Professional interaction between an outpatient general practitioner and phthisiologist in the management of a multimorbid patient
Abstract. Current article considers the aspects of detection, diagnosis, and treatment of tuberculosis (TB) in multimorbid patients. The most common TB-associated conditions are discussed: diabetes mellitus, chronic obstructive pulmonary disease, HIV infection. The importance of primary care physicians’ vigilance for early TB detection is emphasized, taking into account the nonspecific nature of its symptoms in the presence of comorbid conditions. Particular emphasis is placed on the role of the general practitioner in performing preventive screening of the population, identifying individuals at risk, and implementing measures to prevent the development of TB. Treatment of TB in multimorbid patients, as well as drug interactions between anti-TB drugs and medications used to treat comorbid conditions, are discussed in details. An algorithm for examining patients suspected of having TB is presented, which can significantly assist outpatient physicians in their practice.V.N. Larina, E.V. Kudina, O.O. Vinokurova, A.A. Faleeva, D.M. Pozdniakova
Keywords
tuberculosis
multimorbidity
comorbidity
coinfection
general practitioner
phthisiologist
tuberculosis screening
drug interactions
treatment adherence
outpatient care
interdisciplinary interaction
References
- Клинические рекомендации. Туберкулез у взрослых. Российское общество фтизиатров, Национальная ассоциация некоммерческих организаций фтизиатров «Ассоциация фтизиатров». Рубрикатор клинических рекомендаций Минздрава России. 2025. ID: 16_4. Доступ: https://cr.minzdrav.gov.ru/view-cr/16_4 (дата обращения – 04.08.2026). [Clinical guidelines. Tuberculosis in adults. Russian Society of Phthisiology, Association of Phthisiologists. Rubricator of clinical guidelines of the Ministry of Healthcare of Russia. 2025. ID: 16_4. URL: https://cr.minzdrav.gov.ru/view-cr/16_4 (date of access – 04.08.2026) (In Russ.)].
- Basham CA, Karim ME, Johnston JC. Multimorbidity prevalence and chronic disease patterns among tuberculosis survivors in a high-income setting. Can J Public Health. 2023;114(2):264–76.
PMID: 36459364. PMCID: PMC10036698. https://doi.org/10.17269/s41997-022-00711-y
- Stubbs B, Siddiqi K, Elsey H, Siddiqi N, Ma R, Romano E, et al. Tuberculosis and non-communicable disease multimorbidity: An analysis of the World Health Survey in 48 low- and middle-income countries. Int J Environ Res Public Health. 2021;18(5):2439.
PMID: 33801381. PMCID: PMC7967573. https://doi.org/10.3390/ijerph18052439
- Jarde A, Romano E, Afaq S, Elsony A, Lin Y, Huque R, et al. Prevalence and risks of tuberculosis multimorbidity in low-income and middle-income countries: A meta-review. BMJ Open. 2022;12(9):e060906.
PMID: 36175100. PMCID: PMC9528681. https://doi.org/10.1136/bmjopen-2022-060906
- Поликлиническая терапия. Мультиморбидный пациент. Учебник. Под ред. В.Н. Лариной. М.: Юрайт. 2026; 242 с. [Outpatient therapy. The multimorbid patient. Textbook. Ed. by Larina VN. Moscow: Yurait. 2026; 242 pp. (In Russ.)]. ISBN 978-5-534-21918-0.
- Лушникова А.В., Великая О.В. Туберкулез легких и ХОБЛ. Современные проблемы науки и образования. 2013;(6):624. [Lushnikova AV, Velikaya OV. Pulmonary tuberculosis and COPD. Sovremennye problemy nauki i obrazovaniya = Modern Problems of Science and Education. 2013;(6):624 (In Russ.)]. EDN: RVCXAB.
- Byrne AL, Marais BJ, Mitnick CD, Lecca L, Marks GB. Tuberculosis and chronic respiratory disease: A systematic review. Int J Infect Dis. 2015;32:138–46.
PMID: 25809770. https://doi.org/10.1016/j.ijid.2014.12.016
- Adefuye MA, Manjunatha N, Ganduri V, Rajasekaran K, Duraiyarasan S, Adefuye BO. Tuberculosis and cardiovascular complications: An overview. Cureus. 2022;14(8):e28268.
