FeedbackScreening people with diabetes for TB
- Well-designed trials and rigorous quasi-experimental studies in different settings are required to investigate the effects of systematic screening for TB in people with diabetes on individual outcomes (diagnostic delay, TB treatment outcomes, costs to patients, social consequences) and population outcomes (TB prevalence, incidence, transmission), as well as to understand the accuracy and guide the choice of different screening algorithms (symptom screening, CXR with CAD and mWRDs), the duration of screening intervals, the frequency of screening and the mode of delivering the intervention.
- Subpopulations of people with diabetes for whom further investigation is required would include people who have uncontrolled and controlled diabetes, people with types 1 and 2 diabetes, people with newly diagnosed diabetes, pregnant women, and children and adolescents with diabetes.
Prevention of TB among people with diabetes
- Strong evidence from clinical trials is lacking on the effectiveness, safety, feasibility, costeffectiveness and acceptability of systematic testing and treatment of TB infection in people with diabetes, including those at risk of MDR-TB, as compared with people receiving standard care for control of diabetes. Methods to measure both the incidence of and risk for TB disease could be explored, such as the use of genotyping to distinguish between reactivation and reinfection.
- The performance of TB infection tests should be evaluated in people with diabetes, to assess reinfection and to understand how best to use the available tools (e.g. combination or sequential use of a tuberculin skin test and interferon-gamma release or other tests of TB infection).
- Studies of pharmacokinetics could help to establish optimal daily dosages of and interactions between rifamycin-containing TB prevention regimens and diabetes medications.
- The durability of protection provided by different TPT regimens, including long-acting injectables, should be evaluated in settings in which TB is endemic, including the efficacy of repeated courses of TPT among people with diabetes. Studies of the preferences of people with diabetes for different regimen characteristics would be helpful.
- Prospective randomized studies are required to determine the incremental benefits of routine monitoring of liver enzyme levels over education and clinical observation alone for preventing severe clinical adverse events among people with diabetes.
TB treatment in people with diabetes
- Well-designed randomized controlled trials and studies to compare the effectiveness, safety, pharmacokinetics, cost effectiveness and acceptability of different TB treatment regimens (including for treatment of MDR-TB) among people with diabetes are required.
- Operational research should be conducted to assess the effectiveness of different models of people-centred care (including telemedicine and community care) for TB and diabetes and linkage to onward diabetes care after completion of TB treatment.
Screening people with TB for diabetes
- Evidence is required to compare the effectiveness and cost-effectiveness of different algorithms with different diabetes tests, pre-screening with symptoms and risk scores for enhanced detection of diabetes in people with TB.
- Well-designed studies are required to assess the optimal timing for diabetes treatment among people with TB (e.g. 1–3 months after initial diagnosis of diabetes).
Diabetes treatment for people with TB
- Well-designed studies are required to assess the impact of TB treatment on the effectiveness of diabetes treatment and the optimal dosing of diabetes treatment.
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