Pusat Diabetes dan Lipid, Divisi Metabolik-Endokrin, Departemen Ilmu Penyakit Dalam, FKUI / RSUPN Cipto Mangunkusumo, Jakarta Diabetic Complications Diabetic Ketoacidosis = DKA Hyperosmolar Hyperglycemia Nonketoric Coma = HHNC Retinopathy Nephropathy Neuropathy Macroangiopathy Chronic : Acute Microangiopathy CAD PVD Stroke Hypoglycemia Metabolic Decompensation Sebab Kesadaran Menurun pada Diabetes Melitus Ketoasidosis Diabetik Hiperosmolar non Ketotik Asidosis Laktat
Hipoglikemia Sebab Lain - Trauma - Obat - Penyakit Lain : Stroke Koma hepatik Uremik Diagnosis Banding Koma Glukosa Keton Hipervent. Dehid. TD Kulit mg/d L DKA >300 +s/d4+ ++ ++ N/ hngt
................................................................ Aktivasi gejala Keringat autonomik Gemetar ..................................... Berdebar ...... Neuroglikopenia berat Kejang ............................................................... Koma
Waktu Diagnosis Relatif mudah: pemeriksaan GD Trias Whipple: Keluhan dan gejala hipoglikemia s/d kesadaran menurun, Kadar Glukosa < 45 mg/dL (pada wanita dapat < 30 mg/dL), Bangun kembali setelah diberikan glukosa
Perlu pemantauan yang lama jika pasien memakai obat long acting Jika hipoglikemia berkelanjutan dapat menyebabkan kerusakan otak permanen, demensia Respons Perubahan Hormonal pada Hipoglikemia: Penurunan sekresi insulin Peningkatan katekolamin dan epinefrin Peningkatan sekresi glukagon Peningkatan sekresi kortisol Peningkatan hormon pertumbuhan Penatalaksanaan Hipoglikemia Ringan: Berikan gula murni (bukan pemanis) yang cukup sampai keluhan hilang Pastikan pemberian makanan / kalori cukup untuk selanjutnya, terutama jika OAD long acting Berat: Berikan glukosa 40 % IV sampai pasien sadar Berikan infus rumatan D10 6-8 jam perkolf cek glukosa darah setiap jam jika < 100 mg/dL berikan kembali bolus D40 Jika sudah 2 kali berturut-turut >100 mg/dL, setiap 2 jam Jika sudah 2 kali berturut-turut > 100 md/dL, setiap 4 jam, dst sampai yakin bahwa kadar glukosa darah stabil aman
Perhatikan obat hipoglikemik yang dipakai: Obat kerja panjang, pemantauan dapat lama, berhari Perhatikan pula fungsi ginjal dan hati dan usia pasien
Oral Antidiabetic Agents: side effects Risk of hypoglycaemia Weight gain
Gastrointestinal side-effects
Adapted from DeFronzo RA. Ann Int Med. 1999; 131: 281303. *Observed in patients with renal impairment Oedema Lactic acidosis
*
Anaemia Principles in Selecting Antihyperglycemic Interventions Effectiveness in lowering blood glucose Extraglycemic effect that may reduce longterm complications Safety profile Tolerability Ease of use Cost Nathan DM et al. Clinical Diabetes. 2009; 27 (1): 4-16 Diagnosis Type 2 DM Lifestyle changes A1C (%)* 6.5-7 7-8 8-10 Oral Combination Oral # : SU Metformin AGI TZD Meglitinides Specific condition: Short/Rapid-acting I nsulin analog Pre-mixed I nsulin analog Monotherapy* : Metformin AGI TZD Specific Condition: SU Meglitinides Short/Rapid-acting I nsulin analog Combination Oral+Insulin : Metformin TZD SU Long-acting I nsulin Short/Rapid-acting I nsulin analog Pre-mixed I nsulin analog NPH Other Combination >10 Insulin Therapy: Short/Rapid-acting I nsulin analog NPH or Long-acting I nsulin Pre-mixed I nsulin analog In selected Patients with A1C> 10% OHO Combination might be effective Target Achieved Target not Achieved Target Achieved Target Achieved Target Achieved Target not Achieved Target not Achieeved Target not Achieved Intensification Therapy OR
Continue Treatment Continue Treatment Intensification Therapy OR
Continue Treatment Intensification Therapy OR Continue Treatment Intensification of Insulin Treatment Basal+bolus
Algorithm for Management of Type 2 DM without Metabolic Decompensation Indonesian Society of Endocrinology 2007
Continue <6.5 Blood Glucose Monitoring (FPG, PPG, Bed time) *surrogate average blood glucose might be used Management of Hyperglycemia In Patients General Principles: Maximal blood glucose control, avoiding hypoglycemia Meticulous, Prudent, Individualized Management of T2DM synchronized with other disease management In critically ill patients, more over in metabolic decompensation, the blood glucose target should be more aggressive and achieved quicker
Sasaran Glukosa darah yang dianjurkan
Pasien Tidak Kritis : Senormal mungkin (110 180 mg/dL) Insulin mungkin diperlukan Sedekat mungkin dengan 130 mg/dL Pasien Kritis: Senormal mungkin (110 180 mg/dL) Umumnya memerlukan insulin Sedekat mungkin dengan 110 mg/dL
