Documente Academic
Documente Profesional
Documente Cultură
Mellitus-Tuberculosis
Comorbidity
December 2014
1
Table of Contents
Forward ................................................................................................................................................... 3
Acknowledgements................................................................................................................................. 4
Abbreviation ........................................................................................................................................... 5
Name of Technical Working Group ......................................................................................................... 6
1. Introduction .................................................................................................................................... 7
1.1 What is tuberculosis (TB)? ...................................................................................................... 7
1.2 What is diabetes mellitus (DM)?............................................................................................. 8
1.3 Current TB-DM comorbidity in the world ............................................................................... 8
1.4 Current burden of TB-DM comorbidity in Cambodia ............................................................. 9
2. Rational for development TB-DM comorbidity management guideline ........................................ 9
3. Screening for DM and TB ................................................................................................................ 9
3.1. Screening for TB in DM patient ............................................................................................... 9
3.2. Screening for DM in TB patients ........................................................................................... 10
4 Referral mechanisms .................................................................................................................... 11
4.1 Refer DM patients with TB suspected/TB from DM clinic to TB ward .................................. 11
4.2 Refer TB patients with DM from TB ward to DM clinic......................................................... 11
5 Management of TB-DM comorbidity patients .............................................................................. 11
Clinical management......................................................................................................................... 11
5.1 Treatment TB-DM comorbidity ............................................................................................. 12
5.2 Drug Interaction: ................................................................................................................... 15
6 Team management .......................................................................... Error! Bookmark not defined.
6.1 Decision on diagnosis: ........................................................................................................... 15
6.2 Decision on Treatment:......................................................................................................... 15
6.3 Decision on follow up:........................................................................................................... 15
6.4 Team meeting: ...................................................................................................................... 15
6.5 Capacity building: .................................................................................................................. 15
7 Prevention diabetes-tuberculosis comorbidity ............................................................................ 16
8 References .................................................................................................................................... 16
Appendix 1: Referral form .................................................................................................................... 18
Appendix 2: TB screening among DM patients ..................................................................................... 19
Appendix 3: DM screening among TB patients ..................................................................................... 20
2
Forward
Diabetes mellitus (DM) and tuberculosis (TB) comorbidity is emerging as a public health
concern in Cambodia. Diabetes triples the risk of developing TB, and the rates of TB are
higher in people with DM than in the general population. Furthermore, treatment outcomes of
individuals with both conditions is poorer than that of individuals with DM or TB alone.
Diabetes can worsen the clinical course of TB, and TB can worsen glycemic control in people
with DM. Therefore, individuals with both conditions require careful clinical management.
Early detection of DM among TB patients and early detection of TB among DM patients are
crucial to better manage the diseases.
Given the absence of a national guideline to manage TB-DM comorbidity, the National
Center for Tuberculosis and Leprosy Control (CENAT), Department of Preventive Medicine
(DPM), World Health Organization (WHO), Cambodia Diabetes Association (CDA) and
other relevant stakeholders, with the support and coordination of the Center for Health and
Social Development (HSD), have set up a Technical Working Group (TWG) to address this
gap. The ultimate goal of the TWG will be to draft a comprehensive guideline for the
management of TB-DM comorbidity that can be adapted and implemented on a national
scale.
I strongly believe that this guideline will become a helpful tool to help health care providers
who are currently working in TB service or in DM service. Patients with TB-DM
comorbidity will be effectively managed through better coordination between the two
services, early case detection, high quality of clinical management and proper follow up.
Finally I would like to acknowledge all members in the technical working group for their
contribution to develop this guideline. Taking this opportunity, I would like to deeply thank
the Center for Health and Social Development for their coordination and financial support for
the guideline development.
3
Acknowledgements
We would like to thank Dr. Mao Tan Eang, Director of National Center for Tuberculosis and
Leprosy Control; Prof. Prak Piseth Rainsey, Director of Department of Preventive Medicine
and Dr. Neeraj Kak, University Research Co., LLC for their valuable and strong support in
developing this national guideline for TB-DM comorbidity management.
Special thanks to all members of the Technical Working Group from both National Center for
Tuberculosis and Leprosy Control (CENAT) and Department of Preventive Medicine (DPM);
World health Organization; Cambodia Diabetes Association (CDA); MoPoTsyo; FHI 360;
Operation ASHA; Sihanouk Hospital Center of Hope; HelpAge Cambodia and Health and
Social Development (HSD) for great participation and contribution in drafting the guideline
on case management of TB-DM comorbidity.
