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Assessing Glycemia in Diabetes

Using
Self-monitoring Blood Glucose

M. Robikhul Ikhsan, dr., Mkes., SpPD


Sub Bagian Endokrinologi Bagian Penyakit Dalam
FK UGM/RS Dr Sardjito
PERKENI Cab. Yogyakarta

ILUSTRASI
Tn. DM, 52 th, menyandang diabetes melitus 3 tahun. Kontrol
rutin tiap bulan
Terapi Glimepiride 2 mg 1x sehari, metformin
3 x !!
500 mg
Pagi Dok

Rendah ?
Normal ?
Tinggi ?

Kemarin
saya cek
Gula darah
saya 152
dok, bagus
tidak Dok?

- jam berapa cek gula nya?


- sudah makan pagi belum?
- berapa jam setelah makan
pagi?
- obat paginya diminum tidak?
- semalam makan terakhir jam
berapa?
- tadi malam obat nya diminum
tidak?
- sarapannya seperti biasa atau
tidak
jumlahnya?
- sempat olah raga tadi pagi?
- kapan cek gula terakhir
sebelum ini?
- berat badan naik atau tidak?
- ada tekanan di pekerjaan?

Daily Blood Glucose Curve

KEPENTINGAN ?
- Penderita DM (WHO)
seluruh dunia : th 2000 : 150 juta th 2025 : 300 juta
Indonesia : th 1995 : 4,5 juta th 2025 : 17,4 juta
- DM merupakan faktor risiko :

IMA/Stroke 2-4 kali


Amputasi ekstremitas bawah 10-15 kali
Kebutaan 25 kali

- 50% penderita DM diketahui setelah terjadi


komplikasi yang berat (gagal ginjal, kaki busuk, dll)

Type 2 diabetes management is multifactorial

Smoking
Education
Lifestyle

Pharmacologic
management
Dyslipidemia
Statin

Physical
Activities
BG Evaluation

Control blood
pressure

Self-monitoring Blood Glucose (SMBG)


Pemantauan Glukosa Darah Mandiri

Self Monitoring Blood Glucose

Pemantauan glukosa darah mandiri satu kesatuan


strategi manajemen penatalaksanaan DM
untuk mengetahui keberhasilan manajemen DM,
mencegah hipoglikemia, menyesuaikan pengobatan
Akurasi pemantauan KGD mandiri tergantung
instrumen dan pengguna.
Perlu pengamatan teknik yang dilakukan diabetisi

PERAN DOKTER DALAM


Self Monitoring Blood Glucose
Mengubah mind set
Menjelaskan manfaat SMBG
Verifikasi sumber DATA
- prosedur pengambilan data
- faktor-faktor yang mempengaruhi

Plan of Action

Kasus
Laki-laki, 46 th
Penderita DM 5 th, kontrol rutin di RS
Tiap bulan
Data Glukosa Darah 3 bulan terakhir
142, 134, 146
- GDP
- GD2J PP 198, 202, 188

WAH HASIL GULA

DARAHNYA CUKUP

BAGUS PAK

SELAMAT YA !! BULAN
DEPAN CEK HbA1c YA

EVALUASI HbA1c
11,5 %

Know Your Number

Poor
Control

14

36
0

13

33
0

12

30
0

11

27
0

10

24
0

21
0

18
0

15
0

12
0

90

Not Good

Pretty
Good

Good
Control

A1c

Blood Sugar

Monitoring Your
Diabetes: What
does an A1c mean
An A1c measures how much
sugar has been sticking to red
blood cells over a 3 month
period of time.
An A1c is a measure of longterm diabetes control.

Goal is A1c <7

3 HARI LAGI KONTROL


RAPOR NYA HARUS
BAGUS AH !!!
MAKAN NASI 3 SENDOK
SAJA, BANYAK MINUM
PUTIH, OLAH RAGA

. bersambung

WAH HASIL GULA


DARAHNYA CUKUP
BAGUS PAK
SELAMAT YA !!
BULAN DEPAN CEK
HbA1c YA

HOREE!!!!
HARUS
DIRAYAKAN NIH

.. 3 tahun kemudian

TARGET GOAL ?
MENGUBAH

mind set !!

Doctor centered
centered

Patient

seberapa besar peran dokter dibanding


partisipasi pasien dalam keberhasilan
manajemen DM?

