Penatalaksanaan DM
Penatalaksanaan DM
Alwi Shahab
Subbagian Endokrinologi Metabolisme
Bagian Ilmu Penyakit Dalam
FK Unsri/ RSMH Palembang
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Diabetes Melitus penyakit kronis yang
ditandai peningkatan kadar glukosa darah,
akibat gangguan sekresi insulin / kerja insulin
atau keduanya.
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Klasifikasi Diabetes Melitus
1. Diabetes Tipe-1 (destruksi sel beta) D. Endokrinopati
Autoimun Acromegali, sindroma Cushing,
Idiopatik Feokromositoma, hipertiroidisme
2. Diabetes Tipe-2 ( resistensi insulin E. Karena obat/zat kimia
disertai defek sekresi insulin atau
sebaliknya) Vacor, pentamidin,asam
nikotinat
3. Diabetes Tipe lain
A. Defek genetik fungsi sel beta Glukokortikoid, hormontiroid,
tiazid, Dilantin, interferon alfa
MODY 1,2,3. DNA mitokondria
B. Defek genetik kerja insulin F. Infeksi : rubellakongenital, CMV
C. Penyakit eksokrin pankreas; G. Sebab imunologi yang jarang :
Pankreatitis,tumor pankreas, Antibodi anti insulin
pankreatektomi, pankreopati H. Sindroma genetik lain:
fibrokalkulus Sindroma Down, Klinefelter,
Turner dll.
4. Diabetes Gestasional
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Global Projections for the
Diabetes Epidemic: 2003-2025
NA EUR
23.0 M EMME
48.4 M WP
36.2 M 58.6 M 19.2 M
↑57.0% ↑21% 39.4 M SEA 43.0 M
↑105% 39.3 75.8 M
M ↑79%
World AFR 81.6
SACA
2003 = 194 M 7.1M M
2025 = 333 M 14.2 M 15.0 M ↑108%
↑ 72% 26.2 M ↑111%
↑85%
Year
31.7 2000 20.8
China
India 17.7
USA
8.4 6.8
Indonesia millions Japan
Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053.
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Diabetes in the World
Year
79.4 2010 42.3
China
India 30.3
USA
21.3 8.9
Indonesia Japan
millions
Reference: Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes. Diabetes Care. 2004; 27(5): 1047-1053 .
06/01/21 7
Current and Projected Prevalence of Diabetes
in Southeast Asia and the Western Pacific
Region Prevalence of Diabetes*) in
% Increase
2000 2030
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Indonesian Diabetes Prevalence
(Guestimate for 2003 / 2005)- BPS& CIA
Tahun
2003 2030
BPS
l Rural 5,548,869 8,076,613
l Urban 8,248.601 12,006,186
l of DM patients 13,797,470 20,082,799
CIA facts book
l Rural 6,379,735 * 9,031,326
l Urban 9,432,108 * 13,352,348
l of DM patients 15,881,843 22,383,674
* 2006
- Total population BPS = 214 juta (est.) & Total population 20 years = 133 juta ;
- urban = 56 juta , rural = 77 juta
- Total population CIA = 245 juta (est.) & Total population 20 years = 152juta ;
- 06/01/21
urban = 64 juta, rural = 88 juta 9
Diabetes in Southeastern Asia
(Extrapolated Statistics)
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Dia
ASKESKIN
bet
Top 10 polyclinic visit (poor people)
es
• 1.Diabetes
is n
• 2.Hypertension
• 3.URI
ot
• 4.Fever
• 5.TBC
a
• 6.Heart Diseases
dis
• 7.General examination-investigation
eas
• 8.Cancer
• 9.Stroke
e
• 10.Epilepsi
of
the
Data: MOH 2006,Mediakom sept-nov 2006
“R
I CH
”
06/01/21 11
Pre-diabetes in Indonesia
The β-cells
Disorganized and misshapen
Marked reduction in β-cell number, less insulin secretion
The α-cells
Normal number, normal function, impaired suppression
of glucagon release
The consequence:
less insulin, relative hyperglucagonemia : hyperglycemia
Reduced Incretin Effect in Type 2
Diabetic Patients
Control Subjects Type 2 Diabetic
80 80
Intravenous Glucose Patients
Oral Glucose
60
INSULIN ( mU/L)
INSULIN ( mU/L)
60
40
Incretin 40
effect *
* *
* * 20
20 * * * *
*
0 0
0 30 60 90 120 150 180 0 30 60 90 120 150 180
TIME (min) TIME (min)
Genetic
+ Increased
Elevated
environtment lipolysis and
release of free circulating FFA
lip
fatty acids ot
o xic
i ty
t y
x ici
Decreased glucose to
uptake into muscle l uco
g
and adipose tissue Hyperglycemia
and raised hepatic
glucose output
Pancreas
Insulin Insulin
(beta cell) resistance
Hepatic
glucose
output Glucose uptake
Hyperglycemia
Muscle
Liver
Adipose
tissue
Adapted with permission from Kahn CR, Saltiel AR. Joslin’s Diabetes Mellitus. 14th ed.