Last but not least, a special thanks to the World Diabetes Foundation (WDF) for their
coordination and financial support, through HSD, to make this guideline happen.
4
Abbreviation
CDA Cambodia Diabetes Association
DM Diabetes Mellitus
TB Tuberculosis
5
Technical Working Group
6
DRAFT GUIDELINES FOR MANAGEMENT OF TB-DM
COMORBIDITY
1. Introduction
1.1 What is tuberculosis (TB)?
TB is an infectious disease caused by the bacillus Mycobacterium tuberculosis. It typically affects the
lungs (pulmonary TB) but can affect other sites as well (extrapulmonary TB). TB is spread through
the air when patients with pulmonary TB (PTB) expel bacteria, for example, by coughing. In general,
around 10% of people infected with M. tuberculosis will develop TB disease. However, the
probability of developing TB is about 3 times higher among people with diabetes and 26-31 times
higher among people infected with HIV. TB is also more common among men than women, and
affects mostly adults in economically productive age groups [1].
The most common method for diagnosing TB worldwide is sputum smear microscopy (developed
more than 100 years ago), in which bacteria are observed in sputum samples examined under a
microscope. Diagnosis using sputum smear microscopy can be made within a day, but this test is not
able to detect several less infectious forms of TB, and sometimes provides false negatives making it
less reliable. In countries with more developed laboratory capacity, cases of TB are also diagnosed via
culture methods (the current reference standard). While culture tests are much more accurate than
sputum smear microscopy, one drawback to their use is the length of time it takes to obtain results (2
6 weeks). Following recent breakthroughs in TB diagnostics, the use of rapid molecular tests for the
diagnosis of TB and drug-resistant TB is increasing (GeneXpert). These tests greatly improve the
accuracy and timeliness of TB diagnosis, simultaneously detecting TB and rifampicin drug resistance
(a reliable indicator for multi-drug resistant TB). In Cambodia, TB diagnoses are made through
sputum smear, X-ray, culture and GeneXpert.
TB mortality rates are high for patients who do not receive treatment. The mortality among
pulmonary TB, HIV-negative cases with sputum smear positive is around 70% within 10 years of
infection. Additionally, the mortality rate among sputum smear negative (but culture-positive) cases is
approximately 20% within 10 years [2].
Based on the current Cambodia National TB treatment guideline, the recommended 1st line treatment
for new TB cases is six-months of Isoniazid, Rifampicin, Ethambutol and Pyrazinamide. In 2012,
treatment success rates among new and relapse cases were at 94%.
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Table 1: Standard Treatment Regimen as the first choice for MDR-TB
Drugs in intensive phase: 8 months Drugs in continuation phase:12 months
- Kanamycine (KM) injection - Levofloxacin PO
- Levofloxacin PO - Ethionamide PO
- Ethionamide PO - Cysloserine PO
- Cysloserine PO - Pyrazinamid PO (Ethambutol PO if
- Pyrazinamid PO (Ethambutol PO if there is no there is no DST confirmed to be
DST confirmed to be resistant) resistant)
According to recent WHO findings, the treatment success rate for patients with MDR-TB is only
86%.
Diabetes occurs when the pancreas does not produce enough insulin, or any insulin at all, when the
body cannot effectively use the insulin it produces (insulin resistance), or both. There are several
types of diabetes mellitus, described in detail below:
Type 1: results from the body's failure to produce enough insulin. This form was previously
referred to as "insulin-dependent diabetes mellitus" (IDDM) or "juvenile diabetes". The cause is
unknown.
Type 2: begins with insulin resistance, a condition in which cells fail to respond to insulin
properly. As the disease progresses, a lack of insulin may also develop. This form was previously
referred to as "non-insulin-dependent diabetes mellitus" (NIDDM) or "adult-onset diabetes". The
primary cause is excess body weight and lack of exercise.
Gestational diabetes: occurs when pregnant women without a previous history of diabetes develop
a high blood glucose level.
Other rare types of diabetes can be caused by conditions such as pancreatitis, cystic fibrosis, or
exposure to a virus or to certain drugs.
