(60/454) (18/556)

BMI 17.7 Kg/m2 21.5 Kg/m2

OR 4.7 (95% CI 2.7-8.1) Alisjahbana B. 2006

 44"

Diabetes" No"diabetes"
CharacterisPca" (n"="86)" (n"="147)" P"
Country"of"enrolment" 0.65"
United"States" 24"(28)" 37"(25)"
Mexico" 62"(72)" 110"(75)"
Age"Mean"("SD)" 49.9"(13)" 40.3"(17)" <"0.0001"
Female"gender" 32"(37)" 42"(29)" 0.17"
EducaPon" 0.70"
None" 13"(15)" 18"(12)"
Elementary"or"middle"school" 57"(66)" 96"(65)"
High"school"or"higher" 16"(19)" 33"(22)"
Employed" 53"(62)" 103"(70)" 0.19"
BMI" 0.0001"
Underweight" 10"(12)" 36"(25)"
Normal"weight" 42"(50)" 87"(60)"
Overweight/obese" 32"(38)" 23"(16)"
Alcohol"abuse" 9"(11)" 32"(22)" 0.03"
Drug"abuse" 11"(13)" 40"(27)" 0.01"
History"of"incarceraPon" 2"(2)" 13"(9)" 0.06"
HIV+" 0"(0)" 9"(6)" 0.03"
References:" ,"2011;"89(5):"352V359."
The Effect of T2DM on the Presentation and Treatment
Response of Pulmonary Tuberculosis
Urban Setting in Indonesia, 737 pulmonary TB were screened for DM using FPG and
were followed up prospectively

14.8% of TB patients had diabetes

Older age
Greater body weight
Had more symptoms
No evidence of more severe TB
After 2 months : Mycobacterium (+) 18.1% vs 10.0%
After 6 months : Mycobacterium (+) 22.2%
Adjusted OR 7.65

Alisjahbana B. Clin Infect Dis. 2007

 46"

Diabetes"Affects"AnP\tuberculosis"Drugs" Tuberculosis"Affects"AnP\diabetes"
Drugs"

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47"
 Tuberculosis Among Diabetes Patients in
Endocrinology Outpatient Clinic of RSCM*
Retrospective Data from Medical Records 2003-2004
n=1893 (1255 completed)

Tahapary D, et al. JDM. 2012

 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)
TST or IGRA should be done at time of DM diagnosis

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 > 126 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
Monitoring more frequently
Blood glucose should be frequently checked
Reinforce lifestyle change

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 Consider delivering DM
meds with TB meds via DOT
 46"

Diabetes"Affects"AnP\tuberculosis"Drugs" Tuberculosis"Affects"AnP\diabetes"
Drugs"

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 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
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Tabel 1. Hal hal yang perlu dipantau
Yang dipantau Waktu Pemeriksaan
Tinggi dan BB Setiap kunjungan
BMI Setiap kunjungan
Pemantauan Setelah pengobatan TB bulan ke 2, ke 5 dan Akhir
Pengobatan
Latihan jasmani Setiap 3 bulan
Diet Setiap kunjungan
HbA1 C Awal diagnosis
Tiap 6 bulan sekali
Merokok Setiap kunjungan
GDP Setiap kunjungan
G 2 jam PP Setiap kunjungan
Periksa profil lemak (TC, Awal diagnosis
HDL, TG and calculated Bila belum ada kelainan diulangi setiap tahunnya.
LDL) Bila sudah ada dislipidemia dilakukan evaluasi ulang
setiap 3 bulan
Pemeriksaan mata DM tipe 2 dilakukan saat diagnosa bila tidak ada
kelainan diulang setiap 1-2 tahun sekali.
Bila ditemukan kelainan maka interval follow up
ditentukan oleh spesialis mata sesuai dengan berat
ringannya kelainan
Pemeriksaan proteinuria DMTipe 2 dilakukan saat diagnosa ditegakan bila tidak
(mikroalbuminuria) dan ada kelainan diulangi setiap tahun sekali
serum kreatinin yg Ditemukan adanya kelainan interval follow up
dikonversikan ke GFR. ditentukan oleh spesialis penyakit dalam sesuai dengan
berat ringannya kelainan
Pemeriksaan Neuropati DM tipe 2 dilakukan saat diagnosa ditegakan kemudian
bila tidak ada kelainan diulangi tiap 1-2 tahun sekali.
Bila ditemukan adanya neuropati maka interval follow
up ditentukan oleh spesialis sesuai dengan berat
ringannya kelainan
Pemeriksaan ECG Pemeriksaan ECG awal dan diulang tiap 1 tahun sekali
Apabila ditemukan kelainan diulang setiap 6 bulan

x-foto thorax Awal diagnosis

Bisa dilakukan setiap 1 tahun sekali
 Conclusions
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 for AFB
Follow up the patient at 6 months and one year after treatment
completion
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