DIABETES MELLITUS

VG. A. Yani Ungaran

DIABETES MELLITUS

Pendahuluan
Penyebab
Patofisiologi
Pengobatan
Komplikasi
Pendidikan untuk pasien

DIABETES MELLITUS
Penyakit metabolik yang ditandai dengan
hiperglikemia kronis yang disebabkan
karena abnormalitas metabolisme
karbohidrat, lemak, dan protein.
Penyebab:
Pankreas tidak memproduksi insulin
Pankreas memproduksi insulin dalam jumlah
yang tidak mencukupi
Respon tubuh yang tidak cukup terhadap
insulin (resistensi insulin)

ETIOLOGI
DM tipe 1
DM tipe 2
Type spesifik
gangguan genetik dari fungsi sel beta
gangguan genetik pada fungsi insulin
penyakit eksokrin pankreas (pancreatitis,
pancreatectomy, neoplasia, cystic fibrosis, dll))
Endocrinopathy (acromegaly, cushings
syndrome, glucagonoma, hyperthyroidisme, dll)

PATOFISIOLOGI

DIAGNOSIS

TUJUAN TERAPI DM
Tujuan umum : meningkatkan kualitas
hidup pasien
Tujuan penatalaksanaan DM :

Jangka pendek
Hilangnya keluhan dan tanda DM
Mempertahankan rasa nyaman
Tercapainya target pengendalian glukosa
darah
Jangka panjang
Tercegah dan terhambatnya progresivitas
penyulit mikroangiopati, makroangiopati dan
neuropati
Tujuan akhir
Turunnya morbiditas dan mortalitas dini DM

TARGET TERAPI
Tabel I. Rekomendasi bagi penderita
Diabetes Dewasa (American Diabetes
Association, 2012)

Kontrol glukosa
HbA1C
<7.0%
Preprandialcapillary plasma 90-130
mg/dl
(5.0-7.2
glucose
mmol/l)
Peak postprandial capillary plasma <180 mg/dl (<10.0 mmol/l)
glucose
Tekanan darah

<130/80 mmHg

Fasting Lipid Profile

LDL
Trigliserida
HDL

<100 mg/dl (<2.6 mmol/l)

<150 mg/dl (<1.7 mmol/l)
>40 mg/dl (>1.1 mmol/l)

TERAPI NON FARMAKOLOGI DAN

FARMAKOLOGI
The major components of the
treatment of diabetes are:
Diet and exercise
Oral hypoglycaemic therapy
Insulin therapy

Diet
Diet is a basic part of management in every
case. Treatment cannot be effective unless
adequate attention is given to ensuring
appropriate nutrition.
Dietary treatment should aim at:
ensuring weight control
providing nutritional requirements
allowing good glycaemic control with blood glucose
levels as close to normal as possible
correcting any associated blood lipid abnormalities

Diet
The following principles are recommended as dietary
guidelines for people with diabetes:
Dietary fat should provide 25-35% of total intake of calories
but saturated fat intake should not exceed 10% of total
energy. Cholesterol consumption should be restricted and
limited to 300 mg or less daily.
Protein intake can range between 10-15% total energy (0.8-1
g/kg of desirable body weight). Requirements increase for
children and during pregnancy. Protein should be derived
from both animal and vegetable sources.
Carbohydrates provide 50-60% of total caloric content of the
diet. Carbohydrates should be complex and high in fibre.
Excessive salt intake is to be avoided. It should be
particularly restricted in people with hypertension and those
with nephropathy.

Exercise
Physical activity promotes weight reduction
and improves insulin sensitivity, thus lowering
blood glucose levels.
Together with dietary treatment, a programme
of regular physical activity and exercise
should be considered for each person. Such a
programme must be tailored to the
individuals health status and fitness.
People should, however, be educated about
the potential risk of hypoglycaemia and how
to avoid it.

Oral Hypoglycaemic
Medications

INSULIN
Insulin atau analog insulin
Ultra-rapid-acting
Insulin Lispro (Humalog)
Insulin Aspart (Novolog)
Insulin glulisin (Apidra)
Short-acting
Regular (human) Humulin R/Novolin R
U-500 (human)
Intermidiate-acting
NPH (human) Humulin N/Novolin N
Insulin detemir (Levemir)
Long-acting
Insulin glargine (Lantus)
Mixtures (human)
70/30 Human/Novolin (70% NPH, 30% regular)
50/50 Humulin (50% NPH, 50% regular)
Mixtures (Insulin Analogues)
75/25 Humalog (75% NPL, 25% lispro)
50/50 Humalog (50% NPL, 50% lispro)
70/30 Novolog Neutral (70% protamin aspartat,
30% aspart)

Onset

Peak

0,2-0,5

0,5-2

0,5-1

2-3

0,5-4
1-3

4-10
9unknown

1-3

No peak

0,5-1
0,5-1

3-12
2-12

0,2-0,5

1-4

Bedtime intermidiate-acting insulin atau bedtime atau

Long-acting insulin pagi hari, dosis awal 10 U atau 0,2 U/kg
Monitor GDP tiap hari, peningkatan dosis 2 U tiap 3 hari sampai
GDP target (70-130 mg/dl atau 3,89-7,22 mmol/l).
Peningkatan dosis bisa lebih besar jika GDP>180mg/dl (>10mmol/l)
Jika hipoglikemia atau
A1C7% setelah 2-3 bln?
GDP<70mg/dl(3,89mmol/l)
dosis bedtime diturunkan
Ya
Tidak
4U atau 10% jika dosis >60U
Lanjutkan regimen:
cek A1c tiap 3 bln
Pre-lunch diluar range:
tambah rapid-acting ins
pd wkt makan pagi

Tidak

Jika GDP mencapai target,

cek GDPP, tergantung hasil,
tambah injeksi kedua, ~4U &
penyesuaian 2U/3hari

Pre-dinner diluar range: Sebelum tidur diluar range:

tambah NPH ins pd mkn
tambah rapid-acting ins
pagi atau rapid-acting
pada saat makan malam
pd makan siang

A1C7% setelah 3 bln?