PMID: 36158349. PMCID: PMC9491794. https://doi.org/10.7759/cureus.28268
- Барканова О.Н., Гагарина С.Г., Калуженина А.А., Попкова Н.Л. Туберкулез легких и заболевания желудочно-кишечного тракта. Лекарственный вестник. 2015;9(2):33–37. [Barkanova ON, Gagarina SG, Kaluzhenina AA, Popkova NL. Pulmonary tuberculosis and gastrointestinal diseases. Lekarstvennyy vestnik = Medicinal Bulletin. 2015;9(2):33–37 (In Russ.)]. EDN: UDOLSD.
- Caceres G, Calderon R, Ugarte-Gil C. Tuberculosis and comorbidities: treatment challenges in patients with comorbid diabetes mellitus and depression. Ther Adv Infect Dis. 2022;9:20499361221095831.
PMID: 35646347. PMCID: PMC9130847. https://doi.org/10.1177/20499361221095831
- Walaza S, Tempia S, Dawood H, Variava E, Moyes J, Cohen AL, et al. Influenza virus infection is associated with increased risk of death amongst patients hospitalized with confirmed pulmonary tuberculosis in South Africa, 2010–2011. BMC Infect Dis. 2015;15:26.
PMID: 25623944. PMCID: PMC4316613. https://doi.org/10.1186/s12879-015-0746-x
- Dong YH, Chang CH, Wu FL, Shen LJ, Calverley PMA, Lofdahl CG, et al. Use of inhaled corticosteroids in patients with COPD and the risk of TB and influenza: A systematic review and meta-analysis of randomized controlled trials. Chest. 2014;145(6):1286–97.
PMID: 24504044. https://doi.org/10.1378/chest.13-2137
- Jeon CY, Murray MB. Diabetes mellitus increases the risk of active tuberculosis: A systematic review of 13 observational studies. PLoS Med. 2008;5(7):e152.
PMID: 18630984. PMCID: PMC2459204. https://doi.org/10.1371/journal.pmed.0050152
- Baker MA, Harries AD, Jeon CY, Hart JE, Kapur A, Lonnroth K, et al. The impact of diabetes on tuberculosis treatment outcomes: A systematic review. BMC Med. 2011;9:81.
PMID: 21722362. PMCID: PMC3155828. https://doi.org/10.1186/1741-7015-9-81
- Комиссарова О.Г., Полушкина Е.Г., Абдуллаев Р.Ю. Туберкулез и сахарный диабет: современное состояние проблемы. Врач. 2023;34(8):27–32. [Komissarova OG, Polushkina EG, Abdullaev RYu. Tuberculosis and diabetes mellitus: Current state of the problem. Vrach = The Doctor. 2023;34(8):27–32 (In Russ.)].
EDN: POVJXF. https://doi.org/10.29296/25877305-2023-08-05
- Багишева Н.В., Мордык Д.И., Мордык А.В. ХОБЛ и туберкулез: существует ли связь? Медицинский вестник Северного Кавказа. 2019;14(1):135–140. [Bagisheva NV, Mordyk DI, Mordyk AV. COPD and tuberculosis: Is there a relationship? Meditsinskiy vestnik Severnogo Kavkaza = Medical News of North Caucasus. 2019;14(1):135–140 (In Russ.)].
EDN: OWWHXO. https://doi.org/10.14300/mnnc.2019.14070
- Meintjes G, Maartens G. HIV-associated tuberculosis. N Engl J Med. 2024;391(4):343–55.
PMID: 39047241. https://doi.org/10.1056/NEJMra2308181
- Гордеева О.М., Карпина Н.Л. Диагностика туберкулеза у больных с терминальной стадией хронической болезни почек. Врач. 2020;31(2):23–29. [Gordeeva OM, Karpina NL. Diagnosis of tuberculosis in patients with end-stage chronic kidney disease. Vrach = The Doctor. 2020;31(2):23–29 (In Russ.)].
