Essential hypertension
95%
No underlying cause
Secondary hypertension
Renal
Parenchyma
Vascular
Endocrine
Misc.
2nd Hypertension
Secondary HTN
A. Renal (80%) AGN Renal Artery stenosis
CGN,
CPN,
Polycyst. K.D
Usia Lanjut
Sex (Pria dan Wanita pasca menopause)
Riwayat Keluarga dengan penyakit
kardiovaskular
Sedentary life style & psycho-social
stress
Smoking ,High cholesterol diet, Low fruit
consumption
Obesity
Diabetes dan Dislipidemia
Konsumsi Alkohol
NEXT STEP..
Hypertension
Heart Left
Gangrene of the
Failure Ventricular Myocardial
Lower Hypertrophy Infarction
Extremities
Aortic Coronary
Aneurym Heart Disease
HYPERTENSION
Hypertensive
Blindness encephalopath
Cerebral y
Chronic
Stroke Preeclampsi Hemorrhag
Kidney
a/Eclampsia e
Failure
Haemodynamic Pattern in
Hypertension
Haemodynamic Pattern in
Hypertension
Young : BP = CO X PR
Elderly : BP = CO X PR
Pengukuran Tekanan Darah
Pengukuran di Klinik
Pada kesempatan pertama ukur kedua
lengan.
Pada populasi lansia ukur minimal 2 posisi.
Pengukuran Mandiri
Pada populasi White Coat hypertension
Pada populasi Masked hypertension
Risiko hipotensi karena obat
Hipertensi Sekunder-TOD
Pemeriksaan Penunjang
Managing
Hypertension
Goals of therapy
Lifestyle modification
Pharmacologic treatment
Algorithm for treatment of hypertension
Follow up and monitoring
Target Th/..
Konsep Pencegahan:
Primer : Pola Hidup, IMT, DASH, 1
sendok the garam dapur , aerobik 30
mnt 4 x/mgg, dan tidak merokok.
Sekunder : cek tekanan darah rutin ,
pengobatan tepat.
Tersier : cegah komplikasi dan
peningkatan kualitas hidup.
Classification and
management of blood
pressure for adults
Hipertensi Tidak Terkendali
Hipertensi resisten
Terjadi peningkatan TD akut pada pasien
kronis
Hipertensi pada usia kurang dari 30 tahun
tanpa risiko.
Hipertensi terakselerasi.
Resistant
Hypertension :
Improper blood pressure measurement
Volume overload
Excess sodium intake
Volume retention from kidney disease
Nonadherence
Inadequate doses & Inappropriate combinations
Nonsteroidal anti-inflammatory drugs; cyclooxygenase 2
inhibitors
Sympathomimetics (decongestants, anorectics)
Steroids
Excess alcohol intake
SESI 2:
Tatalaksana
Diabetes
(T2DM)
DR AGUS LASTYA EKA P SPPD
KLASIFIKASI DAN DIAGNOSIS
1. Type 1 diabetes
2. Type 2 diabetes
3. Gestational diabetes mellitus (GDM)
4. Specific types of diabetes due to other
causes.
DIAGNOSTIC TESTS FOR
DIABETES
A1C >6.5%. The test should be performed in a laboratory using a
method that is certied and standardized
OR
FPG >126 mg/dL (7.0 mmol/L). Fasting is dened as no
caloric intake for at least 8 h.*
OR
2-h PG > 200 mg/dL (11.1 mmol/L) during an OGTT. The test
should be performed as described by the WHO, using a glucose
load containing the equivalent of 75 g anhydrous glucose
dissolved in water.*
OR
In a patient with classic symptoms of hyperglycemia or
hyperglycemic crisis, a random plasma glucose > 200 mg/Dl
(11.1 mmol/L).
Screening Test
T2DM
CATEGORIES OF INCREASED
RISK FOR DIABETES
+ peripheral
hepatic renal glucose
glucose glucose uptake
production excretion
Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
Multiple, Complex
Pathophysiological
Abnormalities in T2DM
GLP-1R Insulin
agonists pancreatic
incretin Glinides S U s insulin
effect secretion
DPP-4 pancreatic
inhibitors glucagon
_ secretion
gut ?
carbohydrate
delivery & HYPERGLYCEMIA
absorption
Metformin TZDs
_
+ SGL2 i
peripheral
hepatic renal glucose
glucose glucose uptake
production excretion
Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
Oral Mechanism Advantages Disadvantage Cos
Class s t
Biguanide Activates AMP- Extensive Gastrointestinal Low
s kinase (?other) experience Lactic acidosis
Hepatic No hypoglycemia (rare)
glucose Weight neutral B-12 deficiency
production ? CVD
Contraindications
Sulfonylu Closes KATP Extensive Hypoglycemia Low
reas experience Weight
channels
Microvascular Low durability
Insulin
risk ? Blunts
secretion
ischemic
preconditioning
Meglitinid Closes K Postprandial Hypoglycemia Mod
ATP
es glucose Weight .