Lippincott
06/01/21Williams & Wilkins; 2005:145–168. 17
1. Del Prato S, Marchetti P. Horm Metab Res. 2004;36:775–781. 2. Porte D Jr, Kahn SE. Clin Invest Med. 1995;18:247–254.
Type 2 DM :
Component of Metabolic Syndrome
The Problem :
Modern Life Has Both Conveniences and Costs
Illustration taken from: Lambert C, Bing C. The Way We Eat Now. Harvard Magazine. May-June, 2004;50.
06/01/21 18
Metabolic syndrome :
International Diabetes Federation Definition:
Abdominal obesity plus two other components: elevated
BP, low HDL, elevated TG, or impaired fasting glucose
Stroke
Diabetic 2 to 4 fold increase in
cardiovascular
Retinopathy mortality and stroke3
Leading cause
of blindness
in working age Cardiovascular
adults1
Disease
8/10 diabetic patients
die from CV events4
Diabetic
Nephropathy Diabetic
Leading cause of
Neuropathy
end-stage renal disease2 Leading cause of
non-traumatic lower
extremity amputations5
1
Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 2Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98.
06/01/21 3
Kannel WB, et al. Am Heart J 1990; 120:672–676. 4Gray RP & Yudkin JS. In Textbook of Diabetes20 1997.
Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
5
Pathophysiology of Diabetic Complications
Hyperglycemia
Hyperglycemia
AGE
AGEformation
formation Glucose
Glucoseautoxidation
autoxidation Sorbitol
Sorbitolpathway
pathway
Oxidative
Oxidativestress
stress Antioxidants
Antioxidants
leukocyte
leukocyteadhesion
adhesion Endothelial
Endothelialdysfunction:
dysfunction: Hypercoagulability:
lipid Hypercoagulability:
lipidperoxidation
peroxidation NO
NO Fibrinolysis
Fibrinolysis
foam
foamcell
cellformation
formation Endothelin
Endothelin11 platelet
plateletreactivity
reactivity
TNF
TNF
Prostacyclin
Prostacyclin coagulability
coagulability
Thromboxan
Thromboxan
06/01/21 Vascular
Vascular complications
complications 21
HYPERGLYCEMIA “PAHA” OXIDATIVE STRESS
CHRONIC HYPERGLYCEMIA
OXIDATIVE STRESS
OXIDATIVE STRESS
INSULIN SENSITIVITY -CELL FUNCTION
ASK-DNC
Atherogenic risk markers associated with
Type 2 DM and insulin resistance
Abdominal obesity WHR, FFA, TNF, resistin, adiponectin,
II--hydroxysteroid dehydrogenase type 1
Tes
Glukosa Glukosa Tes Toleransi
Plasma Plasma Glukosa Oral
Stadium Puasa Sewaktu (TTGO)
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Pemeriksaan penyaring perlu dilakukan
pada kelompok risiko tinggi :
• Protein : 10 - 20 %
06/01/21 32
THE BENEFIT OF EXERCISE FOR
DIABETIC PATIENTS
• DM TYPE I
• IMPROVE GLYCEMIC CONTROL IN SOME
PATIENTS, MAINLY IN THOSE LESS PRONE TO
HYPOGLYCEMIA
• REDUCE CORONARY ARTERY DISEASE RISK
• REDUCE THE RISK OF CARDIOVASCULAR AND
PERIPHERAL ARTERIAL DISEASES
Exercise in
Normal Person
HORMONES
Insulin
Cathecolamines
Cortisol Glucose ENERGY
Glucagon FFA
Growth Hormone
EXERCISE
AEROBIC Adr/N-adr Muscle
Insulin ↓ Glycolysis ↑
Glucose uptake ↑
Intervensi Farmakologik
06/01/21 37
ADA/EASD: Metabolic
Management of Type 2 Diabetes
01/06/21 Page 38
Nathan DM et al. Diabetes Care 2009; 32(1) : 194-203
Step One…
Lifestyle intervention and metformin
If HbA1c > 7%
If HbA1c > 7%
Add basal or
intensify insulin
* Check HbA1c every 3 months until HbA1c <7%, and then at least every 6 months.
** Preferred based on effectiveness and expense. Nathan DM et al. Diabetes Care 2009; 32(1) : 194-203
Step One: Lifestyle and Metformin
Lifestyle interventions:
- Weight loss, exercise,
- Diet should be implemented by regis-
tered dieticians
If HbA1c ≥ 7%*
If HbA1c ≥ 7%
If HbA1c ≥ 7%
Add basal or
intensify insulin
* Check HbA1c every 3 months until HbA1c <7%, and then at least every 6 months.
