The Interaction of Diabetes and Tuberculosis

van Crevel, R.; Critchley, J.A. The Interaction of Diabetes and Tuberculosis: Translating Research to Policy and Practice. Trop. Med. Infect. Dis. 2021, 6, 8.

  • Increased Risk: People with diabetes have a 2–3 times higher risk of developing TB compared to non-diabetic individuals.
  • Altered TB Presentation: Diabetes alters TB symptoms, with more severe presentations, higher TB scores, more cavitation, and a longer time to achieve smear or culture negativity.
  • Worsened Treatment Outcomes: Diabetes, especially when poorly controlled, worsens TB treatment outcomes, including doubling the risk of death during treatment.
  • Increased Bacterial Load: Diabetes may increase the bacterial load of Mycobacterium tuberculosis, leading to prolonged infectiousness.
  • Screening Challenges: Screening diabetes patients for TB may have low yield, except in high TB incidence areas. Risk scores for identifying undiagnosed diabetes among TB patients need further validation.
  • Drug Interactions: Rifampicin increases the metabolism of many diabetes medications, requiring dose adjustments or substitutions, except for metformin.
  • Metformin Advantages: Metformin remains the preferred glucose-lowering agent for diabetes patients with TB due to its low hypoglycemia risk, low cost, and lack of significant interaction with rifampicin.
  • Metformin Disadvantages: Metformin can cause gastrointestinal side effects, which may worsen with TB drugs, and carries a rare but serious risk of lactic acidosis, especially in patients with decreased kidney function.
  • Infection Control: TB patients should avoid specialized diabetes services during early TB treatment to prevent Mycobacterium tuberculosis transmission.

    • Some Outstanding Clinical and Population Health Questions Related to Diabetes-Associated TB:

    • Are there any differences in the risk of TB disease or treatment outcomes between people with type 1 and type 2 diabetes?
    • Is intermediate hyperglycemia ("pre-diabetes") a risk factor for TB disease and death?
    • Does diabetes (type 1 or type 2) or intermediate hyperglycemia affect the risk of LTBI?
    • What are the costs, risks, and benefits of preventive therapy for LTBI, both for individuals and populations?
    • How can health systems be organized to strengthen multi-morbidity care and prevention, e.g., through the strengthening of primary care?
    • How should routine medications to reduce CVD risk be used in patients with TB and DM, and when should they be introduced?
    • Which anti-DM medications should be used in TB patients? How and when should they be introduced and adjusted for dosage?
    • Should TB treatment be intensified or prolonged in people with diabetes?
    • How can smoking cessation and relapse prevention interventions be incorporated into TB-DM management?
    • Do TB survivors with diabetes face long-term sequelae and higher risks, even after successful treatment completion (e.g., TB recurrence, cardiovascular or pulmonary disease, or poor quality of life/disability)? How should they be followed up after the completion of treatment?
    • How can the TB community advocate for investment in diabetes prevention and management?

     

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