channels
Dosing flexibility ? Blunts
Insulin
ischemic
secretion
preconditioning
Dosing
frequency
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin Metformin Metformin Metformin Metformin Metformin
+ + + + + +
Triple Sulfonylurea Thiazolidine-
dione
DPP-4
Inhibitor
SGLT-2
Inhibitor
GLP-1 receptor
agonist
Insulin (basal)
therapy + + + + + +
TZD SU SU SU SU TZD
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
Figure 2. Anti-hyperglycemic
injectable Basal Insulin + Mealtime Insulin or GLP-1-RA
therapy
therapy
in T2DM: General DiabetesCare2015;38:140149;Diabetologia 2015;58:429-442
Healthy eating, weight control, increased physical activity & diabetes education
Mono-
therapy Metformin
Efcacy* high
Hypo risk low risk
Weight neutral/loss
Side effects GI / lactic acidosis
Costs low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin Metformin Metformin Metformin Metformin Metformin
+ + + + + +
Triple Sulfonylurea Thiazolidine-
dione
DPP-4
Inhibitor
SGLT-2
Inhibitor
GLP-1 receptor
agonist
Insulin (basal)
therapy + + + + + +
TZD SU SU SU SU TZD
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
Figure 2. Anti-hyperglycemic
injectable Basal Insulin + Mealtime Insulin or GLP-1-RA
therapy
therapy
in T2DM: General DiabetesCare2015;38:140149;Diabetologia 2015;58:429-442
Healthy eating, weight control, increased physical activity & diabetes education
Mono-
therapy Metformin
Efcacy* high
Hypo risk low risk
Weight neutral/loss
Side effects GI / lactic acidosis
Costs low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin Metformin Metformin Metformin Metformin Metformin
+ + + + + +
Triple Sulfonylurea Thiazolidine-
dione
DPP-4
Inhibitor
SGLT-2
Inhibitor
GLP-1 receptor
agonist
Insulin (basal)
therapy + + + + + +
TZD SU SU SU SU TZD
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
Figure 2. Anti-hyperglycemic
injectable Basal Insulin + Mealtime Insulin or GLP-1-RA
therapy
therapy
in T2DM: General DiabetesCare2015;38:140149;Diabetologia 2015;58:429-442
Healthy eating, weight control, increased physical activity & diabetes education
Mono-
therapy Metformin
Efcacy* high
Hypo risk low risk
Weight neutral/loss
Side effects GI / lactic acidosis
Costs low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin Metformin Metformin Metformin Metformin Metformin
+ + + + + +
Triple Sulfonylurea Thiazolidine-
dione
DPP-4
Inhibitor
SGLT-2
Inhibitor
GLP-1 receptor
agonist
Insulin (basal)
therapy + + + + + +
TZD SU SU SU SU TZD
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
+
Combination
injectable Basal Insulin + Mealtime Insulin or GLP-1-RA
therapy DiabetesCare2015;38:140149;Diabetologia 2015;58:429-442
Healthy eating, weight control, increased physical activity & diabetes education
Mono-
therapy Metformin
Efcacy* high
Hypo risk low risk
Weight neutral/loss
Side effects GI / lactic acidosis
Costs low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin Metformin Metformin Metformin Metformin Metformin
+ + + + + +
Triple Sulfonylurea Thiazolidine-
dione
DPP-4
Inhibitor
SGLT-2
Inhibitor
GLP-1 receptor
agonist
Insulin (basal)
therapy + + + + + +
TZD SU SU SU SU TZD
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
Figure 2A. Anti- +
Combination
hyperglycemic
injectable therapy Basal Insulin + Mealtime Insulin or GLP-1-RA
therapy
in T2DM:
DiabetesCare2015;38:140149;Diabetologia 2015;58:429-442
Healthy eating, weight control, increased physical activity & diabetes education
Mono-
therapy Metformin
Efcacy* high
Hypo risk low risk
Weight neutral/loss
Side effects GI / lactic acidosis
Costs low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin Metformin Metformin Metformin Metformin Metformin
+ + + + + +
Triple Sulfonylurea Thiazolidine-
dione
DPP-4
Inhibitor
SGLT-2
Inhibitor
GLP-1 receptor
agonist
Insulin (basal)
therapy + + + + + +
TZD SU SU SU SU TZD
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
Figure 2B. Anti- +
Combination
hyperglycemic
injectable therapy Basal Insulin + Mealtime Insulin or GLP-1-RA
therapy
in T2DM:
DiabetesCare2015;38:140149;Diabetologia 2015;58:429-442
Healthy eating, weight control, increased physical activity & diabetes education
Mono-
therapy Metformin
Efcacy* high
Hypo risk low risk
Weight neutral/loss
Side effects GI / lactic acidosis
Costs low
If HbA1c target not achieved after ~3 months of monotherapy, proceed to 2-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
If HbA1c target not achieved after ~3 months of dual therapy, proceed to 3-drug combination (order not meant to denote
any specific preference - choice dependent on a variety of patient- & disease-specific factors):
Metformin Metformin Metformin Metformin Metformin Metformin
+ + + + + +
Triple Sulfonylurea Thiazolidine-
dione
DPP-4
Inhibitor
SGLT-2
Inhibitor
GLP-1 receptor
agonist
Insulin (basal)
therapy + + + + + +
TZD SU SU SU SU TZD
If HbA1c target not achieved after ~3 months of triple therapy and patient (1) on oral combination, move to injectables, (2) on GLP-1 RA, add
basal insulin, or (3) on optimally titrated basal insulin, add GLP-1-RA or mealtime insulin. In refractory patients consider adding TZD or SGL T2-i:
Metformin
Figure 2C. Anti- +
Combination
hyperglycemic
injectable Basal Insulin + Mealtime Insulin or GLP-1-RA
therapy
therapy
in T2DM: DiabetesCare2015;38:140149;Diabetologia 2015;58:429-442
Special population
Framework for considering treatment goals for
glycaemia, blood pressure, and dyslipidemia in
older adults with diabetes
Management of Diabetes in
Pregnancy