PERAN DOKTER DALAM


Self Monitoring Blood Glucose
Mengubah mind set

Menjelaskan manfaat SMBG


Verifikasi sumber DATA
- prosedur pengambilan data
- faktor-faktor yang mempengaruhi

Plan of Action

Does management of glycemia in


diabetes reduce acute and/or longterm complications?
Diabetic Vascular Complication Risk Reduction
per 1% Decrease in HbA1c
Study
Heart
DCCT
29-35%

Eye

Kidney
27-38%

Nerve
22-28%

40%*

Kumamoto
28%
50%
Not statistically
significant because of a small number of events;
25%*
all other values significant

UKPDS
18%

NCV = nerve conduction velocity

14%

19%

26%

NCV

PENGARUH SMBG TERHADAP QoL

Control
SMBG

Schwedes, Diabetes Care 25: 1928-1932, 2002

Benefits affect of SMBG on


Diabetes Management
Estey A, et al. Diabetes Educ 16:291-295, 1989
Allen BT, et al. Diabetes Care 13:1044-1050, 1990
Rutten G, et al. Fam Pract 7:273-278, 1990
Gallichan MJ. Practical Diabetes 11:28-30, 1994
Miles P, et al. BMJ 315:348-349, 1997
McMurray SD, et al. Am J Kidney Dis 40:566-575, 2002
Ozmen B, et al. Endocrinologist 12:349-356, 2002
Schwedes U, et al. Diabetes Care 25:1928-1932, 2002
Jones H, et al. Diabetes Care 26:732-737, 2003
Nyomba BLG, et al. Diabet Med 2:129-135, 2003
Polonsky WH, et al. Diabetes Care 26:3048-3053, 2003
Etc.

Who should monitor


glycemia?

+
Patient
Selfmonitoring
of blood
glucose

Healthcare
professionals
Regular monitoring of HbA1c

Diabetes care team

Combined synergistic efforts of team are


crucial to ensure effective monitoring of
glycemic control

Self-monitoring of blood
glucose (SMBG)
Regular SMBG increases
the proportion of
individuals achieving their
glycemic targets
Individuals should monitor
postprandial glucose as
part
of their SMBG schedule
Regular discussion of
results with diabetes care
team is essential

HbA1c 8.0
90%

HbA1c >
8.0

80%
70%
60%
50%
40%
30%
20%
10%
0%
Regular
SMBG
Performer
s (21%)

Irregular
SMBG
Performer
s (42%)

Not
Monitore
d (37%)

Self-monitoring Blood Glucose


(SMBG)
Insulin-Treated Type 2 Diabetes
Two studies support SMBG use in insulin-treated
type 2 diabetics in patients who were able to adjust
insulin doses and adherent SMBG users testing seven
or more times per week
One large RCT in which patients were given free
meters showed a significant HbA1c reduction of
0.63% in patients with poor control at baseline (HbA1c
>10%) in 6 month
Harris MI. Diabetes Care 2001;24:979-982
Evans JMM, et al. BMJ 1999;319:83-86
Karter AJ, et al. Am J Med 2001;111:1-9
Franciosi M, et al. Diabetes Care 2001;24:1870-1877
Soumerai SB, et al. Arch Intern Med 2004;164:645-652

PERAN DOKTER DALAM


Self Monitoring Blood Glucose
Mengubah mind set
Menjelaskan manfaat SMBG

Verifikasi sumber DATA


- prosedur pengambilan data
- faktor-faktor yang mempengaruhi
Plan of Action

POLA HIPERGLIKEMIA DIABETISI


Hiperglikemia Puasa
Hiperglikemia post-prandial
Hiperglikemia sepanjang hari
Kadar glukosa darah puasa adalah KGD yang diperiksa
dalam keadaan puasa atau minimal 8 jam tanpa asupan
kalori
KGD 2 jam post-prandial diambil 2 jam setelah makan
(Diit dan aktifitas seperti biasa)
Kadar glukosa darah Random(?)

- jam berapa cek gula nya?


- sudah makan pagi belum?
- berapa jam setelah makan
pagi?
- obat paginya diminum tidak?
- semalam makan terakhir jam
berapa?
- tadi malam obat nya diminum
tidak?
- sarapannya seperti biasa atau
tidak
jumlahnya?
- sempat olah raga tadi pagi?
- kapan cek gula terakhir
sebelum ini?
- berat badan naik atau tidak?
- ada tekanan di pekerjaan?

Perlunya merekonstruksi
hasil pemeriksaan glukosa
darah
240 mg/dl
240 mg/dl
240 mg/dl
60 mg/dl

115
mg/dl

180
mg/dl

125
mg/dl

FREKUENSI PEMERIKSAAN KGD


MANDIRI
Insulin multiple daily injections: minimal 3 kali (ideal 7
kali sehari) DATA AWAL
Anti diabetik oral atau insulin 1 kali atau 2 kali injeksi
sehari, atau diet disesuaikan
Pemantauan KGD mandiri untuk membantu
menyesuaikan dosis atau mencapai target
(tidak harus tiap hari)

Self Monitoring Blood


Glucose
YES
+

Bagian Integral dari


EffectDiabetes
and Consequencies
Manajemen
NO

Increased awareness of disease,


concern
about
complications
+
Patient adjusts daily routine
according
to BG
values
+
More therapy
adjustments
+
More training/counselling by
physician
+
More attention from physician
-