Ya

Cek kembali gula darah sebelum makan, jk diluar range, ditambahkan injeksi

Titrasi Dosis Insulin

GDP dalam 3 hari

Penyesuaian
dosis insulin
basal

PPG atau bedtime

selama 3 hari

Penyesuaian
dosis rapid-acting
insulin

9,90 (>180)
8,80 to 9,90 (160 to 180)
7,70 to 8,75 (140 to 159)
6,60 to 7,65 (120 to 139)
5,50 to 6,55 (100 to 119)
4,40 to 5,45 (80 to 99)
3,30 to 4,35 (60 to 79)
<3,30 (<60)

8
6
4
2
1
Maintain
-2
-4

9,90 (>180)
8,80 to 9,90 (160 to 180)
7,70 to 8,75 (140 to 159)
6,60 to 7,65 (120 to 139)
5,50 to 6,55 (100 to 119)
4,40 to 5,45 (80 to 99)
3,30 to 4,35 (60 to 79)
<3,30 (<60)

3
2
2
1
Maintain
-1
-2
-4

Titrasi Dosis Pre-mixed Insulin

GDP dalam 3 hari

Penyesuaian
dosis presupper

PPG atau bedtime

selama 3 hari

Penyesuaian
dosis
prebreakfast

9,90 (>180)
7,76 to 9,90 (141 to 180)
6,11 to 7,70 (111 to 140)
4,40 to 6,05 (80 to 110)
3,30 to 4,35 (60 to 79)
<3,30 (<60)

6
4
2
Maintain
-2
-4

9,90 (>180)
7,76 to 9,90 (141 to 180)
6,11 to 7,70 (111 to 140)
4,40 to 6,05 (80 to 110)
3,30 to 4,35 (60 to 79)
<3,30 (<60)

6
4
2
Maintain
-2
-4

Tatalaksana Terapi DM tipe 2

(ADA 2012)
At the time of type 2 diabetes diagnosis, initiate
metformin therapy along with lifestyle
interventions, unless metformin is contraindicated.
In newly diagnosed type 2 diabetic patients with
markedly symptomatic and/or elevated blood
glucose levels or A1C, consider insulin therapy,
with or without additional agents, from the outset.
If noninsulin monotherapy at maximal tolerated
dose does not achieve or maintain the A1C target
over 36 months, add a second oral agent, a GLP-1
receptor agonist, or insulin.

Tier 1 : Well-validated core therapies

At diagnosis
Lifestyle
+
Metformin

Lifestyle + Metformin
+
Basal Insulin

Lifestyle + Metformin
+
Intensive insulin

Lifestyle + metformin
+
Sulfonylurea
STEP 1

STEP 2

STEP 3

Tier 2 : Less well-validated therapies

Lifestyle + Metformin
+
Pioglitazone
No hypoglycaemia
Oedema/CHF
Bone loss
Lifestyle + Metformin
+
GLP-1 agonist
No hypoglycaemia
Weight loss
Nausea/vomiting

Lifestyle + Metformin
+
Pioglitazone
+
Sulfonylurea

Lifestyle + Metformin
+
Basal Insulin

KOMPLIKASI

PENDIDIKAN UNTUK
PASIEN
Diabetes self-management education
(DSME) :
Proses terjadinya penyakit dan pilihan terapi
Terapi gizi medis
Aktivitas fisik
Penggunaan obat efektivitas terapi
Monitoring gula darah dan pemahaman hasil
Komplikasi akut (pencegahan, deteksi dan terapi)
Komplikasi kronik (pencegahan, deteksi dan
terapi)
Tujuan terapi dan pemecahan masalah
Perawatan pre-konsepsi, manajemen selama
kehamilan dan GDM

PENDIDIKAN UNTUK
PASIEN
Diabetes self-management education (DSME):
(Survival skills)
Bagaimana menggunakan obat

Bagaimana melakukan test gula darah

penggunaan alat, jadwal test

Tanda dan gejala hypo/hyperglikemia

waktu, aksi obat, teknik dan cara pemberian (insulin)

Penyebab dan terapinya

Pengaturan nutrisi

Macam makanan, waktu makan, jumlah dan

keseimbangan nutrisi

PENDIDIKAN UNTUK
PASIEN
Topik penting untuk edukasi ke
pasien tentang penanganan DM :
Pasien mengetahui target nilai kadar gula
darah yang dinginkan
Pasien mengetahui nilai kadar gula darahnya
sendiri
Peranan obat dalam mengontrol kadar gula
darah, bukan menyembuhkannya
Konsekuensi yang serius dari kadar gula
darah yang tidak terkontrol
Pentingnya kontrol teratur