It is currently estimated that the prevalence of DM will increase from about 382 million in 2013 to
around 592 million in 2030. In 2013, about 80% of DM patients lived in developing countries where
healthcare resources were limited. Of even greater concern, about 48% of these patients with DM
were undiagnosed[5].
With the increased number of DM patients among low-resource health care systems, TB-DM
comorbidity will inevitably increase as well. This will in turn hamper WHOs target to scale down
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global TB incidence by 90%, or less than 10 cases per 100,000 population, in 2035[3] and will further
impede the worlds long-term vision to eliminate TB as a public health concern by reducing TB
incidence to less than 1 case per million of population by 2050[6].
Pulmonary TB (PTB):
One of the most common symptoms of PTB is chronic cough which is defined as a cough of at
least two weeks. Other symptoms of PTB include[10]: fatigue, chest pain, shortness of breath, loss of
appetite and hemoptysis.
Extra-pulmonary TB (ETB):
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There are different forms of ETB. The most commonly observed forms of ETB include: lymph node
TB, pleural TB, pericardial TB, meningitis TB, and bone TB. General symptoms of ETB are similar
to that of PTB: unexplained weight loss, nocturnal fever, and drenching nigh sweat. Other symptoms
are varied depending on the affected organs.
All DM patients that have presented TB symptoms should be tested for TB. Diagnosis of PTB and
ETB can be done using one of the following methods:
Sputum Smear:
- Smear Positive:
At least two sputum specimens positive by microscopic examination, OR
One sputum specimen positive by microscopic examination AND radiological
abnormalities consistent with PTB, OR
One sputum specimen positive by microscopic examination, and culture positive for
Mycobacterium Tuberculosis.
- Smear Negative: At least 6 sputum specimens negative by microscopic examination
including radiological abnormalities consistent with active PTB
Chest Xray: In active pulmonary TB, a chest Xray can show opacification, infiltrates or
consolidations and/or cavities with or without mediastinal or hilar lymphadenopathy or pleural
effusions (tuberculous pleurisy). In miliary TB, a pattern of many tiny nodules throughout the
lung fields is common. In HIV and other immunosuppressed persons, any abnormality may
indicate TB or the chest X-ray may even appear entirely normal.
GeneXpert: A cartridge-based, automated diagnostic test that can identify Mycobacterium
tuberculosis (MTB) DNA and resistance to rifampicin (RIF) by nucleic acid amplification
technique (NAAT). It is recommended by CENAT for diagnosing PTB among high risk groups
such as diabetic patients, elderly, those living with a PTB patient, HIV patients and prisoners.
Culture: Mycobacterial culture is more sensitive than sputum smear and can identify drug
resistant strains. However, this method takes a long time to produce results. There are different
methods for mycobacterial culture. Solid media is a traditional culture method for mycobacterium
and drug susceptibility testing (DST). The growth of TB bacilli on traditional solid medium
requires 4-8 weeks and 28-42 days to know drug susceptibility testing (DST). Liquid culture is
another method recommended by WHO to be used in low income settings. This culture method is
more sensitive than solid culture. For DST, this method takes only 10 days. However this system
is more prone to contamination.
Histology: In general, for extra-pulmonary TB, there are fewer M. bacterium organisms in
infected sites. In this case, culture and histological examination of tissue specimens, such as may
be obtained by needle biopsy of lymph nodes, are important diagnostic tests.
Primary screening for DM among TB patients can be done using a glucometer in the TB ward, at HCs
or during outreach within communities by trained staff consisting of doctors, nurses, laboratory
technicians, and/or DOT workers. The following tests should be conducted:
The fasting blood sugar (FBG) test: performed at least 8 hours after last meal
The random blood sugar (RBG) test: performed at any time
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Postprandial blood glucose (PPBG) tests: performed at least 2 hours after the last meal.
According to the clinical practice guideline for type 2 diabetes in Cambodia [11], if FBS is 126
mg/dl (7mmol/L) or RBS (at least 2 hours after meal) is 200 mg/dl (11.1mol/L), patients are likely to
have diabetes and this should be confirmed by a repeated test on another occasion unless there are
obvious symptoms. In this case, the patients have to be referred to a DM clinic for DM work up and
management.
If someone is found to have impaired fasting glucose (FBS is 110-125mg/dl) then they are at
increased risk of developing diabetes and other cardiovascular complications. Healthcare providers
should give advice on how to maintain a healthy diet, the proper amount of physical activity,
appropriate weight management and smoking cessation [11]. A repeat DM screening should be done 4
weeks after the first test.
