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IHS Diabetes Care & Outcomes Audit
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IHS Standards of Care for Patients
with Type 2 Diabetes
     September 2006    

Part 2: Supporting Statements 
  5.      Other Topics for Consideration
  c.   Tuberculosis Treatment


A positive PPD skin test (i.e., >10 mm induration 48-72 hours after administration) means that a person has either latent tuberculosis infection (LTBI), LTBI that has been treated, or active tuberculosis (TB) disease.  Active TB disease needs to be ruled out prior to starting treatment for patients  with LTBI.  Treatment for active TB and LTBI are different.

Diabetes and Latent Tuberculosis

Adults with diabetes and LTBI are at high risk of progressing to active TB if they are not treated for LTBI.  Studies have shown that the risk is 2 to 6 times greater than in patients without diabetes. Other factors that further increase the risk for TB include:

     ·  Recent PPD conversion within 2 years

     ·  Intravenous drug use

     ·  Chest film showing prior active disease that was never treated

     ·  Immuno-suppressive drugs

     ·  Chronic kidney disease (CKD)  

Cutaneous anergy increases as patients age and develop complications of diabetes, such as CKD.  Anergy may lead to false negative PPD test results.  

In most cases, progression of LTBI to active TB can be prevented by treatment with isoniazid (INH).  In general, adults with diabetes who have a positive PPD (accurately read by a provider trained in interpreting PPD tests) should receive treatment for LTBI, except in the following circumstances:

    ·      Severe liver disease

    ·      Suicidal ideation

    ·      Adverse reaction to INH  

Providers should follow and monitor patients for potential hepatotoxicity if they are receiving LTBI treatment.  National recommendations emphasize monitoring hepatotoxicity through systematic repetitive patient education and clinical evaluation for signs and symptoms of hepatotoxicity.  However, providers should also consider liver function tests at baseline and after one month, especially in patients receiving other potentially heptotoxic medications.  Some experts recommend that INH be discontinued if transaminase levels exceed three times the upper limit of normal when associated with symptoms, or five times the upper limit of normal if the patient is asymptomatic.     

      

IHS Tuberculosis Protocol for Patients with Diabetes:

Check the PPD status of all patients with diabetes. 

 If the PPD status is negative or unknown:  

· PPD testing should be done within one year of initial work up for diabetes diagnosis; patients should be treated if they have LTBI.  
· If no PPD has been placed since the diagnosis of diabetes, a PPD status needs to be determined. 
· Subsequent PPD testing is done only if there is contact with an active TB case.  

              If the PPD status is positive:  

· Check for completion of past treatment for active TB or LTBI (6-9 months of INH for LTBI or multiple drug therapy for active disease).  
· If the patient has not been adequately treated, search for active disease by history (weight loss, etc), fever (record temperature) and recent chest x-ray (within 6 months).  

If there is no evidence of active disease, treat all patients with diabetes for LTBI (9 months of INH 300 mg daily), regardless of age, unless the patient has liver disease, suicide ideation or a previous adverse reaction to INH. 

 ·        Patients with diabetes should be given pyridoxine (10-50 mg/day) with their INH.  

 ·        Consider directly observed therapy of LTBI when possible, especially for patients on dialysis.

 

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