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•Tuberculosis and Diabetes – Dec. 10, 2009
•Richard Brostrom, M.D. •1 of 9
Integrating Diabetes and TB ProgramsNational Web‐based Seminar ‐ Dec 10, 2009
Richard Brostrom, M.D.‐M.S.P.H.Commonwealth of the Northern Mariana Islands (CNMI)
Division of Public Health
Department of Public Health DDiabetes and TTuberculosis: DDouble TTrouble
Overview Diabetes in the CNMI
Tuberculosis in the CNMI
Integrating Diabetes Mellitus (DM) and g g ( )Tuberculosis (TB) Programs Diagnosing DM in TB Cases
Treating TB Cases with DM
Managing DM during TB Treatment
Opportunities for TB Prevention
R.Brostrom – DPH
Department of Public Health
Mainland US To Scale
•Tuberculosis and Diabetes – Dec. 10, 2009
•Richard Brostrom, M.D. •2 of 9
Department of Public Health Carolinian in Saipan, 1905
R.Brostrom – DPH
Department of Public Health Dietary Change After 1944
R.Brostrom – DPH
Department of Public Health Diabetes Around the World
Saipan - Carolinians
Saipan - Chamorros
Nauru
Pima Indians
0 10 20 30 40 50
World Average
U.S.
Cook Islands
Kirabati
New Caledonia
Percent of Adults with DiabetesR.Brostrom – DPH
•Tuberculosis and Diabetes – Dec. 10, 2009
•Richard Brostrom, M.D. •3 of 9
Department of Public Health Global Rising Tide of Diabetes
•Millions of Cases in 2000 and Projected Cases for 2030
R.Brostrom – DPH
Department of Public Health TB Cases in CNMI
120
140
160
180
000
/yr
CNMI Rate US Rate
0
20
40
60
80
100
'92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06
Rat
e p
er 1
00,
Year
R.Brostrom – DPH
Department of Public Health Linking Tuberculosis and Diabetes
Immune Suppression in Diabetics
TB largely cell‐mediated immunity
Diabetics with decreased function of WBC
Chemotaxis, phagocytosis, Th‐1 cytokines, p g y , y
Linking by Social Determinants: PovertyLinking by Social Determinants: Poverty
Poverty ‐> Crowding ‐> Higher TB rates
Poverty ‐> Poor Diet ‐> ↑Obesity/Diabetes
R.Brostrom – DPH
•Tuberculosis and Diabetes – Dec. 10, 2009
•Richard Brostrom, M.D. •4 of 9
Department of Public Health TB and DM in CNMI
Tracking DM since 2005
Recording DM in TB database
Diabetes
By far our most common co‐morbidity
More important than HIV, ETOH, Homelessness, and IV drug use combined!
Similar for other locations with lower HIV prevalence and higher diabetes prevalence
R.Brostrom – DPH
Department of Public Health TB and DM in CNMI: 2008 (age 30 and older)
50%
60%
70%
80%
with
Dia
bete
s
0%
10%
20%
30%
40%
All TB Cases Adult Pacific Islander
Perc
ent T
B P
atie
nts
w
R.Brostrom – DPH
Department of Public Health Comparing TB Risks in the CNMI
Tuberculosis ComorbidCondition
Relative Risk of Activation
ComorbidPopulation in
CNMI
Projected TB Cases in the CNMI, 10 yrs
HIV 10 x 9 1
Diabetes 3 x 5,000 150
Assumptions: 50 percent PPD +
Baseline 50 yrs/5% activation
1% activation in 10 years
R.Brostrom – DPH
•Tuberculosis and Diabetes – Dec. 10, 2009
•Richard Brostrom, M.D. •5 of 9
Department of Public Health
Warning:Warning:
Four Steps for DM‐TB Care“Saipan Standards”
UNOFFICIALUNOFFICIAL
GUIDELINESGUIDELINES
AHEADAHEAD
R.Brostrom – DPH
Department of Public Health Four Steps for DM‐TB Care“Saipan Standards” (2)
1.1. Diagnose Diabetes in TB PatientsDiagnose Diabetes in TB Patients
2.2. Adjust TB Treatment for Persons with DiabetesAdjust TB Treatment for Persons with Diabetesjj
3.3. Help Manage Diabetes During TB TreatmentHelp Manage Diabetes During TB Treatment
4.4. Prevent TB in Persons with Diabetes Prevent TB in Persons with Diabetes
R.Brostrom – DPH
Department of Public Health 1. Diagnose Diabetes in TB Patients
A.A. Screen all TB cases over age 25 for diabetesScreen all TB cases over age 25 for diabetes
• Initial labwork (fasting, if possible)
• Serum glucose >125 mg/dl (fasting) = Diabetes
• Serum glucose >200 mg/dl (random) = Diabetes
B.B. Repeat glucose testing at 4 weeksRepeat glucose testing at 4 weeks
