FARMAKOTERAPI

DIABETES MELLITUS (DM)

apt. Putri Ramadhani, M.Farm.Klin

DEFINISI Diabetes Mellitus (DM)
 Diabetes Melitus penyakit metabolik dengan
karakteristik hiperglikemia akibat kelainan sekresi
insulin, kerja insulin dan kedua- duanya (Perkeni,
2015).
 Diabetes merupakan suatu gangguan kronis yang
diakibatkan ketidakcukupan produksi insulin oleh
tubuh atau ketidakmampuan tubuh menggunakan
insulin (IDF, 2015).
Batasan DM

1. Gejala DM + GDA ≥ 200 mg/dl ( 11,1 mmol/L)

2. GDP ≥ 126 mg/dl (7 mmol/L).

3. GD ≥ 200 mg/dl sesudah beban glukosa 75 g pada TTGO

4. HbA1c > 6,5% .

(Uji dilakukan-Lab menggunakan metoda yang
disertifikasi-National Glycohemoglobin Standardization
Program (NGSP)

Gejala DM : Poliuria, polidipsia, polifagia, BB turun

tanpa sebab jelas
PREVALENSI Diabetes Mellitus
 Prevalensi Diabetes Melitus pada populasi
usia 20-79 tahun pada tahun 2019 di
dunia diperkirakan mencapai 9,3% dan
akan terus meningkat (International
Diabetes Federation)
 Indonesia menempati posisi ke 7
dalam jumlah penderita
Klasifikasi Diabetes Mellitus (DM)
- DM tipe I : destruksi sel beta → defisiensi insulin absolut
- DM tipe II : resistensi insulin dan atau defek sekresi
insulin
- DM tipe lain :
- defek genetik – fungsi β pankreas
- penyakit dari pankreas eksokrin (pankreatitis,
Neoplasia)
- endokrinopati (al. acromegaly, cushing syndrome)
- induksi obat atau zat kimia ( glukokortikoid, hormon
tiroid, thiazida, fenitoin, asam nikotinat dll.)
- DM Gestasional
KLASIFIKASI DM
1. Type 1 DM
It is due to insulin deficiency and is formerly known as.
-Type I
-Insulin Dependent DM (IDDM)
-Juvenile onset DM

2. Type 2 DM
It is a combined insulin resistance and relative deficiency in insulin secretion and is
frequently known as.
-Type II
-Noninsulin Dependent DM (NIDDM)
-Adult onset DM
3. Gestational Diabetes Mellitus (GDM):

Gestational Diabetes Mellitus (GDM) developing during some cases of pregnancy but
usually disappears after pregnancy.

4. Other types:

 Secondary DM
 ETIOLOGI

1. Etiology of Type 1 Diabetes

Usia
dan
gender
8
2. Etiology of Type 2 Diabetes

9
 Pathophysiology

Type 1 DM

Type 1 DM is characterized by an absolute deficiency

of insulin due to immune- mediated destruction of
the pancreatic b-cells

In rare cases the b-cell destruction is not due to

immune mediated reaction (idiopathic type 1 DM)

11
12
 Pathophysiology

Type 1 DM
 There are four stages in the development of
Type 1 DM:

1. Preclinical period with positive b-cell antibodies

2. Hyperglycemia when 80-90% of the

β- cells are destroyed.

3. Transient remission (honeymoon phase).

4. Establishment of the disease

13
 Pathophysiology

Type 2 DM
Type 2 DM is characterized by the presence of both insulin resistance
(tissue insensitivity) and some degree of insulin deficiency or b- cell
dysfunction

Type 2 DM occurs when a diabetogenic lifestyle (excessive calories,

inadequate caloric expenditure and obesity) is superimposed upon a
susceptible genotype

14
 Laboratory Tests

1. Glucosuria
To detect glucose in urine by a paper strip
Semi-quantitative
Normal kidney threshold for glucose is essential

2. Ketonuria
– To detect ketonbodies in urine by a paper strip
• Semi-quantitative

15
 Laboratory Tests (Cont’d)

3. Fasting blood glucose

Glucose blood concentration in samples obtained after at least 8

hours of the last meal

4. Random Blood glucose

– Glucose blood concentration in samples obtained at any time
regardless the time of the last meal

