DIABETES

MELITUS
dr. Ni Luh Putri Primasari,
M.Biomed, SpPD
Apakah diabetes itu?
adalah keadaan yang timbul
karena ketidakmampuan tubuh
mengolah karbohidrat / glukosa
akibat kurangnya jumlah insulin
atau insulin tidak berfungsi
sempurna
 Prevalensi diabetes melitus di seluruh dunia

Number of persons
< 5,000
5,000–74,000
75,000–349,000
350,000–1,500,000
> 1,500,000
No data available

Total kasus > 300 juta usia dewasa

Adapted from World Health Organization.
The World Health Report: life in the 21st century, a vision for all. Geneva: WHO, 1998.
 Keluhan tidak khas
• Kesemutan
• Gatal di daerah genital
• Keputihan
• Infeksi sulit sembuh
• Bisul yang hilang timbul
• Pengelihatan kabur
 Faktor resiko DM
• Usia > 45 th
• Kegemukan
• Hipertensi
• Rw. Keluarga DM
• Rw. Melahirkan bayi dgn BB >
4000 gr
• Rw. DM pada kehamilan
• Rw. TGT atau GDPT
• Penderita PJK, TBC,
hipertiroidisme
• Kadar lipid abnormal (HDL < 40
mg/dl, TG > 200 mg/dl, kolestrol
> 200 mg/dl
 Kriteria Diagnosis
1. Gejala Diabetes
• Konsentrasi gula darah acak > 200 mg/dl

2. Gula darah puasa: atau

• GDP > 126 mg/dl. Tidak ada konsumsi kalori dlm 8 jam
• Diulang 2 kali dalam hari yg berbeda

atau
3. 2 jam setelah tes glukosa dgn beban 75 gr
• OGTT > 200 mg/dl.

Slide 8
 Klasifikasi Diabetes
• Tipe 1 diabetes
• Ditandai dgn defisiensi insulin absolut yg disebabkan
destruksi pancreatic beta-cells
• Tipe 2 diabetes
• Ditandai dgn resistensi insulin dgn defisiensi insulin
relatif
• Tipe Lain
• Gestational diabetes
• Intoleransi glukosa yg diketahui saat kehamilan dan
biasanya membaik setelah kelahiran bayi
Slide 9
Diabetes Care 1997; 20: 1183-1197
 Apa yang Terjadi Bila Seseorang
Menderita Diabetes?

• Efek jangka pendek

• Efek jangka panjang
 Efek jangka pendek

• Hipoglikemia
• Hiperglikemia
Pemicu kadar gula darah
rendah/hipoglikemia:
mengabaikan makan
aktivitas yang meningkat
olahraga berat
minum obat terlampau banyak
suntikan insulin dosis tinggi
perubahan kebutuhan tubuh akan obat
konsumsi alkohol
 1. Penyuluhan
• Tidak hanya oleh dokter
• Segenap jajaran terkait: perawat
penyuluh, pekerja sosial, ahli
gizi, dll.
• Prinsip: dukungan positif, hindari
kecemasan, informasi bertahap
mulai yang sederhana,
pengobatan yang sesederhana,
kompromi dan negoisasi, jangan
memaksakan kehendak, motivasi
dan diskusikan hasil
pemeriksaan
2. Perencanaan makan
• Komposisi
seimbang
Kh (60-70%), protein
(10-15%), lemak (20-
25%)

• Jumlah kalori:
pertumbuhan, status
gizi, umur, stres akut,
kegiatan jasmani
Kalori basal: 30 Kcal/kg
BB idaman
 3. Latihan jasmani
• Teratur (3-4 x/minggu)- 30 menit
• Sasaran: 75-85% nadi maks
• Jenis olah raga: CRIPE (continous, rhytmical,
interval, progressive, endurance training)
4. Obat berkhasiat hipoglikemik
1. Obat hipoglikemik oral

2. Insulin
 Obat hipoglikemik oral
Obat yang merangsang sekresi insulin
Sulfonylurea
generasi 1 : tolbutamide, chlorpropamide
generasi 2 : glyburide (glibenclamide), glipizide,
glimepiride

Obat yg bekerja pada reseptor insulin

Biguanides : metformin
Thiazolidinediones : rosiglitazone, pioglitazone

Obat yg menghambat penyerapan glukosa di usus

α glucosidase inhibitors : acarbose, miglitol
 Kriteria Kontrol Diabetes

Good Fair Poor

Kadar gula darah puasa 80-109 110-125 ≥126
(mg/dl)
Kadar gula darah 2J PP (mg/dl) 80-144 145-179 ≥180
A1C (%) <6.5 6.5-8 >8
Kolesterol total (mg/dl) <200 200-239 ≥240
Kolesterol LDL (mg/dl) <100 100-129 >130
Kolesterol HDL (mg/dl) >45
Trigliserida (mg/dl) <150 150-199 ≥200
Indeks massa tubuh (IMT) 18.5-22.9 23-25 >25
(kg/m2)
Tekanan darah (mmHg) <130/80 130-140/80-90 >140/90

