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Definisi

Menurut American Diabetes


Association (ADA) tahun 2010,
Diabetes
melitus merupakan suatu kelompok
penyakit metabolik dengan
karakteristik hiperglikemia yang
terjadi karena kelainan sekresi
insulin, kerja insulin, atau kedua-
duanya.
Tujuan penatalaksanaan secara
umum adalah meningkatkan
kualitas
hidup penyandang diabetes.
Kriteria untuk Skrining Diabetes Tipe 2 dan
Prediabetes Asimtomatik pada Dewasa

Usia 45 tahun tanpa faktor risiko lain dislipidemia


Riwayat keluarga DMT2 HDL-C <35 mg / dL
CVD Trigliserida> 250 mg / dL
Kegemukan Gangguan toleransi glukosa, Glukosa
BMI 30 kg / m2 puasa terganggu, dan / atau sindrom
BMI 25-29,9 kg / m2 ditambah metabolik
faktor risiko lain * Hipertensi (BP> 140/90 mm Hg atau
gaya hidup terapi untuk hipertensi)
Riwayat diabetes gestational atau
penyerahan bayi dengan berat lebih
dari 4 kg
paparan glukokortikoid kronis

Skrining pada individu berisiko dengan nilai-nilai glukosa dalam batas normal setiap
3 tahun
Pertimbangkan skrining tahunan untuk pasien dengan 2 atau lebih faktor risiko

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How is diabetes screened and diagnosed?
Diagnostic Criteria for Prediabetes
and Diabetes in Nonpregnant Adults

Normal High Risk for Diabetes Diabetes


IFG
FPG <100 mg/dL FPG 126 mg/dL
FPG 100-125 mg/dL
2-h PG 200 mg/dL
IGT
2-h PG <140 mg/dL Random PG 200 mg/dL +
2-h PG 140-199 mg/dL
symptoms*
5.5 to 6.4%
6.5%
A1C <5.5% For screening of
Secondary
prediabetes
*Polydipsia (frequent thirst), polyuria (frequent urination), polyphagia (extreme
hunger), blurred vision, weakness, unexplained weight loss.
A1C should be used only for screening prediabetes. The diagnosis of

prediabetes, which may manifest as either IFG or IGT, should be confirmed with
glucose testing.

Glucose criteria are preferred for the diagnosis of DM. In all cases, the diagnosis
should be confirmed on a separate day by repeating the glucose or A1C testing.
FPG,When A1C glucose;
fasting plasma is usedIFG,for diagnosis,
impaired follow-up
fasting glucose; glucose
IGT, impaired glucose testing should
tolerance; PG, plasma be done when
glucose.
possible to help manage DM.
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Pilar penatalaksanaan DM

1. Edukasi
2. Terapi gizi medis
3. Latihan jasmani
4. Intervensi farmakologis
EDUKASI
Terapi Nutrisi Medis
Karbohidrat yang dianjurkan sebesar 45-65% total asupan
energi.
Sukrosa tidak boleh lebih dari 5% total asupan energi.
Asupan lemak dianjurkan sekitar 20-25% kebutuhan kalori.
Protein dibutuhkan sebesar 10 20% total asupan energi.
Pada pasien dengan nefropati perlu penurunan asupan
protein menjadi 0,8 g/Kg BB perhari atau 10% dari
kebutuhan energi
Anjuran asupan natrium untuk penyandang diabetes sama
dengan anjuran untuk masyarakat umum yaitu tidak lebih
dari 3000 mg atau sama dengan 6-7 gram (1 sendok teh)
garam dapur. Penderita hipertensi, pembatasan natrium
sampai 2400 mg garam dapur.
Anjuran konsumsi serat adalah 25 g/hari
kebutuhan kalori basal yang besarnya 25-30
kalori/kgBB ideal

IMT = BB(kg)/ TB(m2)

Klasifikasi IMT*
BB Kurang < 18,5

BB Normal 18,5-22,9

BB Lebih 23,0

o Dengan risiko 23,0-24,9

o Obes I 25,0-29,9

o Obes II > 30
Latihan Jasmani
How are glycemic targets achieved for T2D?