16
 Laboratory Tests (Cont’d)

5. Glucose tolerance test

75 gm of glucose are given to the patient with 300 ml of water after

an overnight fast

Blood samples are drawn 1, 2, and 3 hours after taking the glucose

This is a more accurate test for glucose utilization if the fasting

glucose is borderline

17
 Laboratory Tests (Cont’d)

6. Glycosylated hemoglobin (HbA1C)

HbA1C is formed by condensation of glucose with free amino groups

of the globin component of hemoglobin

Normally it comprises 4-6% of the total hemoglobin.

Increase in the glucose blood concentration increases the glycated

hemoglobin fraction.

HbA1C reflects the glycemic state during the preceding 8-12 weeks.

18
 Laboratory Findings (Cont’d)

7. Serum Fructosamine
Formed by glycosylation of serum protein (mainly albumin)

Since serum albumin has shorter half life than hemoglobin,

serum fructosamine reflects the glycemic state in the preceding
2 weeks

Normal is 1.5 - 2.4 mmole/L when serum albumin is 5 gm/dL.

19
 Self Monitoring Test
Self-monitoring of blood glucose
Extremely useful for outpatient monitoring specially for patients
who need tight control for their glycemic state.
A portable battery operated device that measures the color
intensity produced from adding a drop of blood to a glucose
oxidase paper strip.
e.g. One Touch, Accu-Chek, DEX, Prestige and Precision.
21
 Diagnostic Criteria

• Any one test should be confirmed with a second test, most

often fasting plasma glucose (FPG).

• This criteria for diagnosis should be confirmed by repeating the

test on a different day.
23
 Clinical Presentation

Type 1 DM Type 2 DM
- Patients can be asymptomatic
-Polyuria - Polyuria
-Polydipsia
- Polydipsia
-Polyphagia
-Weight loss - Polyphagia
-Weakness - Fatigue
-Dry skin - Weight loss
-Ketoacidosis - Most patients are discovered
while performing urine glucose
screening
24
Characteristics Type 1 Type 2

% of diabetic pop 5-10% 90%

Age of onset Usually < 30 yr + some adults Usually > 40 + some obese
children
Pancreatic function Usually none Insulin is low, normal or high

Pathogenesis Autoimmune process Defect in insulin secretion,

tissue resistance to insulin,
increased HGO
Family history Generally not strong Strong

Obesity Uncommon Common

History of ketoacidosis Often present Rare except in stress

Clinical presentation moderate to severe symptoms: Mild symptoms: Polyuria and

3Ps, fatigue, wt loss and fatigue. Diagnosed on routine
ketoacidosis physical examination
Treatment Insulin, Diet Diet, Exercise
Exercise Oral antidiabetics, Insulin
25
 Tujuan Terapi : Kualitas
Hidup Pasien Diabetes

Diabetes merupakan penyakit kronik yang memiliki resiko

tinggi terjadi komplikasi dan akan memengaruhi kualitas
hidup pasien penderitanya  Perlu tatalaksana yang
tepat

Self care Komplikasi

Faktor yang
Lama
mempengaruhi Ekonom menderita
Kualitas Hidup Pasien i
Diabetes
Usia
dan Komorbi
gender d

Ramadhani, S. (2019). Pengaruh Self-Care terhadap Kadar Glukosa Darah dan Kualitas Hidup
Pasien Diabetes Melitus Tipe-2 dengan Short Form 6 Dimension (SF-6D) [Thesis]. Universitas Gadjah Mada (UGM).
 PENATALAKSANAAN TERAPI
Prinsip

