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    Home > Active Ingredient News > Endocrine System > When tuberculosis "hands in" diabetes, these special treatment details should not be ignored

    When tuberculosis "hands in" diabetes, these special treatment details should not be ignored

    • Last Update: 2021-03-24
    • Source: Internet
    • Author: User
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    Introduction: According to the analysis of the etiology of tuberculosis, about 15% of adult tuberculosis patients are caused by diabetes (DM).

    Because the early detection of comorbidity of tuberculosis and diabetes is difficult, the drug resistance rate is high, the treatment compliance is poor, the management is difficult, and the mortality rate is relatively high, which is one of the important factors that hinder the good results of tuberculosis control.

     Based on this, the National Clinical Medicine Research Center for Infectious Diseases, the National Metabolic Disease Clinical Medicine Research Center, the China National Tuberculosis Association and the "China National Tuberculosis Journal" editorial committee organized national experts in the field of tuberculosis and diabetes prevention and treatment, and clinical practice.
    After repeated discussions, combined with clinical experience and evidence-based medicine, the "Expert Consensus on the Treatment and Management of Co-morbidity of Tuberculosis and Diabetes" (hereinafter referred to as "Consensus") was written.

    Provide guidance and reference for designated tuberculosis medical institutions and general hospitals in the treatment and management of patients with tuberculosis and diabetes comorbidities.

     This article mainly shares the "Particularities of the Treatment of Co-morbidity of Tuberculosis and Diabetes" and the "Adverse Reaction and Treatment in the Treatment of Co-morbidity" (the full version of the "Consensus" download link is attached at the end of the article).

     Clinical characteristics of comorbidity of tuberculosis and diabetes It should be noted that this consensus mainly introduces the clinical characteristics of comorbidity of tuberculosis and diabetes.
    The clinical characteristics of comorbidity of extrapulmonary tuberculosis and diabetes are not included in this consensus.

     1.
    Atypical clinical symptoms Compared with simple pulmonary tuberculosis, the clinical symptoms of pulmonary tuberculosis and diabetes comorbid are usually atypical, which can be manifested as patients with milder symptoms but heavier imaging manifestations.

    A small number of patients have severe symptoms, such as fever and hemoptysis.

    The severity of symptoms may be related to the degree of uncontrolled hyperglycemia and the duration of diabetes.

     2.
    It is easier to form cavities Compared with simple tuberculosis, pulmonary tuberculosis and diabetes are more likely to have cavities when they are comorbid, especially those with poor blood sugar control.
    This is related to the strong cell-mediated inflammatory response of patients to MTB antigen.3.
    The positive rate of sputum bacteria is higher.
    Compared with simple tuberculosis, the positive rate of sputum bacteria is higher when tuberculosis and diabetes are comorbid.
    This is related to the high blood sugar state of diabetic patients, which is a good breeding ground for MTB growth and the patient's low immunity.

     4.
    Compared with simple pulmonary tuberculosis, pulmonary tuberculosis and diabetes are more likely to have multiple segmental or lobular consolidation, caseous necrosis, multiple or single cavities, complicated by bronchial tuberculosis and the occurrence of pulmonary tuberculosis.
    Lung lesions.

     The specificity of treatment of comorbidity of tuberculosis and diabetes 1.
    Recommendations for extending the treatment plan.
    Patients with comorbidity of tuberculosis and diabetes are more likely to have adverse effects of anti-tuberculosis drugs and a higher rate of treatment failure.
    It is proposed in the Union Guidelines for 2019 to appropriately extend anti-tuberculosis The course of treatment.

    At present, studies have suggested that it is more effective to extend the anti-tuberculosis treatment course (9 months) than the standard course of treatment (6 months) without changing the combination of treatment drugs.

    It is recommended to extend the course of treatment if the following conditions occur: (1) Those whose sputum acid-fast bacilli test is still positive at the end of 2 months of intensive treatment; (2) Those with extensive lung disease and cavitation; (3) Poor blood sugar control and insignificant relief of clinical symptoms By.

    Recommended chemotherapy regimen: 2H-RZE/7~10H-RE, the total course of anti-tuberculosis chemotherapy should be 9-12 months.

     2.
    Recommendations for individualized treatment plans.
    Diabetic patients are prone to damage to the optic nerve, peripheral nerves, kidneys and other tissues and organs.
    Anti-tuberculosis drugs may aggravate the complications of diabetes.
    Therefore, anti-tuberculosis treatment needs to be formulated in accordance with the occurrence of diabetic complications in patients.
    Individualized treatment plan.

    Sometimes it is necessary to avoid the use of drugs that exacerbate these complications, such as ethambutol, linezolid, isoniazid, cycloserine, ethionamide/prothionamide, chloroquinolone drugs, injection anti-tuberculosis Drugs (such as streptomycin, amikacin, capreomycin), etc.

     3.
    Treatment of anti-tuberculosis drugs that may aggravate diabetic complications and recommendations (1) Injectable anti-tuberculosis drugs, such as streptomycin, amikacin, capreomycin, etc.
    , are nephrotoxic.
    When diabetic nephropathy is complicated, care should be taken Use or avoid use. If it is necessary for clinical treatment, it should be used at a reduced dose according to the patient's renal function, and the patient's renal function and urine routine should be closely monitored.

    In addition, suspicious drugs that cause hyperuricemia should be used with caution, such as oxazinamide and ethambutol.