4 Referral mechanisms
In order to detect TB in DM cases and DM in TB cases as early as possible, all healthcare providers
should have clear guidance outlining WHEN and HOW to refer suspected/confirmed cases to the
appropriate services.
In health facilities, especially at referral hospitals (RHs) where both DM and TB services are
available, referral must be made internally. If a diabetes clinic recognizes a potential case of TB, they
should refer the TB patient to the TB ward with a referral letter (Apendix1).
In health facilities, especially at RHs where both DM and TB services are available, referral must be
made internally. When a TB ward recognizes a case of DM, they should refer the patient to the DM
clinic ward referral letter (Appendix 1). Patients should be recorded in a registration book. (See
Appendix 3 for the algorithm of DM screening among TB cases)
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which can in turn result in poor TB treatment outcomes. In diabetes management, blood sugar can be
poorly controlled due to chronic inflammation, drug interactions and poor adherence to drug
treatment. This will worsen TB treatment outcomes and could lead to other diabetes complications
[12].
Table 2 and 3 summarize the TB treatment regimen patients based on the National Treatment
Guideline 2011:
Treatment Category 1: This treatment category is for:
- New smear positive PTB
- Smear negative PTB, severe form
- Extra PTB, severe form
- TB/HIV patients.
Table 2: Category 1 treatment (initial and continuous phases) for 6 months duration in Cambodia
Initial Phase: 2 months: 2RHZE Continuation Phase: 4 months: 4RH
Patients have to take 4 TB drugs every morning Patients have to take 2 TB drugs every morning
for 2 months under direct observation by health for 4 months under direct observation by health
center staff or a trained person called DOT. center staff or a trained person called DOT.
The 4 drugs are: Rifampicin, Isoniazid, The 2 drugs are: Rifampicin, Isoniazid
Pyrazinamide, Ethambutol
Drug Dosages
Patients Initial Phase Continuation Phase
Weight RHZE (150/75/400/275 mg) RH (150/75 mg)
30-39 kg 2 tablets 2 tablets
40-54 kg 3 tablets 3 tablets
55-70 kg 4 tablets 4 tablets
> 70 kg 5 tablets 5 tablets
Dosage/kg/day: R: 10mg, H: 5mg, Z: 25mh, E: 15mg
For TB meningitis, or miliary TB, we add streptomycin during initial phase because it can better
diffuse through meningeal barriers. The infection of streptomycin has also to be done under DOT. The
dosage of the drug is as follow:
Patients Initial Phase Continuation Phase
Weight RHZE (150/75/400/275 mg) Streptomycin 1000mg RH (150/75 mg)
30-39 kg 2 tablets 500 2 tablets
40-54 kg 3 tablets 750 3 tablets
55-70 kg 4 tablets 1000 4 tablets
> 70 kg 5 tablets 1000 5 tablets
Dosage/kg/day: R: 10mg, H: 5mg, Z: 25mg, E: 15mg, S: 15mg
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- Return after default cases
- Others
Tablet 3: Category 2 treatment for 8 months period (initial and continuous phases)
Initial Phase: 3 months: 2RHZE/S and 1RHZE Continuation Phase: 5 months: 5RH/5E
In first 2 months, patients have to take 4 combined Patients have to take 3 TB drugs every
TB tablets and receive injection every morning morning for 5 months under direct observation
under direct observation by health center staff or by health center staff or trained person called
trained person called DOT. The 4 combined DOT. The 3 drugs are: Rifampicin, Isoniazid
drugs are: Rifampicin, Isoniazid, Pyrazinamide, (combined) and Ethambutol
Ethambutol. Injection drug is streptomycin.
In 3rd month, patients need to take only the 4
combined tablets above under DOT.
