Forum Apoteker Indonesia Jakarta, 4 April 2012

FARMAKOTERAPI DIABETES TIPE 2

Dra. Retnosari Andrajati , PhD. Apt. Fakultas Farmasi Universitas Indonesia

WHO definition
Diabetes mellitus is
a metabolic disorder of multiple etiology, characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.

Epidemiologi

Diabetes is highly prevalent, afflicting approximately 150 million people worldwide. The number is expected to rise to 300 million in the year 2025 . Much of this increase will occur in developing countries. (WHO 2003 Adherence to long term therapies;Evidence for
action)

DM di Indonesia

2006 ; Kematian di RS 2.38%

(Indonesian Health Profile 2007)

2007 Kematian 5,7% (Indonesian Health profile 2008,

Ministry of Health Republik Indonesia)

Prediksi WHO: 8.4 million 2000 21.3 million in 2030. (Konsesus Pengelolaan dan Pencegahan DMtipe 2 di Indonesia, PB PERKENI)

DM Etiological Type Konsesus Pengelolaan dan Pencegahan

DMtipe 2 di Indonesia, PB PERKENI

Type Type 1 Type 2 Autoimmune Idiopathic Predominantly insulin resistance. Predominantly secretory defect

Other specific types Gestational Diabetes

DiabetesTipe 2

90% DM Terkait dengan berat badan berlebih dan resistensi insulin. Fungsi Sel beta pankreas menurun sejalan dengan waktu terapi insulin dapat diperlukan. Gejala dapat sama dengan DM tipe 1 , tetapi sering lemah terlambat diketahui.

Diagnosis berdasarkan gula darah

glucose plasma fasting 2 hour postprandial <100 mg/dl < 140 mg/dl 00-125 mg/dl 140-199 mg/dl 126 mg/dl > 200

Normal Pradiabetes1 IFG/IGT Diabetes mg/dl

IFG : Impaired fasting glucose IGT : Impaired glucose tolerance

Glycated haemoglobin HBA1c

Apa akibat dari DM ?

Komplikasi akut : infeksi, hipoglikemia, ketoasidosis. Kronik: mata, ginjal, saraf dan kardiovaskuler.

Sasaran terapi

Mempertahankan kadar glukosa darah pada tingkat yang sedapat mungkin normal Menghindari komplikasi akut dan kronik

Komplikasi DM

Meningkatkan risiko penyakit jantung dan stroke 50% orang dengan DM meninggal karean penyakit jantung dan stroke. Neuropati + menurunnya aliran darah ulkus kaki amputasi. 10-20% penderita DM gagal ginjal Diabetic neuropathy (50%) : kesemutan, nyeri, baal dan lemah pada tangan dan kaki Diabetic retinopathy, krn kerusakan pembuluh darah kebutaan
Sesudah 15

tahun 10 % gangguan penglihatan2%

buta.

Tujuan terapi
Mengeliminasi gejala hiperglikemia; Mencapai kontrol optimum; Menurunkan komplikasi mikro dan makrovaskuler; Menganani gangguan penyerta; Sedapat mungkin membuat pasien mencapai pola hidup normal

Terapi
Edukasi Rekomendasi nutrisi Latihan Farmakoterapi

Golongan Sulfonilurea

Biguanid Meglitinad

Obat hipoglikemik oral Contoh Mekanisme kerja Gliburid/glibenkla Merangsang sekresi kel mid, glipizid, pankreas glikazid, glikuidon Metformin Menurunkan produksi glukosa hati Replaginid Merangsang sekresi kel pankreas

Thiazolidindion

Inhibitor aglukosidase

Rosiglitazon, Meningkatkan kepekaan troglitazon, reseptor insulin pioglitazon Akarbose, miglitol Menghambat enzimenzim-enzim pencernaan

ROTD Paling umum: ggn saluran cerna, mual, panas, rasa penuh. Hipoglikemi, reaksi alergi pd kulit, eksim, pruritis, eritema, urtikaria, fotosensitif, leukopenia, trombositopenia, anemia aplastik, agranulositosit, anamia hemolitik, lemah, parestresia, tinitus, pusing, vertigo, malaise, test fungsi hati meningkat. Monitoring hipoglikemia, Syndrome of inappropriate secretion of antidiuretic hormone (SIADH):retensi air dg hiponatremia

Thiazolidinedion
Rosiglitazon, pioglitazon, troglitazon

Mekanisme kerja: Memperbaiki sensitivitas insulin pd sel otot dan lemak Menghambat glukoneogenesis di hati ROTD gangguan Kardiovaskuler

Alfa glukosidase inhibitor

Akarbose oligosakarida kompleks MK: menghambat pencernaan karbohidrat glukosa yg diabsorpsi< ROTD: 77%: flatuluns 33%: diare 21%: nyeri perut Reksi hipersensitivitas : ruam : jarang

Obat ADO baru

DPP-4 Inhibitors: menghambat enzim (DPP-4) yang secara normal mendeaktivasi protein (GLP1) yang mempertahankan sirkulasi insulin .Sitagliptin. Incretin Mimetics: menyerupai kerja inkretin untuk merangsang pembentukan insulin

Criteria of Controlled Diabetes

good Fasting blood glucose 2 hour postprandial Hba1c (%) Total cholesterol HFL cholesterol LDL cholesterol Fasting triglycerides 80-<100 80-144 <6.5 <200 mg/dl >45 (male) >55(female) <100 <200 borderline 100-125 145-179 6.5-8 200-250 35-45 45-55 100-130 200-250 poor 126 180 >8 >250 <35 <45 >130 >250

Criteria of Controlled Diabetes

good Body mass index(kg/m2) male female Blood pressure (mmHg) borderline poor

<25.0 <24.0 <130/80

25.0-27.0 24.0-26.0 -

>27.0 >26 -

Essential components of diabetic counseling

Counseling regarding the disease Counseling regarding lifestyle modifications Counseling regarding medications Counseling regarding acute complications Counseling regarding chronic complications Counseling in special populations Counseling regarding self Monitoring of Glucose

Counseling regarding lifestyle modifications

Diet
Carbohydrates 46-65% Protein

10-20% Fat 20-25%

Exercise and physical activity Alcohol intake and smoking

Counseling points for oral hypoglycemic agents

Counseling points for insulin

References
1. Konsensus Pengelolalan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia 2006. Available at: http://www.perkeni.net (Accessed on 2 th August 2010) 2. Pharmaceutical care untuk penyakit diabetes. Departemen Kesehatan RI, 2006. 3. Diabetes fact sheet no.312,World Health Organization 2009. Available at http://www.who.int/mediacentre/factsheets/fs312/en/print.html (accessed on 4th August 2010) 4. Khatib OMN ed.Guidelines for the prevention, management and care of Diabetes mellitus. World Health Organization 2006. Available at http://www.who.int (accessed on 2th August 2010). 5. Palaian S., Role of pharmacist in counseling Diabetes Patients. The Internet Journal of Pharmacology 2005 : Volume 4 Number 1. (accessed on 2th August 2010) 6. Jennings DL., Ragucci KR., Chumney ECG., Wessel AM., Impact of clinical pharmacist intervention on diabetes related quality of life in an ambulatory care clinic. Pharmacy Practice 2007:5(4): 169-173. Available at www.pharmacy.practice.org ((accessed on 2th August 2010) 7. Working together to manage diabetes. A guide for pharmacy, podiatry, optometry and dental professional .National Diabetes Education Program 2007. Available at www.cdc.gov/phtnonline ((accessed on 2th August 2010)

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