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Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
Should all diabetics with TB be on insulin?
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Should all diabetics with TB be on insulin?

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Lectured delivered at the 2010 Philippine Coalition Against Tuberculosis annual convention

Lectured delivered at the 2010 Philippine Coalition Against Tuberculosis annual convention

Published in: Health & Medicine
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  • 1. TB and Diabetes: Should all diabetics with TB be on insulin? Iris Thiele Isip Tan MD, FPCP, FPSEM Clinical Associate Professor, UP College of Medicine Section of Endocrinology, Diabetes & Metabolism, UP-PGH http://www.endocrine-witch.info
  • 2. Insulin for Diabetics with TB
  • 3. 1 3 Drug effects/ Indications interactions for insulin Insulin 2 for Diabetics 4 with TB Immune Treatment dysfunction goals
  • 4. 1 3 Drug effects/ Indications interactions for insulin Insulin 2 for Diabetics 4 with TB Immune Treatment dysfunction goals
  • 5. Rifampicin: a potent Cyt P450 inducer lowers the serum levels of SU and metformin Guptan & Asha. Ind J Tub 2000
  • 6. Placebo Rifamipicin Rifampicin can induce CYP2C9-mediated metabolism Modest reduction of plasma glimepiride concentration “probably of limited clinical significance” Niemi et al. Br J Clin Pharmacol 2000;50:591-595
  • 7. Case report 62/M on chlorpropamide 250 mg daily Given Rifampin 600 mg daily Chlorpropamide increased to 400 mg daily Self & Morris. Chest 1980
  • 8. Case report 65/M on gliclazide 80 mg daily FPG 6.4 mmol/L HbA1c 5.4% Atypical mycobacteriosis Rifampicin, INH, EMB, Clarithromycin FPG increased to 11.3 mmol/L Gliclazide increased up to 160 mg daily When rifampicin discontinued, gliclazide reduced to 80 mg daily (HbA1c 5.6%) Sellers & Dean. Diabetes Care 2000
  • 9. SU and Metformin contraindicated in liver disease Drug-induced hepatitis with TB treatment Prevalence: 9.7% (Malaysia) & 12% (HK) Alcohol abuse and chronic hepatitis are independent risk factors Marzuki et al. Singapore Med J 2008;49(9):688 Yew et al. Eu Resp J 1196;(9):389-90
  • 10. Metformin can cause anorexia and GI discomfort 1930’s case series: giving insulin for weight gain Photo from Seattle Municipal Archives Accessed from http://www.flickr.com
  • 11. “The use of insulin to cause a gain in weight in undernourished children and in lean but otherwise healthy adults is now a well-established procedure. It seems reasonable therefore to try its effects in undernourished persons suffering from pulmonary tuberculosis.” Heaton TG. Can Med Assoc J 1932;498-501
  • 12. Conclusion “Insulin has a real place in the treatment of chronic forms of pulmonary tuberculosis, febrile or afebrile, if the patient is undernourished. In some such cases insulin is the best drug treatment we have.” Heaton TG. Can Med Assoc J 1932;498-501
  • 13. 1 3 Drug effects/ Indications interactions for insulin Insulin 2 for Diabetics 4 with TB Immune Treatment dysfunction goals
  • 14. 1 3 Drug effects/ Indications interactions for insulin Insulin 2 for Diabetics 4 with TB Immune Treatment dysfunction goals
  • 15. Immunologic abnormalities Pulmonary physiologic in diabetes dysfunction Abnormal chemotaxis, adherence, phagocytosis and microbicidal Diminished bronchial reactivity function of PMNs Decreased peripheral monocytes Reduced elastic recoil and lung with impaired phagocytosis volumes Poor blast transformation of Reduced diffusion capacity lymphocytes Occult mucus plugging of Defective C3 opsonic function airways Reduced ventilatory response to hypoxemia Worsened by hyperglycemia Guptan & Shah. Ind J Tub 2000
  • 16. TB infection produces glucose intolerance that improves or normalizes with TB treatment Not specific to TB, also seen in pneumonia Jawad et al. J Pakistan Med Assoc 1995;45(9):237-8
  • 17. n=496 Mycobacterial clearance from sputum is delayed during the first phase of treatment in patients with diabetes Diabetes: independent risk factor for a 5-delay in mycobacterial clearance within first 60 days Restrepo et al. Am J Trop Med Hyg 2008;79(4):541-4
  • 18. Diabetes increased risk of active pulmonary TB only in those with HbA1c >7% Active Adj HR 3.11 [95%CI 1.63-5.92, p =0.001) Culture confirmed Adj HR 3.08 [95%CI 1.44-6.57, p =0.004) Pulmonary Adj HR 3.11 [95%CI 1.79-7.33, p <0.001) Leung et al. Am J Epid 20008;167:1486-94
