integrating diabetes and tb programsnid]/cntc_tbdm...adjust tb treatment for dm a.a. ensure ensure...

•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



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



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



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




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



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



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




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



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


R.Brostrom – DPH

integrating diabetes and tb programsnid]/cntc_tbdm...adjust tb treatment for dm a.a. ensure ensure...

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