DM
MUHAMMMAD UMAR FERDIANSAH
Amd.Kep
SMF Ilmu Penyakit Dalam
Poli Spesialis RS AL-Irsyad Surabaya
2014
A etiologicalClassif c
iation
of D specific
isorders
of
Other
types
G lycaem ia
Genetic defects of betacell
Type 1 (betacell
destruction, usually
leading to absolute insulin
deficiency) : Autoimmune:
Idiopathic
Type 2 (may range from
predominantly insulin
resistance with relative
insulin deficiency to a
predominantly secretory
defect with or without
insulin resistance)
function
Drug or chemicalinduced
Infections
Uncommon forms of
immunemediated diabetes
Gestational diabetes
Diabetes Melitus
DM
1.
2.
DM
1.
DM
1.
2.
3.
4.
5.
6.
7.
tipe 1
Autoimun
idiopatik
tipe 2
Resistensi insulin/ def insulin relatif
tipe lain
Defek genetik (MODY,DNA mitokondria)
Defek genetik kerja insulin
P eksokrin pankreas (pankreatitis, tumor, pankreopati
fibrocalculus)
Endokrinopati ( akromegali, S Cushing, feokromositoma,
hipertoroidism)
Karena obat ( vacor, petamidin, glukorkortikoid, hormon tirod,
dinlatin dll)
Infeksi (rubella kongenital, CMV)
Imunologi ( antibodi anti insulin)
Types-continued
Infections
Congenital rubella
Cytomegalovirus
Others
Uncommon forms of
immunemediated
diabetes
Insulin autoimmune
syndrome (antibodies to
insulin)
Antiinsulin receptor
antibodies
Stiff Man syndrome
Others
Drug or Chemical
induced Diabetes
Nicotinic acid
Glucocorticoids
Thyroid hormone
Alphaadrenergic agonists
Betaadrenergic agonists
Thiazides
Dilantin
Pentamidine
Vacor
Interferonalpha therapy
Others
W H O diagnostic criteria
whole blood
plasma
Diabetes mellitus (fasting) > 6.1mmol/l
>
7.0mmol/l
2 hour post glucose load
> 10.0 mmol/l
>
11.1mmol/l
IGT (fasting)
< 6.1mmol/l
< 7.0mmol/l
&
&
2 hr post glucose load
> 6.7 mmol/l
> 7.8 mmol/l
IFG (fasting)
> 5.6 mmol/l
> 6.1mmol/l
& <6.1 mmol/l
2hr post glucose load
<7.8 mmol/l
& <7.0mmol/l
<6.7 mmol/l
Type 1 diabetes
Previously known as IDDM(Insulin
dependent diabetes)
Ketosis prone:Usually diagnosed in
younger age group(<30 years) (Peak
incidence 11-13 yr)
Prevalence highly variable but
approximately 0.20% with an incidence
of 15-20 per 100000 population aged
less than 21
Highest rate in Finland and Sicily( 30
new cases per 100000) to lowest in Japan
and Korea (1 new case per 100000)
Seasonal variation- with lowest rate in
spring and summer
Type 1 diabetes
Presentation of type 1 is acute with symptoms
Type 2 diabetes
Previously known as NIDDM
Non ketosis prone: , diagnosis > 30 years
Prevalence highly variable1-2%, with a slight
male excess
1 in 1000 population as new cases each year
Rates in relation to age ; 15- 44 yrs 0.5%,4564-1.8%,>65- 4.0%
Rural population
<1%
(Papua,Solomon,Bantu)
Euro/N Americans
1-10%( Urban Bantu)
Indo Asians abroad 10-20%(Australia,
Aborigines)
Pima Indians
>20% (Nauru)
Insulin
resistance
Type 2
diabetes
-cell
dysfunction
gliclazide, Tolbutamide,Glimiperide,
Repaglanide etc.
Biguanides:Metformin
Alpha glucosidase inhibitor:Acarbose
Thiazolidinedione derivatives:
Troglitazone,
Rosiglitazone,Pioglitazone.