• Rifampin and INH can markedly elevate glucose
• Use the same glucose criteria
• Serum glucose >200 mg/dl (random) = Diabetes
C. C. Ask about Ask about polyuriapolyuria//polydipsiapolydipsia at TB clinic visitsat TB clinic visits
R.Brostrom – DPH
•Tuberculosis and Diabetes – Dec. 10, 2009
•Richard Brostrom, M.D. •6 of 9
Department of Public Health 2. Adjust TB Treatment for DM
A.A. Ensure TB medications are properly dosedEnsure TB medications are properly dosed
• Check creatinine for diabetic nephropathy
• May have to adjust PZA and EMB
• B6 for higher rates of INH‐neuropathy6 g p y
B.B. Observe closely for treatment failureObserve closely for treatment failure
• Poor absorption of some TB meds in DM
• Many interactions between TB and DM meds
• May be slight increase in drug resistance in DM
R.Brostrom – DPH
Department of Public Health 2. Adjust TB Treatment for DM (2)
C.C. “Assure the Cure”“Assure the Cure”
• Consider treatment for 9 mo. in persons with DM
• Relative immune suppression
• Often higher burden of diseaseg
• ATS: Cavitary disease and delayed sputum clearance
• Upon completion of therapy
• Obtain smear and culture for test‐of‐cure
• Annual follow‐up for next 2 years
R.Brostrom – DPH
Department of Public Health 3. Help Manage Diabetes During TB Tx
A.A. Encourage lifestyle changes for persons with Encourage lifestyle changes for persons with diabetes in TB Clinicdiabetes in TB Clinic
• DOT worker to encourage lifestyle changes at each visit
• Dietary changes and physical activity are key
• Check blood glucose frequently in TB Clinic
• Delivering DM meds with TB meds via DOT
• Clinician: Encourage lifestyle changes at TB Clinic visits
• Refer to Diabetes Center for support
B.B. Refer to clinician comfortable treating diabetesRefer to clinician comfortable treating diabetes
• Ensure diabetes clinician is aware of TB medication
R.Brostrom – DPH
•Tuberculosis and Diabetes – Dec. 10, 2009
•Richard Brostrom, M.D. •7 of 9
Department of Public Health Diabetes and TB: Challenge or Opportunity?
Clinical Disease vs. Lifestyle DiseaseClinical Disease vs. Lifestyle Disease
130 t i 6 th130 t i 6 th130 encounters in 6 months 130 encounters in 6 months
Rare opportunity to impact lifestyle! Rare opportunity to impact lifestyle!
R.Brostrom – DPH
Department of Public Health Program Integration Efforts
Diabetes Medications
Frequent Glucose
Monitoring
Improved Glucose Control
Continuous Diabetes Education
TB Cases at Diabetes Wellness Center
R.Brostrom – DPH
Department of Public Health Checking Blood Glucose in TB Clinic
R.Brostrom – DPH
•Tuberculosis and Diabetes – Dec. 10, 2009
•Richard Brostrom, M.D. •8 of 9
Department of Public Health
Month 1Diet Control
(late)
Month 2Diabetes
Medications
Month 6Diabetes Care
Standards
DOT-based Educational Objectives
Medications
Month 3Moderate Exercise
Month 4Diabetes
Complications
Month 5Weight Loss
(post-Tx)
Standards
R.Brostrom – DPH
Department of Public Health 4. Prevent TB in Persons with Diabetes
A.A. Screen all “highScreen all “high‐‐risk” diabetics for TBrisk” diabetics for TB
• TST/IGRA at time of DM diagnosis
• Repeat screening every 5 years
R.Brostrom – DPH
p g y y
B.B. Encourage prophylaxis for latent TB disease Encourage prophylaxis for latent TB disease with INH for 9 monthswith INH for 9 months
• INH more likely to cause neuropathy
• Add B6 to preventive treatment
Department of Public Health Look for TB in your Local Diabetes Clinic
Is there PPD solution in Is there PPD solution in your Diabetes Clinic?your Diabetes Clinic?
R.Brostrom – DPH
•Tuberculosis and Diabetes – Dec. 10, 2009
•Richard Brostrom, M.D. •9 of 9
Department of Public Health Look for Diabetes in your Local TB Clinic
Is there a Is there a GlucometerGlucometer in in your Tuberculosis Clinic?your Tuberculosis Clinic?
R.Brostrom – DPH
Department of Public Health
R.Brostrom – DPH