Co-morbidities add to the morbidity and mortality of many people with TB and addressing the co-morbidities must be a part of the holistic palliative care approach of TB patients.
Common co-morbidities encountered in practice, include -
• Diabetes mellitus20, HIV and depression, which are the commonest associations. Other co-morbidities include chronic kidney disease, coronary artery disease, malignancies, chronic liver disease and COPD21.
• Malnutrition is another area of focus, being both a cause and consequence of Tuberculosis.
• Occupational lung diseases like Silicosis add to the morbidity of lung damage caused by Tuberculosis.
• Another issue that needs to be addressed is substance abuse including nicotine dependence, alcoholism and the use of recreational drugs.

1. Diabetes mellitus
India, being the Diabetes capital of the world, Diabetes is the commonest co-morbidity encountered among people with Tuberculosis22,23,24. Diabetes is associated with a twofold risk of death during TB treatment, a fourfold risk of TB relapse after treatment completion and a twofold risk of multidrug-resistant TB (MDR-TB)22. The palliative care team needs to be aware of the need to manage the co-morbidities of DM and TB together. Issues that need to be addressed include insulin requirements and dosing of the patient, pill burden of adding more drugs to the wide repertoire of drugs already being used by the patient and addressing various acute and chronic complications of diabetes like diabetic ketoacidosis, hypoglycemia, the various vascular and neurological complications of diabetes. While planning a palliative care unit, the focus of the administrator should be on procuring adequate glucometers and consumables for monitoring blood sugar in the palliative care ward, training health care workers including the staff nurses on basic diabetic management like for example using a sliding scale for managing sugar, focusing on preventing complications of Diabetes like foot care, avoiding bed sores etc.and having a specialist physician or diabetologist on call to attend to the complicated cases. The Central TB division, Government of India has provided resources on the management of TB – DM23.

2. HIV
Another common co-morbidity that needs attention is HIV and its complications. The dreadful duo of HIV- TB co-infection is still a cause of high mortality in our country. Though TB is manifested across the spectrum of HIV illness irrespective of the CD4 count, the clinical presentation varies and an awareness of a thorough clinical evaluation and investigation needs to be highlighted to the palliative care team. Issues that need to be assessed also include compliance to medications both anti- retroviral and anti- tuberculous therapy. The added pill burden, the side effects, issues in swallowing these pills due to presence of other opportunistic infections like esophageal candidiasis have to be evaluated. A periodic monitoring of the liver and renal parameters and issues with tolerance of medications are areas to be addressed. The national guidelines for HIV care issued by the National Aids control organization, Government of India26deals extensively with management of HIV TB and will be a useful resource for the palliative care team.

3. CAD (Coronary Artery Disease)
Other co-morbidities that need addressing include coronary artery disease, chronic kidney disease, chronic liver disease and malignancies21. Given the high prevalence of smoking among people developing Tuberculosis, CAD is a common ailment in this cohort of patients and one of the leading causes of mortality. A specialist opinion, where feasible, could be obtained or the palliative care physician can be trained in basic management like using antiplatelet for the needy patients.

4. CKD (Chronic Kidney Disease)
Chronic kidney patients including those on dialysis need modification of drugs which can be done by a physician or specialist based on the availability. The dosing of drugs can be referred to from various guidelines27. Also, in this cohort of patients, a judicious enquiry in to the shadows in an X-ray which could be due to fluid overload, or secondary bacterial, viral and fungal infections are needed. Special considerations including use of Rifampicin and other ATT drugs in post-transplant patients should be done in consultation with the concerned specialists.

5. CLD (Chronic Liver Disease)
Chronic liver disease issues include selection and dosage of drugs to be used and this needs to be guided by the Child Pugh classification and use of non or less hepatotoxic drugs in these patients, with a periodic assessment of the liver function. It is not uncommon, in our country to see patients continuing consuming alcohol even while on treatment of Tuberculosis leading to poor outcome and adverse events29,30,31 and in the setting of palliative care, the guidance of a psychologist or psychiatrist may be crucial.

6. Malignancy 
With increasing longevity, there is a rising incidence of various malignancies and this co-morbidity too needs to be addressed. People with malignancy, are per se prone to Tuberculosis due to their immuno-suppression and also become liable to TB due to immuno-suppression created by chemotherapeutic agents32,33,34. Patients with esophageal malignancy have dysphagia to even liquids and it would be unrealistic to expect the patient to swallow the big ATT pills.  A tailored regimen to suit the individual’s needs is needed and specialist consultation obtained. Another area that needs to be addressed in these patients is management of TB infection. Pain amelioration is another area to focus on in this group of patients.

7. COPD
COPD and other lung ailments are also co-morbidities commonly encountered in daily practice. Breathlessness, for all we know, may not always be due to parenchymal involvement in the phthisic patient but due to airway involvement in COPD. COPD or other co-morbidities like bronchiectasis or underlying interstitial lung disease, occupational lung disease should be treated optimally with inhaled bronchodilators and appropriate disease-modifying medications. Patients with moderate to severe obstructive or restrictive lung disease will benefit from pulmonary rehabilitation, and palliation of chronic refractory breathlessness with opioids if symptoms persist despite optimization of medications35,36.

8. Substance abuse
Substance abuse disorders like nicotine dependence, alcoholism, recreational drug use which are associated issues also need to be addressed by linkages to de-addiction, smoking cessation clinics, counseling and behavioral change. The central TB division, Government of India has created a framework for collaborative efforts in this regard37.

9. Malnutrition
Last but not the least, another area to be managed is undernutrition which is associated with higher morbidity and mortality in patients with Tuberculosis, being both a cause and effect of Tuberculosis and is also associated with higher hepatotoxicity of ATT drugs38,39. A comprehensive plan to address the individual nutritional needs of the patient on palliative care taking into consideration his caloric and protein requirements, the feasibility and local availability, and also addressing the individual’s food needs to be worked out.

10. IRIS
TB-IRIS may occur in up to one third of patients who have been diagnosed with TB and started on ART. It typically presents within 3 months of the initiation of ART but can occur as early as 5 days. It usually presents with appearance of new or worsening of existing TB signs and symptoms and may be accompanied with increase in size or number of enlarged lymph nodes, appearance of new sites of TB, radiological deterioration etc. Such cases would require the use of anti-inflammatory drugs, including corticosteroids.