Patogenesis
MRDM
Gejala klinis :
fase kompensasi
Laboratorium
Diagnosis
Kriteria definitif
1.
1.
2.
3.
4.
Resistensi ketoasidosis
5.
6.
Tanda malabsrbsi
7.
Kalsifikasi pankreas
Fibrocalculus Pancreatic DM
(FCPD)
1. DM umur 15 40 th, tanda
malnutrisi (BBR< 80 %), Tx
insulin, resistensi insulin,
resistensi ketoasidosis,
kalsifikasi pankreas dengan
atau tidak disertai tanda
malnutrisi.
2. Tes fungsi pankreas
menurun :
1. BT- PABA urine < 60 % dan
atau
2. Isoenzyme amylase positif
2.
Keluhan klinis
Positit
GDP
GDS
Negatif
126
200
GDP
GDS
< 126
200
126
200
< 110
110 - 190
Ulang GDS atau GDP
GDP
GDS
> 126
200
< 126
< 200
TTGO
2J PP
200
D IAB E TE S
MELLITUS
140 - 190
TGT
< 140
GDPT
Normal
PENATALAKSANAAN
TERAPI PRIMER
1.
Diit (21 macam). Diit B, B1, B puasa, B1 puasa, B2, B3, Be, M, M
puasa, G, KV, H dan GL.
Mengikuti 3 J ( Jumlah kalori dihabiskan, Jadwal ditepati,Jenis gula pantang)
Diit tepat diberikan. Kumur setelah makan.
Diit B2 untuk px ND stad II
Diit B3 untuk px ND stad III
Diit Be untuk px ND stad IV
2.
3.
TERAPI SEKUNDER
4.
5.
Cangkok Pankreass
Obat
Hipoglikemik(OHO)
Rasional
Cara kerja
1.
2.
3.
.
Sulfonilurea
Tolbutamide, Acetahesamide, Tolazamid, Carbutamide, glycodiazin, klorpropamide
Glibornurid, Glipizid, Glipizide GITS, Glisoxepid, Glibenclamide, Gliclazid, Gliquidon
Glimepiride
Biguanide
Phenformin, Metformin, Buformin
Syarat OHO berhasil baik: diit dan latihan sesuai 3 J, diberikan pada px umur
> 40 th, lama DM < 5 th, Tx insulin belum pernah, KAD belum pernah.
INSULIN
Indikasi
1.
2.
3.
4.
5.
DMTI
MRDM
DM-tipe X
Koma diabetik
DM tipe 2 : gagal sek OHO,hamil, gangren, kurus, fraktur,
hepatitis/sirosis hati, operasi
Cara pemberian
Rumus 5 1.
5 gr glukosa alkohol (maltose dll) diperlukan 1 U IR
Rumus 2,5 1.
2,5 gr glukosa diperlukan 1 U IR
TKOI. PPS (pagi OHO, sore insulin) & PPP (pagi OHO & insulin)
Hipoglikemia
Penanganankomplikasiakut
4.
Gejala
.
.
.
Terapi: kausal
Diagnosis
Patogenesa
infeksi,
steroid,
Terapi
mirip terapi KAD, tanpa BIK
1.
2.
3.
NaCl 0,9 % bila Na < 150 mEq/l; NaCl 0.45 % bila Na >150 mEq/l
IR seperti KAD
Antibiotika sesuai indikasi
KRITERIA KAD
1.
2.
3.
KLASIFIKASI KAD
I.
II.
III.
IV.
PATOGENESA
1.
2.
Hiperglikemia
hiperketogenesis
TERAPI
3.
Fase I (gawat)
4.
Fase II (fase rehabilitasi)
Dengan batas kedua fase glukosa darah 250 mg/dl
Goal
Take Action
Preprandial
<80
80-120
glucose mg/dl
>140
Bedtime
<100
100-140
glucose
>1
mg/dl
60
HbA1c %
<7
>8
ADA Diabetes Care 2000
Terima kasih