GULA DARAH TINGGI


Konfirmasi
- KGD puasa diperiksa minimal 8 jam
tanpa asupan kalori
- KGD post prandial diambil kapan?
- Obat diminum/insulin disuntik tidak?
- Tanyakan pola makan
- Tanyakan alat yang digunakan dan cara
penggunaan
Analisis hasil perlu konfirmasi tampilan klinis,
periksa silang dengan keluhan DM/BB
Bila perlu sarankan pemeriksaan KGD di lab klinik

Self-monitoring Blood Glucose (SMBG)


Standardization and Confounders
International Organization for Standardization recommends that more
than 95% of readings be within 15 mg/dL for glucose readings below
75 mg/dL and within 20% for higher values
Under optimal circumstances, most meters meet these accuracy
standards

Operator-related errors are a more


common source of error than instrumentFailure to calibrate meter,
Poor errors:
hand washing, Dirty meters,
related
Improper storage of test strips

Lewandrowski K, et al. Am J Med 1992;93:419-426


Johnson RN, et al. Clin Chim Acta 2001;307:61-67
Bergenstal R, et al. Diabetes Educ 2000;26:981-989

LANGKAH-LANGKAH
PELAKSANAAN
Self Monitoring Blood

Glucose

First step:
Do several blood glucose profiles within one week
Date

Before
breakfast

1 -2 h
after
breakfast

Before
lunch

1 -2 h
after
Lunch

before
dinner

1 -2 h
after
dinner

before
sleep

Second step:
Visualise BG profiles to understand them

Before
breakfast

1 -2 h
after
breakfast

Before
lunch

1 -2 h
after
lunch

Before
dinner

1 -2 h
after
dinner

Before
sleep

Third step:
Modify lifestyle and determine effect on BG
- Before and 1.5-2 h after good/bad meal or drink
- Before and after physical activity
- Impact of 15 min walk before a meal
- Impact of evening walk on FBG in the morning

Fourth step:
Maintenance by individual measurements per day
and BG profiles from time to time
more tests if insulin treated,
less intense if oral drugs or diet

Please note:
SMBG is effective also in patients on diet only

Plasma glucose: Whole blood glucose


{1,0-(0,0024 x Hct)}
Table Whole BG Plasma G at different HCT levels

HCT

Whole BG

Plasma Glucose

25

100

106,4

35

100

109,2

45

100

112,1

55

100

115,2

65

100

118,5

Condition that affect hematocrit


Lower:

Pregnancy
Cancer
AIDS
Anemia
Hemorrage
Fluid infusion
Dialysis

Raise:

- Polycytemia
- Dehydration

Substances interfered meter


accuracy:

Uric acid
Glutathione
Ascorbic acid
Contamination or insufficiency of the blood sample
(unwashed hand, unclean test strips or meters)
decrease accuracy meter readings
Method :
Glucose oxidase; glucose dehydrogenase,
hexokinase

Arterial glucose level Highest


Venous glucose level Lowest
Capillary glucose level (4-20%) higher than venous

Current Technology

Glucose Test Strip Technology affected by the presence of nonglucose sugars:

Glucose Dehydrogenase Pyrroloquinolinequinone


(GDH-PQQ)
Glucose test strip technologies not affected by the presence of nonglucose sugars:

Glucose Oxidase (GOD)


Glucose Dehydrogenase Nicotine Adenie
Dinucleotide (GDH-NAD)
Glucose Dehydrogenase Flavin Adenine
Dinucleotide (GDH-FAD)
Laboratory-based blood glucose assays do not use GDH-PQQ

ILUSTRASI
Laki-laki, 58th
Penderita DM 8 th, kontrol rutin di RS
Tiap bulan
Data Glukosa Darah terakhir

196
- GDP
- GD2JPP 308

MAAF DOK !!
BEBERAPA HARI
TERAKHIR INI
BANYAK KENDUREN,
MANTEN, SUNATAN,
TILIK BAYI

PETUGAS KESEHATAN CENDERUNG MEMBERI TOLERANSI

TIDAK SELALU ALASAN


YANG DISAMPAIKAN
PASIEN BENAR
202, 189, 196
- GDP
- GD2JPP 286, 278, 308
Data KGD dalam 3 bulan terakhir

PERAN DOKTER DALAM


Self Monitoring Blood Glucose
Mengubah mind set
Menjelaskan manfaat SMBG
Verifikasi sumber DATA
- prosedur pengambilan data
- faktor-faktor yang mempengaruhi

Plan of Action

Pilar pengelolaan
DM

PENDEKATAN PASIEN SECARA


HOLISTIK DAN TERINTEGRASI
Edukasi
Pengaturan diet/makan
Latihan jasmani/olah raga
Farmakologi/obat-obatan
Evaluasi/monitoring

Choose and
the real
Superman