EDN: JRGTRA. https://doi.org/10.29296/25877305-2020-02-05
- Гарант.Ру. Приказ Минздрава России от 29 декабря 2014 г. № 951 «Об утверждении методических рекомендаций по совершенствованию диагностики и лечения туберкулеза органов дыхания». Доступ: https://www.garant.ru/products/ipo/prime/doc/70749840/ (дата обращения – 04.08.2026). [Garant.Ru. Order of the Ministry of Healthcare of Russia No. 951 of December 29, 2014 “On approval of methodological recommendations for improving the diagnosis and treatment of respiratory tuberculosis.” URL: https://www.garant.ru/products/ipo/prime/doc/70749840/ (date of access – 04.08.2026) (In Russ.)].
- Бородулин Б.Б., Бородулина Э.В., Суслин С.А., Кудлай Д.А. Оптимизация выявления туберкулеза участковым терапевтом. Врач. 2019;30(5):57–61. [Borodulin BB, Borodulina EV, Suslin SA, Kudlay DA. Optimization of tuberculosis detection by a district physician. Vrach = The Doctor. 2019;30(5):57–61 (In Russ.)].
EDN: JAARAS. https://doi.org/10.29296/25877305-2019-05-11
- Гарант.Ру. Приказ Минздрава России от 11 апреля 2025 г. № 190н «Об утверждении порядка и сроков проведения профилактических медицинских осмотров граждан в целях выявления туберкулеза». Доступ: https://www.garant.ru/hotlaw/federal/1816764/ (дата обращения – 04.08.2026). [Garant.Ru. Order of the Ministry of Healthcare of Russia No. 190n of April 11, 2025 “On approval of the procedure and timing of preventive medical examinations of citizens for tuberculosis detection.” URL: https://www.garant.ru/hotlaw/federal/1816764/ (date of access – 04.08.2026) (In Russ.)].
- Корчагина С.А., Николаев В.А., Петрова Н.С. Сравнительный анализ факторов риска развития туберкулеза в разных возрастных группах. Научное обозрение. Медицинские науки. 2021;(3):79–84. [Korchagina SA, Nikolaev VA, Petrova NS. Comparative analysis of risk factors for tuberculosis development in different age groups. Nauchnoe obozrenie. Meditsinskie nauki = Scientific Review. Medical Sciences. 2021;(3):79–84 (In Russ.)]. EDN: GXYXTN.
- World Health Organization. WHO consolidated guidelines on tuberculosis. Module 1: Prevention – tuberculosis preventive treatment. 2nd ed. Geneva: World Health Organization. 2024; 268 pp. ISBN: 978-92-4-009619-6.
- Saukkonen JJ, Duarte R, Munsiff SS, Winston CA, Mammen MJ, Abubakar I, et al. Updates on the treatment of drug-susceptible and drug-resistant tuberculosis: An official ATS/CDC/ERS/IDSA clinical practice guideline. Am J Respir Crit Care Med. 2025;211(1):15–33.
PMID: 40693952. PMCID: PMC11755361. https://doi.org/10.1164/rccm.202410-2096ST
- Васильева И.А., Самойлова А.Г., Зимина В.Н., Баласанянц Г.С., Шовкун Л.А., Смердин С.В. с соавт. Справочник по терапии туберкулеза у взрослых. М.: Медицинские знания и технологии. 2025; 68 с. [Vasilieva IA, Samoilova AG, Zimina VN, Balasanyants GS, Shovkun LA, Smerdin SV, et al. Handbook of tuberculosis therapy in adults. Moscow: Medical Knowledge and Technologies. 2025; 68 pp. (In Russ.)]. ISBN: 978-5-6049908-9-6.
- Ogawa K, Kurosaki A, Miyamoto A, Fujie T, Yamashiro T, Yasuda T, et al. Clinicoradiological features of pulmonary tuberculosis with interstitial pneumonia. Intern Med. 2019;58(17):2443–49.
PMID: 31118378. PMCID: PMC6761332. https://doi.org/10.2169/internalmedicine.2341-18
- Tsilika M, Antonakos N, Gkavogianni T, Koutelidakis IM, Mavrou I, Dimopoulos G, et al. Impact of comorbidities on the performance of interferon-gamma release assay in an elderly Greek population without overt immunodeficiency. Int J Antimicrob Agents. 2020;56(3):106073.