The dosages of the treatment are as follow:
Initial Phase Continuation Phase
Patients Month 1 and month 2 Month 3 Month 4 to Month 8
Weight RHZE Streptomycin RHZE RH E
150/75/400/275mg 1000mg 150/75/400/275mg 150/75 mg 400 mg
30-39 kg 2 tablets 500 2 tablets 2 tablets 1.5 tablets
40-54 kg 3 tablets 750 3 tablets 3 tablets 2 tablets
55-70 kg 4 tablets 1000 4 tablets 4 tablets 3 tablets
> 70 kg 5 tablets 1000 5 tablets 5 tablets 3.5 tablets
Dosage/kg/day: R: 10mg, H: 5mg, Z: 25mg, E: 15mg, S: 15mg
Table 4: treatment category 3 (initial and continuous phases) for 6 months duration in Cambodia
Initial Phase: 2 months: 2RHZE Continuation Phase: 4 months: 4RH
Patients have to take 4 TB drugs every morning for Patients have to take 2 TB drugs every
2 months under direct observation by health center morning for 4 months under direct
staff or trained person called DOT. The 4 drugs observation by health center staff or trained
are: Rifampicin, Isoniazid, Pyrazinamide, person called DOT. The 2 drugs are:
Ethambutol Rifampicin, Isoniazid
Drug Dosages
Patients Initial Phase Continuation Phase
Weight RHZE (150/75/400/275 mg) RH (150/75 mg)
30-39 kg 2 tablets 2 tablets
40-54 kg 3 tablets 3 tablets
55-70 kg 4 tablets 4 tablets
> 70 kg 5 tablets 5 tablets
Dosage/kg/day: R: 10mg, H: 5mg, Z: 25mh, E: 15mg
LIFESTYLE MANAGEMENT
Maintain healthy weight:
- Control weight: Normal BMI is between 18.6-22.9 kg/m2
- Control central Obesity: Men should be < 85cm; women should be < 80cm
Healthy Diet:
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- Eat a variety of foods at each meal
- Eat smaller but regular portions of starchy carbohydrate at each meal e.g. rice, noodles or
beans.
- Increase the amount of fruit and vegetables every day and eat a variety. Eat one or two
servings of fruit (especially low GI) per day.
- Avoid foods with high amounts of sugar such as soft drinks (coca cola), sweets or condensed
milk.
- Reduce saturated fat and high fat foods such as fried foods (e.g. deep fried banana), Prohok
and pork fat.
- Use unsaturated vegetable oils such as sunflower, olive or canola during cooking, rather than
saturated oils (palm oil or coconut oil) or pork fat. Cut off fat before cooking.
- Decrease salt intake, limit intake of Prohok, MSG, fish sauce, soy sauce and salted meat or
fish.
- Use other flavors (e.g. lemon juice, pepper) and herbs.
- Reduce alcohol, especially strong alcohols like rice wine, whisky.
- Most people in Cambodia do not eat enough protein. Good sources of protein include tofu,
beans, fish, eggs and chicken.
Physical Activities:
- The best activity is brisk walking 30 minutes per day on most days of the week is
recommended (>150 min/week).
- If weight loss is desired then this may require longer periods of activities such as 50 60
minutes of moderate intensity on most days and avoid sedentary activities such as TV.
- Those who have peripheral neuropathy should do other activities such as cycling or
resistance exercise.
- Proper foot wear must be worn
- Look for opportunities to walk or bicycle instead of using a motorbike/car.
Smoking cessation:
- Ask all patients if they smoke.
- Advise about the importance of smoking cessation: (reduce risk of cardio-vascular diseases,
better glycemic control, decrease risk of neuropathy, decrease risk of end-stage renal failure,
decrease risk of peripheral vascular disease which a risk factor of amputation).
- Assist them by encouraging them to set a quit date and giving educational material
- Arrange for follow-up.
- Give counseling yourself or contact a counselor in your region (Example: staff from ADRA
or from National Centre for Health Promotion).
ANTI-DIABETIC AGENTS:
Lifestyle interventions should remain the underlying theme throughout the treatment. If patients blood
glucose level is very high (e.g. fasting BSL>180 or postprandial >360 or HbA1c>9%) then medication
needs to be used early to decrease glucose levels and relieve symptoms AND TITRATE to a second agent
more rapidly if sugars not falling.
- Oral drugs:
Obese patients with DM 2: (BMI 23mg/m2):
Step1: Lifestyle advice and Metformin. If glycemic target is not met Step2
Step2: Add additional oral agent and titrate: Sulfonylurea or Thiazolidinedione. If
glycemic target is not met Step3
Step3: Further Adjustments. Add third oral agent or start Insulin
Lean patients with DM2:
Step1: Lifestyle advice. If glycemic target is not met Step2
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Step2: Start oral agent, titrate, and add other if needed: Sulfonylurea (Exam:
Glibenclamide, Meformin, Thiazolidinedione). If glycemic target is not met
Step3
Step3: Further Adjustments. Add third oral agent or start Insulin
- Insulin: If morning fasting glucose is > 126mg/dl, commence evening intermediate acting
insulin (such as protaphane) before patient going to bed. It can be started from 8-10 units
(0.1-0.2 unit/kg) and increase 2-4 units every 4-5 days or until glycemic target is met.
