Slow responders to tuberculosis (TB) treatment in Virginia have prolonged treatment duration and consume more programmatic resources. Diabetes is an independent risk factor for slow response and low serum anti-TB drug concentrations. Thus, a statewide initiative of early therapeutic drug monitoring (TDM) for isoniazid and rifampin at 2 weeks after TB treatment was piloted for all diabetics with newly diagnosed TB. During the period of early TDM, 12/01/2011–12/31/2012, 21 diabetics had concentrations performed and 16 (76%) had a value below the expected range for isoniazid, rifampin, or both. Fifteen had follow-up concentrations after dose adjustment and 12 (80%) increased to within the expected range (including all for rifampin). Of 16 diabetic patients with pulmonary TB that had early TDM, 14 (88%) converted their sputum culture to negative in <2 months. Early TDM for diabetics was operationally feasible, may speed response to TB therapy, and can be considered for TB programs with high diabetes prevalence. 1. Introduction Tuberculosis (TB) and diabetes mellitus have been described as the “convergence of two epidemics” and given the increasing rates of obesity and diabetes worldwide and the continued high rates of TB in low-income countries, it is estimated that the number of individuals with both TB and DM will increase dramatically [1]. Compared to those without diabetes, diabetics are at greater risk for incident TB [2, 3], where for instance, among Hispanic people aged 25–54 years, TB risk attributable to diabetes is estimated at 25% [1]. The largest meta-analysis to date demonstrated that diabetic patients were 3.1 times more likely to develop TB than nondiabetics, a risk which was amplified in regions outside North America [3]. Furthermore, when active TB disease develops, diabetes contributes to increased severity and poor treatment outcome [4]. Diabetics with TB appear more likely to die than non-diabetics with TB when adjusting for comorbid conditions and have higher rates of relapse after treatment completion [5, 6]. In Virginia, diabetics were 7 times more likely to have slow response to TB therapy [7]. In addition to other complications of treatment, slow response prolongs infectiousness and often extends the treatment duration. While other comorbid immunosuppressing conditions or Mycobacterium tuberculosis drug resistance certainly contribute to slow response in Virginia, uniquely the majority of diabetics had serum anti-TB drug concentrations of isoniazid and rifampin below the expected range, and diabetes was an independent risk factor
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