* Beberapa Institusi mungkin menganggap nilai ini terlalu over agresif karena kepedulian akan risiko hipoglikemia A D A Clinical Practice Recommendation Diabetes Care. 2007;3(suppl 1): S 32-33 The Nice-Sugar Study ICU setting 3 or more consecutive days Intensive (81-108 mg/dL) Conventional (<180 mg/dL) Outcome mortality at 90 days 3054 intensive control vs. 3050 conventional Similar characteristic baseline Primary outcome available for 3010 and 3012 respectively
829 (27.5 %) mortality in intensive control, OR 1.14 751 (24.9%) mortality in conventional group
Severe hypoglycemia (< 40 mg/dL) 206 (6.8%) in intensive control 15 (0.5 %) in conventional group
The NICE Sugar study investigators. Intensive vs. conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283-97 Blood Glucose Target Critically ill surgical patients: as normal as possible (110 140 mg/dL)* Insulin is needed, IV protocol Close to 110 mg/dL (A) Critically ill non surgical pts: as normal as possible (110 140 mg/dL)* Insulin is needed, IV protocol Keep BG < 140 mg/dL (C) Non critically ill: as normal as possible, no specific goals Insulin is preferred FBG <126 mg/dL, Random BG<180-200 mg/dL (E)
* Some institutions might considered this blood glucose target as over aggressive due to their cautious attitude toward hypoglycemia A D A Clinical Practice Recommendation Diabetes Care. 2009;32(suppl 1): S 32-33 Pemantauan kadar glukosa darah harus cermat Hyper- glycemia Acidosis Ketosis DKA Kitabchi and Wall Hyperglycemia states DM HHNC IGT Stress Metabolic Acidosis states Lactic acidosis Hyperchloremic acidosis Salicylism Uremic acidosis Drug-induced acidosis Ketotic states Ketotic hypoglycemia Alkaholic ketosis Starvation ketosis DKA Episode and Mortality Rate at Dr. Cipto Mangunkusumo Hospital, Jakarta Year Number of Cases Mortality rate %
Pathogenesis of DKA and HHNC HHNC DKA Precipitating Factors of DKA & HHNC Infection Cerebro vascular accident Pancreatitis Myocardial infarction Trauma Medication Newly diagnosed type 1 diabetes Discontinuation of or inadequate insulin Substance abuse Not found
Clinical Features of DKA Abdominal pain Leg cramps Nausea and vomiting Confusion and drowsiness Coma Polyuria and nocturia Weight loss Weakness Blurred vision Kussmaul respiration DKA HHNC HHNC HHNC Principal Management of DKA and HHNC Hour Hydration Insulin K + Correction HCO3 - correction
0 guyur 50 mEq per If pH guyur six hour <7 7-7.1 >7.1 guyur Start hour 2 iv bolus iv, Cont by infusion dst dst dst Management of DKA at Cipto Mangunkusumo Hospital, Jakarta A B C D E Penatalaksanaan Ketoasidosis Diabetik * 1 jam 2 kolf, 1 jam 1 kolf, dst * Na Cl Fisiologis * 1/2 N, 2A - Kalau Na > 150 mek/l
1. Rehidrasi Cepat 2. Insulin Bolus 10 U IV. G.D setiap jam Drip 5 U/jam sampai g.d. < 200 mg/dl - D5 % Drip 2,5 U/jam sampai g.d. stabil 200 - 300 mg/dl Drip 1 U/jam + sliding scale g.d. tiap 4 jam Dosis terbagi 3-4 kali sehari 3.Kalium < 3,5 mek/L -- 50 mek/L 3,5 - 5 mek/L -- 25 mek/L >5 mek/L -- 0 4. Na HCO3 pH < 7 - 7,1 5. Faktor Presipitasi ***Dosis Kecil 5 U IM *** Pemantauan dengan Urin Suhendro 2008 Pengukuran asam laktat perlu pada pengelolaan KAD Serum laktat > 4 mmol/L petanda prognostik buruk Jika disertai kesadaran menurun prognostik buruk
Perlu pengelolaan yang ketat sejak awal Pasang CVP segera Hidrasi dicapai dengan lebih cepat Prevention (1) Better access to medical care Intensive patients education Effective communication acute illness Review sick-day management Insulin treatment Blood glucose goal Treat fever and infection Start easy digestible liquid diet Do not stop insulin or oral anti diabetes Prevention (2) Increase BG monitoring during acute illness Check ketone bodies (either urine or blood) when BG > 300 mg/dL Peran Dokter Umum Pencegahan terjadinya Hiperglikemia dengan mengelola DM sebaik-baiknya mencegah komplikasi kronik mencegah komplikasi akut DKA menghindari komplikasi hipoglikemia Jika menjumpai pasien tersangka komplikasi akut: Pastikan bukan hipoglikemia, kalau ragu, jangan takut memberikan D40 Jika bukan hipoglikemia, tetapi KAD: Infus NaCl dan segera kirim ke RS Jikalau ada (misal di RS primer) dapat diberikan insulin, kemudian rujuk Memerlukan perawatan yang cermat, segera di RS dengan peralatan yang memadai Hibiscus rosasinensis Hatur Nuhun