‘The tubercular diabetic’ ============================= * Hemantha Chandrasekara * Kevin Hardy Editor–We read with great interest the article by Bailey and colleagues (*Clin Med* August 2011 pp 344–7). Treatment of people with tuberculosis (TB) and diabetes is indeed complicated. Not only does rifampicin potentially adversely alter the pharmacokinetics of gliclazide,1 glipizide,2 pioglitazone,3 nateglinide4 and repaglinide,5 but like isoniazid, it may increase insulin requirements.6 Liver and nerve toxicity from anti-TB drugs may be difficult to distinguish from diabetes-associated non-alcoholic fatty liver disease and peripheral neuropathy respectively and for those with co-morbid HIV infection with access to treatment, there is the added complication of antiretroviral-associated insulin resistance.7 TB itself may precipitate hyperglycaemia by a stress hormone response and there is some evidence of glucose intolerance in TB patients reverting to normal in up to 75% of patients after three months of TB treatment.8 We wholeheartedly endorse Bailey and Grant's conclusion that TB and diabetes demand increased attention from clinicians and academics if we are to ensure that future patients receive optimal management of both conditions. ## Footnotes * Please submit letters for the editor's consideration within three weeks of receipt of *Clinical Medicine*. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk * © 2011 Royal College of Physicians ## References 1. Park JY, Kim KA, Park PW, Park CW, Shin JG Effect of rifampin on the pharmacokinetics and pharmacodynamics of gliclazide Clin Pharmacol Ther 2003 74 334–40 [CrossRef](http://www.rcpjournals.org/lookup/external-ref?access_num=10.1016/S0009-9236(03)00221-2&link_type=DOI) [PubMed](http://www.rcpjournals.org/lookup/external-ref?access_num=14534520&link_type=MED&atom=%2Fclinmedicine%2F11%2F6%2F628.1.atom) [Web of Science](http://www.rcpjournals.org/lookup/external-ref?access_num=000185873500005&link_type=ISI) 2. 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Hatorp V, Hansen KT, Thomsen MS Influence of drugs interacting with CYP3A4 on the pharmacokinetics, pharmacodynamics, and safety of the prandial glucose regulator repaglinide J Clin Pharmacol 2003 43 649–60 [CrossRef](http://www.rcpjournals.org/lookup/external-ref?access_num=10.1177/0091270003043006011&link_type=DOI) [PubMed](http://www.rcpjournals.org/lookup/external-ref?access_num=12817528&link_type=MED&atom=%2Fclinmedicine%2F11%2F6%2F628.1.atom) [Web of Science](http://www.rcpjournals.org/lookup/external-ref?access_num=000183065700011&link_type=ISI) 6. Atkin SL, Masson EA, Bodmer CW, Walker BA, White MC (1993) Increased insulin requirement in a patient with type 1 diabetes on rifampicin. Diabet Med 10:392, doi:10.1111/j.1464-5491.1993.tb00086.x. [CrossRef](http://www.rcpjournals.org/lookup/external-ref?access_num=10.1111/j.1464-5491.1993.tb00086.x&link_type=DOI) [PubMed](http://www.rcpjournals.org/lookup/external-ref?access_num=8508626&link_type=MED&atom=%2Fclinmedicine%2F11%2F6%2F628.1.atom) 7. Tebas P Insulin resistance and diabetes mellitus associated with antiretroviral use in HIV-infected patients: pathogenesis, prevention, and treatment options J Acquir Immune Defic Syndr 2008 49Suppl 2 S86–92doi:10.1097/QAI.0b013e31818651e6 [CrossRef](http://www.rcpjournals.org/lookup/external-ref?access_num=10.1097/QAI.0b013e31818651e6&link_type=DOI) [PubMed](http://www.rcpjournals.org/lookup/external-ref?access_num=18725817&link_type=MED&atom=%2Fclinmedicine%2F11%2F6%2F628.1.atom) [Web of Science](http://www.rcpjournals.org/lookup/external-ref?access_num=000258848600003&link_type=ISI) 8. Oluboyo PO, Erasmus RT The significance of glucose intolerance in pulmonary tuberculosis Tubercle 1990 71 135–8doi:10.1016/0041-3879(90)90010-6 [CrossRef](http://www.rcpjournals.org/lookup/external-ref?access_num=10.1016/0041-3879(90)90010-6&link_type=DOI) [PubMed](http://www.rcpjournals.org/lookup/external-ref?access_num=2219464&link_type=MED&atom=%2Fclinmedicine%2F11%2F6%2F628.1.atom) [Web of Science](http://www.rcpjournals.org/lookup/external-ref?access_num=A1990DJ72600010&link_type=ISI) # ‘The tubercular diabetic’ {#article-title-10} We read with appreciation the comments of Chandrasekara and Hardy. The management of concomitant tuberculosis and diabetes mellitus remains challenging and highlights two important factors. Firstly, that our level of clinical suspicion of dual pathology here in the UK needs to be raised so that management can be optimised, including appropriate adjustment and monitoring of medication. Secondly, that as diabetes progresses in low-income countries we need to consider collectively how best to manage this chronic disease in resource-limited settings and indeed this is a focus of our ongoing research. ## Footnotes * Please submit letters for the editor's consideration within three weeks of receipt of *Clinical Medicine*. Letters should ideally be limited to 350 words, and sent by email to: clinicalmedicine{at}rcplondon.ac.uk * © 2011 Royal College of Physicians