PMID: 32629117. https://doi.org/10.1016/j.ijantimicag.2020.106073
- Cardinale L, Volpicelli G, Lamorte A, Martino J, Veltri A. Revisiting signs, strengths and weaknesses of standard chest radiography in patients of acute dyspnea in the emergency department. J Thorac Dis. 2012;4(4):398–407.
PMID: 22934143. PMCID: PMC3426742. https://doi.org/10.3978/j.issn.2072-1439.2012.05.05
- Багишева Н.В., Мордык А.В., Моисеева М.В., Нестерова К.И., Небесная Е.Ю., Ситникова С.В. Отдельные аспекты лечения пациентов с впервые выявленным туберкулезом легких с множественной лекарственной устойчивостью в сочетании с хронической обструктивной болезнью легких: в фокусе ингаляционные глюкокортикостероиды. Вестник современной клинической медицины. 2022;15(2):7–14. [Bagisheva NV, Mordyk AV, Moiseeva MV, Nesterova KI, Nebesnaya EYu, Sitnikova SV. Selected aspects of treatment of patients with newly diagnosed multidrug-resistant pulmonary tuberculosis combined with chronic obstructive pulmonary disease: Focus on inhaled glucocorticosteroids. Vestnik sovremennoy klinicheskoy meditsiny = The Bulletin of Contemporary Clinical Medicine. 2022;15(2):7–14 (In Russ.)].
EDN: HMGHAJ. https://doi.org/10.20969/VSKM.2022.15(2).7-14
- Белостоцкий А.В., Касаева Т.Ч., Кузьмина Н.В., Нелидова Н.В. Проблема приверженности больных туберкулезом к лечению. Туберкулез и болезни легких. 2015;(4):4–9. [Belostotskiy AV, Kasaeva TCh, Kuzmina NV, Nelidova NV. The problem of treatment adherence in patients with tuberculosis. Tuberkulez i bolezni legkikh = Tuberculosis and Lung Diseases. 2015;(4):4–9 (In Russ.)]. EDN: TUICVJ.
- Di Gennaro F, Pizzol D, Cebola B, Stubbs B, Monno L, Saracino A, et al. Social determinants of therapy failure and multidrug resistance among people with tuberculosis: A review. Tuberculosis (Edinb). 2017;103:44–51.
PMID: 28237033. https://doi.org/10.1016/j.tube.2017.01.002
About the Authors
Vera N. Larina, MD, Dr. Sci. (Medicine), professor, head of the Department of outpatient therapy of the Institute of clinical medicine, N.I. Pirogov Russian National Research Medical University (Pirogov University), Moscow, Russian Federation.E-mail: larinav@mail.ru
ORCID: https://orcid.org/0000-0001-7825-5597
Ekaterina V. Kudina, MD, PhD (Medicine), associate professor of the Department of outpatient therapy of the Institute of clinical medicine, N.I. Pirogov Russian National Research Medical University (Pirogov University), Moscow, Russian Federation.
E-mail: e-kudina@mail.ru
ORCID: https://orcid.org/0000-0002-9547-078X
Olga O. Vinokurova, MD, PhD (Medicine), associate professor of the Department of infectious diseases with courses in epidemiology and phthisiology, RUDN University, Moscow, Russian Federation.
E-mail: vinokurova-oo@rudn.ru
ORCID: https://orcid.org/0000-0001-5689-7628
Anna A. Faleeva, student of the Institute of clinical medicine, N.I. Pirogov Russian National Research Medical University (Pirogov University), Moscow, Russian Federation.
E-mail: aafaleeva@gmail.com
ORCID: https://orcid.org/0009-0001-2841-4681
Dariya M. Pozdniakova, MD, first-year clinical resident of the Department of infectious diseases with courses in epidemiology and phthisiology, RUDN University, Moscow, Russian Federation.
E-mail: 1052250085@rudn.ru
ORCID: https://orcid.org/0009-0005-8115-411X
Similar Articles