** Preferred based on effectiveness and expense. Nathan DM et al. Diabetes Care 2009; 32(1) : 194-203
-.
Step Two: Adding a Second Agent
• After 2 - 3 months, if Step 1 fails to achieve glyce-
mic goals, add one of the following:
- Basal insulin (most effective)
- Sulfonylurea (least expensive)
- TZD (no hypoglycemia) - pioglitazone
If HbA1c ≥ 7%*
If HbA1c ≥ 7%
If HbA1c ≥ 7%
Add basal or
intensify insulin
* Check HbA1c every 3 months until HbA1c <7%, and then at least every 6 months.
** Preferred based on effectiveness and expense. Nathan
. DM et al. Diabetes Care 2009; 32(1) : 194-203
-.
Step Three: Further Adjustments
If Step 2 fails to achieve glycemic goals
after 2 – 3 months …..
• Start or intensify insulin (preferred choice)
- Usually means adding short or rapid acting insu-
lin before selected meals to reduce PPG excur-
sions
- Discontinue use of sulfonylureas or glinides
when short - or rapid - acting insulin injec-
tions are started (not considered synergistic)
• If HbA1c is close to goal (<8.0%) add a third agent
(not the preferred choice due to higher cost and
lower efficacy)
Nathan DM et al. Diabetes Care 2009; 32(1) : 194-203
Efficacy-Cost Ratio of Adding a Third Oral
Therapy vs. Switching to Insulin + Metformin
HbA1c values at study endpoint (Week 24)
70% p=n.s
HbA1c (%) at study endpoint
Portion of patients achieving
60%
50%
40% p=n.s
30%
20%
10%
0%
HbA1c < 7% HbA1c < 8%
Triple oral therapy ($10.40/day) Insulin + metformin ($3.20/day)
• Insulin + metformin
• Insulin + TZD
- However, fluid retention must be considered
• The combination of metformin and TZD has
shown only modest HbA1c reductions (i.e.,
0.3 - 0.8%)
9
Glycosylated
n=19
8
0 3 6 9 12
Time (mo)
Insulin + TZD
(+metformin at Week 16)
7.5 n=14
*
7.0
6.5
6.0 †
*‡ †
5.5
Week 0 Week 16 Week 32
* p<0.05 vs. baseline, † p<0.05 vs. week 16, ‡ p<0.05 vs. INS + MET group.
• Incretin mimetic :
• Sulfonylureas – GLP-1 Analog :
• Exenatide (Byetta)
• Metformin
– DPP-4 Inhibitor :
• Thiazolidinediones • Sitagliptin
• Alpha-Glucosidase • Vildagliptin
Inhibitors • Amylin Analog
• Meglitinides – Pramlintide
• Insulin
– Injectable
– Inhaled
06/01/21 53
Sites of Action of Current OAD
GLUCOSE ABSORPTION
INTESTINE
-glucosidase inhibitors
GLUCOSE DPPIV inhibitor
PRODUCTION PERIPHERAL GLUCOSE
UPTAKE & UTILIZATION
LIVER
Glucose
Biguanides MUSCLE
Thiazolidinediones
ADIPOSE TISSUE
Biguanides
INSULIN SECRETION Thiazolidinediones
Sulphonylureas
Meglitinides
06/01/21 DPPIV inhibitor 54
PANCREAS Modified: Ann Intern Med 1999;131:281
Insulin :
Indications :
- Type 1 DM (absolute)
- Type 2 DM, uncontrolled with maximal doses of OAD
- KAD/ HHS / hyperglycemia with lactic acidosis
- Type 2 DM + Severe metabolic stress :
- Systemic infection
- Surgery
- AMI
- Stroke
- Gestational Diabetes, uncontrolled with diet
- Type 2 DM with impaired liver or kidney function
- Allergy to OAD
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Pemantauan hasil pengobatan :
1. Kadar glukosa darah
2. Kadar HbA1c
3. PGDM ( Pemantauan Glukosa Darah Mandiri)
4. Glukosa urin
5. Benda2 keton
1. Mikroalbuminuri
2. D-Dimer
3. CRP
4. Profil lipid
06/01/21 56
Lowering HbA1c reduces the risk of
complications
Deaths related to
21%
diabetes
HbA1c
Microvascular
37%
1% complications
Myocardial infarction
14%
It’s a Nightmare!
Low-grade
Inflammation
NASH
Hypertension Prothrombotic
Endothelial State
Dyslipidemia Dysfunction
Hyperglycemia
Terima Kasih
06/01/21
©2005. American College of Physicians. All Rights Reserved.
60
Type 2 Diabetes &
Metabolic Syndrome
It’s a Nightmare!
Low-grade
Inflammation
NASH
Hypertension Prothrombotic
Endothelial State
Dyslipidemia Dysfunction
Hyperglycemia
06/01/21 61
©2005. American College of Physicians. All Rights Reserved.