Metfromin and Sulfonylurea can be continued. If blood sugar is still high despite night
time insulin then twice daily intermediate acting insulin or twice daily mixed insulin
maybe required.
6.2 Treatment:
When TB or DM is diagnosed, patients will be referred to the TB or DM clinic respectively for
treatment. At this time, close follow up must be done to make sure that patients receive appropriate
treatment.
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risk factors, availability of DM services, how to make proper referrals, and the potential for poor TB
treatment outcomes if TB co-exists.
This knowledge-sharing will enable both the TB and DM teams to detect cases early, allowing for
patients to be initiated on treatment sooner, and resulting in better management overall of both
diseases which will in turn lead to improved treatment outcomes.
References
1. WHO. Tuberculosis, Fact sheet N104. 2014; Available from:
http://www.who.int/mediacentre/factsheets/fs104/en/.
2. Tiemersma, E.W., et al., Natural History of Tuberculosis: Duration and Fatality of Untreated
Pulmonary Tuberculosis in HIV Negative Patients: A Systematic Review. PLoS ONE, 2011.
6(4): p. e17601.
3. Lnnroth, K., G. Roglic, and A.D. Harries, Improving tuberculosis prevention and care through
addressing the global diabetes epidemic: from evidence to policy and practice. The Lancet
Diabetes & Endocrinology, 2014. 2(9): p. 730-739.
4. Wang, Q., et al., Prevalence of Type 2 Diabetes among Newly Detected Pulmonary
Tuberculosis Patients in China: A Community Based Cohort Study. PLoS ONE, 2013. 8(12): p.
e82660.
5. WHO and International Union Agaisnt Tuberculosis and Lung Disease, Collaborative
Framework for Care and Control of Tuberculosis and Diabetes. 2011.
6. Dye, C., et al., Targets for global tuberculosis control [Short Communication]. The
International Journal of Tuberculosis and Lung Disease, 2006. 10(4): p. 460-462.
8. National Center for Tuberculosis and Leprosy Control, Tuberculosis Report 2012. 2012,
National Center for Tuberculosis and Leprosy Control: Phnom Penh, Cambodia
9. National Institute of Statistics Ministry of Planning, Directorate General for Health Ministry of
Health, and ICF Macro, Cambodia Demographic and Health Survey 2010. 2011: Phnom Penh,
Cambodia and Calverton, Maryland, USA.
10. Ministry of Health, Tuberculosis Standard Treatment Regimens. 2011, National Center for
Tuberculosis and Leprocy Comtrol: Phnom Penh, Cambodia.
11. Department of Preventive Medicine, Clinical Practice Guidelines Type 2 Diabetes, Cambodia
2006. 2006: Phnom Penh, Cambodia.
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12. Riza, A.L., et al., Clinical management of concurrent diabetes and tuberculosis and the
implications for patient services. The Lancet Diabetes & Endocrinology, 2014. 2(9): p. 740-
753.
13. Niazi, A. and S. Kalra, Diabetes and tuberculosis: a review of the role of optimal glycemic
control. Journal of Diabetes & Metabolic Disorders, 2012. 11(1): p. 28.
14. Odone, A., et al., The effect of diabetes and undernutrition trends on reaching 2035 global
tuberculosis targets. The Lancet Diabetes & Endocrinology, 2014. 2(9): p. 754-764.
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Appendix 1: Referral form
18
Appendix 2: TB screening among DM patients
DIABETES CLINIC
SCREENING FOR TB IN DM PATIENTS
SCREEN FOR TB
Do the patients have one of the following symptoms
for at least two weeks: cough? Fever? Drenching
night sweat? Unexplained weight loss?
NO
YES
YES NO
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Appendix 3: DM screening among TB patients
TB CLINIC
SCREENING FOR DM IN TB PATIENTS
DO GLYCEMIC TEST
Do patients have FBS 126mg/dl OR RBS (at
least 2 hours after meal) 200mg/dl?
YES NO
YES
YES NO