  • 19. Diabetics had 6.5x higher odds [95%CI 1.1-3.80, p=0.039] of dying from TB than non-diabetics Relationship between severity of diabetes and TB outcomes could not be evaluated Unclear if tight diabetes control would have a positive impact on treatment outcomes of those with active TB Dooley et al. Am J Trop Med Hyg 20009;80(4):634-9
  • 20. Qing Zhang et al. Jpn J Infect Dis 20009;62:390-391
  • 21. Qing Zhang et al. Jpn J Infect Dis 2009;62:390-391
  • 22. 1 3 Drug effects/ Indications interactions for insulin Insulin 2 for Diabetics 4 with TB Immune Treatment dysfunction goals
  • 23. 1 3 Drug effects/ Indications interactions for insulin Insulin 2 for Diabetics 4 with TB Immune Treatment dysfunction goals
  • 24. Management of Coexistent TB and DM Patients with poor diabetic control should be hospitalized for stabilizing their blood sugar level. Ideally, insulin should be used to control blood sugar levels. Oral hypoglycemics should be used only in cases of mild diabetes. Drug interaction with rifampicin should be kept in mind. Goals of therapy: FPG 120 mg/dL and HbA1c <7% Guptan & Shah. Ind J Tub 2000
  • 25. Indications for insulin in type 2 diabetes with TB Chronic and severe tuberculosis infection Loss of tissue and function of pancreas Requirement of high calorie, high protein diet Interactions and adverse effects of anti-TB drugs Associated hepatic disease Contraindications for oral antidiabetic drugs Aging Rao PV. Int J Diab Dev Countries 1999
  • 26. Brazilian Thoracic Association 2009 TB in Diabetics “Consider extending treatment to 9 months and replace oral hypoglycemic agents with insulin during treatment (keep fasting glycemia <160 mg/dL).” BTA Committee on Tuberculosis & BTA Tuberculosis Working Group J Bras Pneumol 2009;35(10):1018-1048
  • 27. Who should be started on insulin? On Metformin with A1c >8.5% Not reaching A1c target of OHA combination therapy Kidney/liver dysfunction where OHA is contraindicated Severe uncontrolled diabetes with catabolism ADA-EASD 2008 Algorithm. Diabetes Care 31:1-11, 2008
  • 28. Who should be immediately started on insulin? Severely uncontrolled diabetes with catabolism Fasting BG >13.9 mmol/L (250 mg/dL) Random BG consistently > 16.7 mmol/L (300 mg/dL) A1c > 10% Presence of ketonuria Symptomatic diabetes: polyuria, polydipsia, weight loss ADA-EASD 2008 Algorithm. Diabetes Care 31:1-11, 2008
  • 29. 1 3 Drug effects/ Indications interactions for insulin Insulin 2 for Diabetics 4 with TB Immune Treatment dysfunction goals
  • 30. 1 3 Drug effects/ Indications interactions for insulin Insulin 2 for Diabetics 4 with TB Immune Treatment dysfunction goals
  • 31. Glycemic Targets for Type 2 Diabetes ADA- Healthy ADA 1 AACE 3 IDF 4 EASD 5 Hba1c (%)* <6.0 1 <7.0 + <6.5 <6.5 <7.0 + FBG, mmol/L <5.6 2 5.0-7.2 <6.0 <6.0 3.9-7.2 (mg/dL) (<100) (90-130) (<110) (<110) (70-130) PPBG, mmol/L <7.8**2 <7.8 <8.0** <10 <10.0** (mg/dL) (<140) (<140) (<145) (<180) *DCCT-referenced assays: normal range 4–6%; **1–2 hours postprandial. †ADA and ADA/EASD guidelines recommend HbA1C levels ‘as close to normal (<6%) as possible without significant hypoglycemia’1,5 ADA=American Diabetes Association; AACE=American Association of Clinical Endocrinologists;IDF=International Diabetes Federation; EASD=European Association for the Study of Diabetes. 1. 1 American Diabetes Association. Diabetes Care 2006;29(suppl 1):S4–S42. 2. 2 American Diabetes Association. Diabetes Care 2006;29(suppl 1):S43–8. 3. 3 American Association of Clinical Endocrinologists. Endocr Pract 2002;8(suppl 1):40–82. 4. 4 International Diabetes Federation. Global Guideline for Type 2 Diabetes. Brussels: International Diabetes Federation, 2005. http://www.idf.org/webdata/docs/IDF%20GGT2D.pdf. 5. 5 Nathan D. et al. Diabetologia 2006;49:1711–21.
  • 32. Expected Decrease in A1c Step 1: initial 9.0 Basal insulin •Lifestyle change: 1-2% 8.5 SU TZD •Metformin: 1.5% 8.0 Step 2: additional therapy 7.5 •Basal insulin: 1.5-2.5% (at least) 7.0 •Sulfonylureas: 1.5% 6.5 •TZDs: 0.5-1.4% 6.0 •GLP-1 agonist: 0.5-1.0% HbA1c ADA-EASD Consensus. Nathan et al Diabetes Care 2006
  • 33. 1 3 Drug effects/ Indications interactions for insulin Insulin 2 for Diabetics 4 with TB Immune Treatment dysfunction goals
  • 34. Thank You! http://www.endocrine-witch.info

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