Perkeni, 2002
 Diagnosis dini
Terapi Diabetes – terkontrol

Komplikasi diabetes
dapat dicegah

Pasien hidup bahagia

bersama diabetesnya
 Difference between Type 1 and Type 2 Diabetes

Comparison of Type 1 and Type 2 Diabetes

Features Type 1 Diabetes Type 2 Diabetes

Onset Sudden Gradual

Age at Onset Any age (mostly young) Mostly in adults

Body Habitus Thin or normal Often obese

Ketoacidosis Common Rare

Autoantibodies Usually present Absent

Endogenous Insulin Low or absent Normal, decreased or increased

Prevalence Less prevalent More prevalent, typically 90-95%

of all people with diabetes

Slide 24
 The Importance of treating Type 2 Diabetes

Type 2 diabetes is a progressive disease

Postprandial glucos
Diagnosis

Glucose Fasting glucose

Insulin
Insulin resistance

Inadequate
β-cell function
Insulin secretion
Microvascular changes
Macrovascular changes

Prediabetes
NGT Diabetes
(IFG/IGT)

Slide 25
Adapted from Type 2 Diabetes BASICS. International Diabetes Center 2000
 Treatment therapies for Type 2 diabetes

When and How to start treatment

START TREATMENT OAD TREATMENT START INSULIN INSULIN INTENSIFICATION

+-other OAD Basal Basal +

Lifestyle + Basal Premix
or GLP-1 Bolus
Metformin Insulin Insulin
agonists Insulin

HbA1c ≥7.0%

Slide
Adapted 26Raccah et al. Diabetes Metab Res Rev 2007;23:257.
from
 What is good glycemic control?

• Overall aim to achieve glucose levels as close to normal as possible

• Minimise development and progression of microvascular and macrovascular
complications

ADA1
FPG HbA1c PPG
<130 mg/dL < 7.0% <180 mg/dL

IDF2 FPG HbA1c PPG

<110 mg/dl < 6.5% <145 mg/dL

PERKENI3 FPG HbA1c PPG

<100 mg/dl < 7% <140 mg/dl

Slide 27Diabetes Association Diabetes Care 2009;32 (Suppl 1):S1-S97

1. American
2. IDF Clinical Guidelines Task Force. International Diabetes Federation 2005. 3. PERKENI 2011 Konsensus .
 Risk of Complications increases as Hb1Ac increases and that’s

why diabetes must be treated

80

60 Microvascular disease
Incidence per 1.000
patient-years

40 Myocardial infarction

20

0
5 6 7 8 9 10 11 Mean HbA1c (%)
97 126 154 183 212 240 269 Mean mg/dl

Adjusted for age, sex, and ethnic group. The relationship between A1C and mg/dl is described
by the formula 28.7 X A1C – 46.7 = mg/dl.

Slide 28
Stratton IM et al. BMJ 2000;321:405–12
 The benefits of good blood glucose control are clear

Myocardial
Good control is ≤ infarction
7.0% HbA1c
-14%
HbA1c measures the
average
blood glucose level Microvascular
over the HbA1c complications
last three months
-1% -37%

Deaths related
to diabetes

-21%
Source: UKPDS = United Kingdom Prospective Diabetes Study. Stratton IM
Slide 29
et al. BMJ. 2000;321(7258):405-412.
 Practical Monitoring Scheme

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Slide 30
Diabetes Melitus Terpadu. 2009
 Practical Monitoring Scheme Cont…

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Slide 31
Diabetes Melitus Terpadu. 2009
 ABCD Strategy to guide Diabetes Treatment

ABCD Strategy

Age (older) • Increased risk for hypoglycemia & comorbidities

• Less stringent therapy
• Reduce the use of kidney-excreted drugs if possible

Body Weight • BW neutral (gliptins, acarbose, DPPIV inhibitors, long-

acting insulin analogues),
• BW gain (human insulin, sulphonylureas, TZDs)
• BW loss (metformin, GLP1 analogues)

Complications • Major macro- & microvascular complication  less

stringent
• Consider renal or heart failure

Duration of Disease • Strict glycemic control at the early period of the disease 
better prevention of macro & microvascular complications

Slide 32
Source: Diabetes Metab Res Rev 2010; 26: 239–244