Overview Diabetes in the CNMI Tuberculosis in the CNMI Integrating g Diabetes Mellitus (DM) and Tuberculosis (TB) Programs
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1 Integrating Diabetes and TB Programs National 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 Diabetes and Tuberculosis: Double Trouble Overview Diabetes in the CNMI Tuberculosis in the CNMI Integrating g Diabetes Mellitus (DM) and Tuberculosis (TB) Programs Diagnosing DM in TB Cases Treating TB Cases with DM Managing DM during TB Treatment Opportunities for TB Prevention Mainland US To Scale Richard Brostrom, M.D. 1 of 9
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3 Carolinian in Saipan, 1905 Dietary Change After 1944 Diabetes Around the World Pima Indians Nauru Saipan - Chamorros Saipan - Carolinians New Caledonia Kirabati Cook Islands U.S. World Average Percent of Adults with Diabetes Richard Brostrom, M.D. 2 of 9
4 Global Rising Tide of Diabetes Millions of Cases in 2000 and Projected Cases for 2030 TB Cases in CNMI 000/yr Rate per 100, CNMI Rate US Rate '92 '93 '94 '95 '96 '97 '98 '99 '00 '01 '02 '03 '04 '05 '06 Year Linking Tuberculosis and Diabetes Immune Suppression in Diabetics TB largely cell mediated immunity Diabetics with decreased function of WBC Chemotaxis, phagocytosis, Th 1 cytokines Linking by Social Determinants: Poverty Poverty > Crowding > Higher TB rates Poverty > Poor Diet > Obesity/Diabetes Richard Brostrom, M.D. 3 of 9
5 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 TB and DM in CNMI: 2008 (age 30 and older) 80% Percent TB Patients with Diabetes 70% 60% 50% 40% 30% 20% 10% 0% All TB Cases Adult Pacific Islander Comparing TB Risks in the CNMI Tuberculosis Comorbid Condition Relative Risk of Activation Comorbid Population in CNMI Projected TB Cases in the CNMI, 10 yrs HIV 10 x 9 1 Diabetes 3 x 5, Assumptions: 50 percent PPD + Baseline 50 yrs/5% activation 1% activation in 10 years Richard Brostrom, M.D. 4 of 9
6 Four Steps for DM TB Care Saipan Standards Warning: UNOFFICIAL GUIDELINES AHEAD Four Steps for DM TB Care Saipan Standards (2) 1. Diagnose Diabetes in TB Patients 2. Adjust TB Treatment for Persons with Diabetes 3. Help Manage Diabetes During TB Treatment 4. Prevent TB in Persons with Diabetes 1. Diagnose Diabetes in TB Patients A. Screen 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. Repeat 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. Ask about polyuria/polydipsiapolydipsia at TB clinic visits Richard Brostrom, M.D. 5 of 9
7 2. Adjust TB Treatment for DM A. Ensure TB medications are properly dosed Check creatinine for diabetic nephropathy May have to adjust PZA and EMB B 6 for higher rates of INH neuropathy B. Observe 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 2. Adjust TB Treatment for DM (2) C. Assure the Cure Consider treatment for 9 mo. in persons with DM Relative immune suppression Often higher burden of disease 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 3. Help Manage Diabetes During TB Tx A. Encourage lifestyle changes for persons with diabetes 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. Refer to clinician comfortable treating diabetes Ensure diabetes clinician is aware of TB medication Richard Brostrom, M.D. 6 of 9
8 Diabetes and TB: Challenge or Opportunity? Clinical Disease vs. Lifestyle Disease 130 encounters in 6 months Rare opportunity to impact lifestyle! Program Integration Efforts Diabetes Medications Frequent Glucose Monitoring Continuous Diabetes Education Improved Glucose Control TB Cases at Diabetes Wellness Center Checking Blood Glucose in TB Clinic Richard Brostrom, M.D. 7 of 9
9 DOT-based Educational Objectives Month 1 Diet Control (late) Month 6 Diabetes Care Standards Month 2 Diabetes Medications Month 5 Weight Loss (post-tx) Month 4 Diabetes Complications Month 3 Moderate Exercise 4. Prevent TB in Persons with Diabetes A. Screen all high risk diabetics for TB TST/IGRA at time of DM diagnosis Repeat screening every 5 years B. Encourage prophylaxis for latent TB disease with INH for 9 months INH more likely to cause neuropathy Add B 6 to preventive treatment Look for TB in your Local Diabetes Clinic Is there PPD solution in your Diabetes Clinic? Richard Brostrom, M.D. 8 of 9
10 Look for Diabetes in your Local TB Clinic Is there a Glucometer in your Tuberculosis Clinic? Richard Brostrom, M.D. 9 of 9
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