    (2) Ethambutol, linezolid, etc.
    can cause optic nerve damage.
    When tuberculosis and diabetes are comorbid, a comprehensive fundus examination and evaluation should be done before use.
    It is not recommended for patients with stage 3 diabetic retinopathy or above.
    If this is not the case When it is really necessary to use it, under the premise of controlling blood sugar, pay attention to the dose of ethambutol, closely monitor vision, color vision and visual field every month, and use vitamin A, vitamin D and other auxiliary treatment drugs.

    (3) Isoniazid, cycloserine, ethionamide/prothionamide, linezolid and chloroquinolone drugs can cause peripheral neuritis, and diabetes is a high risk factor.

    When diabetes is complicated by peripheral neuropathy, it needs to be closely monitored and used with caution.

    At the same time, add vitamin B6, methylcobalamin and other drugs for adjuvant therapy.

    (4) Chloroquinolones can cause abnormal glucose metabolism and cause blood sugar fluctuations.

    In patients with moxifloxacin, the rate of high blood stasis was 0.
    39%, and the rate of low blood stasis was 1.
    0%; with levofloxacin, the rate of hyperglycemia was 0.
    39%, and the rate of hypoglycemia was 0.
    93%.
    .

    Therefore, the use of these drugs may make the potential abnormal glucose tolerance manifestation, induce diabetes or aggravate the original diabetes condition, so blood glucose monitoring should be strengthened.

     Adverse drug reactions related to the treatment of tuberculosis and diabetes comorbidities and their treatment The incidence of adverse drug reactions (ADRs) in patients with tuberculosis and diabetes comorbidities is higher than that of ordinary tuberculosis patients.

    When adverse reactions occur, relevant laboratory inspections should be carried out in time to determine the types of adverse reactions and accurately assess the severity of the adverse reactions.

    Due to the adverse reactions caused by the superposition of the two types of drugs, it is necessary to comprehensively evaluate the impact of the adjusted drugs on the prognosis.
    In principle, the adjustment of hypoglycemic drugs should be considered first, and the anti-tuberculosis drugs should be reserved first.

     1.
    Treatment of liver damage Liver damage caused by anti-tuberculosis drugs is the main adverse reaction of such drugs. Oral hypoglycemic drugs also have hepatotoxicity.
    When oral hypoglycemic drugs are used in combination with anti-tuberculosis drugs, especially anti-tuberculosis drugs such as isoniazid, rifampicin, pyrazinamide, etc.
    , they can increase hepatotoxicity and should be strictly controlled.
    Monitor liver function.
    If moderate to severe liver damage occurs, insulin may be preferred for hypoglycemic therapy.

    And deal with it in accordance with the relevant diagnosis and treatment principles in the "Guidelines for the Diagnosis and Treatment of Anti-tuberculosis Drug-induced Liver Injury (2019 Edition).

     2.
    Treatment of gastrointestinal reactions Gastrointestinal reactions are most common when using anti-tuberculosis and hypoglycemic drugs.

    Metformin is the most commonly used hypoglycemic drug for patients with comorbidity of tuberculosis and diabetes.
    When combined with anti-tuberculosis drugs, about 30% of patients will have gastrointestinal reactions, thereby reducing the compliance and effectiveness of treatment.

    Gastrointestinal reactions caused by metformin mostly occur in the early stage of treatment (most of them occur in the first 10 weeks).
    It is recommended that metformin start with a small dose and gradually increase the dose, which is an effective way to reduce the occurrence of adverse reactions in the early stage of treatment.

    If a gastrointestinal reaction occurs, liver function should be tested first, and if it is not caused by liver damage, the severity of symptoms should be assessed.

    If the symptoms are mild or moderate, they can be treated symptomatically without stopping the drug; if the mild or moderate symptoms do not get better after treatment and gradually worsen and have severe symptoms, stop using the suspicious drugs and observe the improvement of the symptoms after stopping the drug Happening.

     3.
    Treatment of skin rashes Skin rashes are also more common in the treatment of patients with anti-tuberculosis drugs.

    If the rash is mild, continue treatment with anti-tuberculosis drugs and give symptomatic treatment such as anti-allergy.

    If the rash is severe, all anti-tuberculosis drugs need to be discontinued until the rash is significantly relieved.

    Certain strategies should be followed when re-adding anti-tuberculosis drugs: try the treatment drugs one by one, starting with the drugs least likely to cause allergic reactions, and in principle, it is not recommended to use the highly suspicious allergic drugs again.

    If the rash recurs, the last drug added should be stopped immediately.

    If the rash is petechiae, consider the cause of thrombocytopenia, and you should permanently stop rifampicin or rifapentin.

    If the rash is accompanied by fever or mucosal involvement, all drugs need to be discontinued immediately, and the patient’s original anti-tuberculosis chemotherapy regimen is replaced with an alternative drug combination (for example, the use of some second-line drugs and the first-line drugs that are least likely to cause the rash after the evaluation of the disease).

     4.
    The treatment of other adverse reactions can be handled according to the relevant principles in the "Expert Consensus on the Treatment of Adverse Drug Reactions during Chemotherapy for Drug-resistant Tuberculosis".

     Download link of the full version of "Consensus": http://guide.
    medlive.
    cn/guideline/22444 References: National Infectious Disease Clinical Medicine Research Center, Shenzhen Third People's Hospital, National Metabolic Disease Clinical Medicine Research Center, Central South The Second Xiangya Hospital of the University, the editorial board of the Chinese Journal of Tuberculosis National Defense Association.
    Expert consensus on the treatment and management of comorbidity of tuberculosis and diabetes[J].
    China National Defence Tuberculosis Journal.
    Volume 43, Issue 1, January 2021.
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