Therapeutic Lifestyle Changes

Parameter Treatment Goal


Weight loss
(for overweight
Reduce by 5% to 10%
and obese
patients)
150 min/week of moderate-intensity exercise (eg, brisk
Physical activity
walking) plus flexibility and strength training

Makan makanan biasa dan makanan ringan;


menghindari puasa untuk menurunkan berat badan
Mengkonsumsi diet nabati (tinggi serat, rendah kalori
Diet
/ indeks glikemik, dan tinggi phytochemical /
antioksidan)
Memahami informasi Label Fakta Nutrisi

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Rekomendasi Makan Sehat
Carbohydrat Tentukan karbohidrat sehat (buah-buahan segar dan sayuran, kacang-
e kacangan, biji-bijian); menargetkan 7-10 porsi per hari
Istimewa mengkonsumsi makanan rendah glikemik indeks (indeks
glikemik skor <55 dari 100: roti multigrain, pumpernickel roti, gandum
utuh, kacang-kacangan, apel, kacang, buncis, mangga, ubi jalar, beras
merah)
Fat Tentukan lemak sehat (merkuri rendah / kontaminan yang mengandung
kacang-kacangan, alpukat, minyak tumbuhan tertentu, ikan)
lemak jenuh batas (mentega, daging merah berlemak, minyak tumbuhan
tropis, makanan cepat) dan lemak trans; memilih produk susu bebas
lemak atau rendah lemak
Protein Mengkonsumsi protein dalam makanan dengan lemak rendah jenuh
(ikan, putih telur, kacang-kacangan); tidak ada kebutuhan untuk
menghindari protein hewani
Hindari atau membatasi daging olahan
Micronutrien suplementasi rutin tidak diperlukan; a menyehatkan rencana makan
ts makanan umumnya dapat memberikan mikronutrien yang cukup
Chromium; vanadium; magnesium; vitamin A, C, dan E; dan CoQ10 tidak
dianjurkan untuk kontrol glikemik
suplemen vitamin harus dianjurkan untuk pasien berisiko kekurangan
atau defisiensi

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Algoritma pengelolaan DM tipe 2 tanpa disertai
dekompensasi
Algoritma pengelolaan DM tipe 2 tanpa disertai
dekompensasi (alternatif terutama untuk internist)
Noninsulin Agents Available for
T2D
Class Primary Mechanism of Action Agent(s)
-Glucosidase Menunda penyerapan Acarbose
inhibitors karbohidrat dari usus Miglitol
Decrease glucagon secretion
Amylin analogue Slow gastric emptying Pramlintide
Increase satiety
Decrease HGP
Biguanide Increase glucose uptake in Metformin
muscle
Bile acid Decrease HGP?
Colesevelam
sequestrant Increase incretin levels?
Increase glucose-dependent Alogliptin
Linagliptin
DPP-4 inhibitors insulin secretion
Saxagliptin
Decrease glucagon secretion Sitagliptin
Dopamine-2 Activates dopaminergic Bromocriptin
agonist receptors e
Nateglinide
Glinides Increase insulin secretion
Repaglinide

DPP-4 = dipeptidyl peptidase; HGP = hepatic glucose production.


Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.
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Q4. How are glycemic targets achieved for T2D?
Noninsulin Agents Available
for T2D
Class Primary Mechanism of Action Agent(s)
Increase glucose-dependent Albiglutide
insulin secretion Dulaglutide
GLP-1 receptor
Decrease glucagon secretion Exenatide
agonists
Slow gastric emptying Exenatide XR
Increase satiety Liraglutide

Canagliflozin
Increase urinary excretion of
SGLT2 inhibitors Dapagliflozin
glucose Empagliflozin

Glimepiride
Glipizide
Sulfonylureas Increase insulin secretion
Glyburide

Increase glucose uptake in


Thiazolidinedione Pioglitazone
muscle and fat
s Rosiglitazone
Decrease HGP

GLP-1 = glucagon-like peptide; HGP = hepatic glucose production; SGLT2 = sodium glucose cotransporter 2.
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.
Continued from previous slide
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Q4. How are glycemic targets achieved for T2D?
Effects of Agents Available
for T2D
SU/
Met GLP1RA SGLT2I DPP4I TZD AGI Coles BCR-QR Insulin Pram
Glinide
Mod to
marked
FPG SU: mod (basal
Mild to
lowerin Mod Mod Mild Mod Neutral Mild Neutral Glinide: insulin Mild
mod*
g mild or
premixe
d)
Mod to
marked
(short/
PPG rapid-
Mod to Mod to
lowerin Mild Mild Mod Mild Mod Mild Mild Mod acting
marked marked
g insulin
or
premixe
d)

AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibitors;
FPG = fasting plasma glucose; GLP1RA = glucagon-like peptide 1 receptor agonists; Met = metformin; Mod = moderate; PPG =
postprandial glucose; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU = sulfonylureas; TZD = thiazolidinediones.
*Mild: albiglutide and exenatide; moderate: dulaglutide, exenatide extended release, and liraglutide.
Continued on next slide
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Q4. How are glycemic targets achieved for T2D?
Effects of Agents Available
for T2D
GLP1R SU/
Met SGLT2I DPP4I TZD AGI Coles BCR-QR Insulin Pram
A Glinide

NAFLD
Mild Mild Neutral Neutral Mod Neutral Neutral Neutral Neutral Neutral Neutral
benefit

SU: mod
to
Hypo- severe Mod to
Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral
glycemia Glinide: severe*
mild to
mod

Slight
Weight Loss Loss Neutral Gain Neutral Neutral Neutral Gain Gain Loss
loss

AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibitors;
GLP1RA = glucagon-like peptide 1 receptor agonists; Met = metformin; Mod = moderate; NAFLD, nonalcoholic fatty liver disease; SGLT2I
= sodium-glucose cotransporter 2 inhibitors; SU = sulfonylureas; TZD = thiazolidinediones.
*Especially with short/ rapid-acting or premixed.
Continued from previous slide
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Q4. How are glycemic targets achieved for T2D?
Effects of Agents Available
for T2D
GLP1R SU/
Met SGLT2I DPP4I TZD AGI Coles BCR-QR
Insulin Pram
A Glinide
Increase
Exenatid
Contra- Dose d risks
e May
indicate adjust- Increase of hypo-
Renal contra- GU worsen
d in ment d hypo- glycemi
impair- indicate infection fluid Neutral Neutral Neutral Neutral
stage (except glycemi a and
ment/ GU d CrCl risk retentio
3B, 4, 5 lina- a risk fluid
<30 n
CKD gliptin) retentio
mg/mL
n
GI adverse
Mod Mod* Neutral Neutral* Neutral Mod Mild Mod Neutral Neutral Mod
effects
CHF Neutral Neutral Neutral Neutral Mod Neutral Neutral Neutral Neutral Neutral Neutral
Possible
CVD Neutral Neutral Neutral Neutral Neutral Neutral Safe ? Neutral Neutral
benefit
Mod
Bone
Bone Neutral Neutral Neutral bone Neutral Neutral Neutral Neutral Neutral Neutral
loss
loss

AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; CHF = congestive heart failure; CVD =
cardiovascular disease; DPP4I = dipeptidyl peptidase 4 inhibitors; GI = gastrointestinal; GLP1RA = glucagon-like peptide 1 receptor
agonists; GU = genitourinary; Met = metformin; Mod = moderate; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU =
sulfonylureas; TZD = thiazolidinediones.
*Caution in labeling about pancreatitis.

Caution: possibly increased CHF hospitalization risk seen in CV safety trial.


Continued from previous slide
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Monotherapy, Dual
Q4. How are glycemic targets achieved for T2D?

Therapy, and Triple Therapy


for T2D Monotherapy* Dual therapy* Triple therapy*

Metformin (or First- and second-


other first-line line agent plus
agent) plus
Metformin GLP1RA GLP1RA
GLP1RA SGLT2I SGLT2I
SGLT2I DPP4I TZD
DPP4I TZD Basal insulin
AGI Basal insulin DPP4I
TZD Colesevelam Colesevelam
SU/glinide BCR-QR BCR-QR
AGI AGI
SU/glinide SU/glinide
AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibitors;
GLP1RA = glucagon-like peptide 1 receptor agonists; Met = metformin; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU =
sulfonylureas; TZD = thiazolidinediones.
*Intensify therapy whenever A1C exceeds individualized target. Boldface denotes little or no risk of hypoglycemia or weight gain, few
adverse events, and/or the possibility of benefits beyond glucose-lowering.

Use with caution.


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<130/80

<150 <150

> 50 >40
PENILAIAN HASIL TERAPI
ANAMNESIS
PEMERIKSAAN PENUNJANG, SEPERTI :
1. KADAR GLUKOSA DARAH
2. A1C (3 BULAN SEKALI)
How should glycemia in T1D be managed?

Insulin Regimens
Insulin is required for survival in T1D
Physiologic regimens using insulin
analogs should be used for most patients

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How is diabetes managed in the hospital?
Glucose Screening and
Monitoring
Laboratory blood glucose testing on admission,
regardless of DM history
Known DM: assess A1C if not measured in past 3
months
No history of DM: assess A1C to identify undiagnosed
cases
Bedside glucose monitoring for duration of
hospital stay
Diagnosed DM
No DM but receiving therapy associated with
hyperglycemia
Corticosteroids
Enteral or parenteral nutrition
DM = diabetes mellitus.
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How is diabetes managed in the hospital?
Inpatient Glucose Targets for
Nonpregnant Adults
Hospital Unit Treatment Goal
Intensive/critical care
Glucose range, mg/dL 140-180*
General medicine and surgery, non-ICU
Premeal glucose, mg/dL <140*
Random glucose, mg/dL <180*
*Provided target can be safely achieved.

ICU = intensive care unit.


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When and how should glucose monitoring be used?
Self-monitoring of Blood
Glucose (SMBG)

Noninsulin Users Insulin Users


Introduce at diagnosis All patients using insulin
Personalize frequency of should test glucose
testing 2 times daily
Use SMBG results to inform Before any injection of

decisions about whether to insulin


target FPG or PPG for any More frequent SMBG (after
individual patient meals or in the middle of
Testing
Testingpositivelypositivelyaffects affects the night) may be required
glycemia
glycemiain inT2D
T2Dwhen whenthe
the Frequent hypoglycemia
results
resultsare areused usedto: to: Not at A1C target
Modify
Modifybehavior behavior
Modify
Modifypharmacologic
pharmacologic
treatment
treatment
SMBG, self-monitoring of blood glucose.
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SMBG Frequency vs A1C
11.
0
10.
5
10.
0
Mean A1C

9.5
9.0
13-26 years
8.5
1-13 years
8.0
7.5 26-50 years
50+ years
7.0
6.5
0-2 3-4 5-6 7-8 9- 11- 13
SMBG per day10 12

Miller KM, et al. Diabetes Care. 2013;36:2009-2014.


DM Comprehensive
Management Team

Endocrin-
Endocrin-
ologist
Mental ologist
health
Mental
care
health PCP
profes-
care PCP
sional
profes-
sional

Physician
Exercise Patien assistant
Physician
specialist
Exercise Patien
t
/ assistant
Nurse
practi-
/ Nurse
specialist
t tioner
practi-
tioner

Registere
Dietitian
dRegistere
nurse
Dietitian
d nurse

CDE
CDE

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TERIMA KASIH