Non-farmakologi Farmakologi
Modifikasi Gaya Hidup

Obat antidiabetika
Edukasi
Pengaturan Diit
Olahraga

27/03/2022 Zullies Ikawati's Presentation 4

Modifikasi Gaya Hidup Sehat:
Pengaturan diet
Perlu ditekankan pentingnya keteraturan makan
dalam hal:
• jadwal makan,
• jenis dan jumlah makanan,
Makan tiga kali sehari untuk mendistribusikan
asupan karbohidrat dalam sehari.
Kalau diperlukan dapat diberikan makanan
selingan buah atau makanan lain sebagai
bagian dari kebutuhan kalori sehari
Pemanis alternatif dapat digunakan sebagai
pengganti gula,asal tidak melebihi batas
aman konsumsi harian (Accepted Daily
Intake)
Gaya hidup sehat utk penderita DM
dan mencegah DM
● Turunkan berat badan
● Olahraga/latihan jasmani
teratur
● Menghindari stress
● Jika sudah harus
pengobatan  patuh pada
pengobatan
Modifikasi Gaya Hidup Sehat:
Latihan jasmani teratur
● 3-4 kali seminggu selama kurang lebih 30 menit
● Kegiatan sehari-hari seperti berjalan kaki ke pasar,
menggunakan tangga, berkebun harus tetap
dilakukan
● Latihan jasmani bermanfaat untuk menurunkan
berat badan dan memperbaiki sensitivitas insulin
 akan memperbaiki kendali glukosa darah.
● Olahraga yang disarankan adalah yang bersifat
CRIPE(Continuous, Rhytmical, Interval,
Progressive, Endurance Training), yaitu yang
bersifat aerobik seperti: jalan kaki, bersepeda
santai, jogging, dan berenang
● disesuaikan dengan umur dan status kesegaran
jasmani.
● Untuk mereka yang relatif sehat, intensitas
latihan jasmani bisa ditingkatkan, yang sudah
mendapat komplikasi DM dapat dikurangi.
Modifikasi Gaya Hidup Sehat:
Pengaturan aktivitas
 Terapi farmakologi dengan Obat Antidiabetes

DPP-4 = dipeptidyl peptidase; SGLT-2 = Sodium Glucose co-transporter 2

Oral Hypoglycaemic Medications
Macam obat antidiabetes oral dan waktu minumnya
Golongan Nama Obat Waktu minum
Sulfonilurea dan Glinid Glibenklamid, glimepirid, Setengah jam sebelum makan
repaglinid, nateglinid sampai just before meals

Biguanid metformin Setelah makan atau

bersama makan
Tiazolidindion Pioglitazon Setelah makan atau
bersama makan
Inhibitor Alfa-glukosidase acarbose Pada suapan pertama makan
Inhibitor DPP-IV (Dipeptidyl sitagliptin Tdk dipengaruhi makanan 
Peptidase-IV dengan atau tanpa makanan
Penghambat SGLT- Canagliflozin, Pagi, dengan atau tanpa
2 (Sodium Empagliflozin, makan
Glucose Co- Dapagliflozin,
transporter 2) Ipragliflozin
 Oral Hypoglycaemic Medications

GLP-1RA = Glucagon like peptide-1 Receptor Agonist

 TARGET PENGOBATAN DM
12

GLIKEMIK NON-GLIKEMIK

A1c <7% (ADA) TD <140/90 (JNC8)

A1c <6,5% (AACE) TD <140/80 (ADA)

Premeal (pre-prandial)
70-130 mg/dL LDL-C <100 mg/dL

Post-prandial
<180 mg/dL TG <150 mg/dL
Algoritma Terapi Diabetes Mellitus tipe 2

(Perkeni, 2021)
 Diabetes
Management
Algorithm
Sulfonylureas (Cont’d)
First generation
• e.g. tolbutamide, chlorpropamide, and acetohexamide
• Lower potency, more potential for drug interactions and side effects
Second generation
• e.g. glimepiride, glipizide, and glyburide
• higher potency, less potential for drug interactions and side effects
All sulfonylurea drugs are equally effective in reducing
the blood glucose when given in equipotent doses.

39
 Major Pharmacokinetic Properties of Sulfonyl Ureas

Eqv. Dose Duration Active metabolites

(mg) (h)

First Generation
Tolbutamide 1000-1500 12-24 Yes (p-OH derivative)

Chlorpropamide 250-375 24-60 Yes (2’-OH and 3’OH groups)

Tolazamide 250-375 12-24 No (4-COOH derivative)

Second
generation
Glipizide 10 10-24 No (cleavage of pyrazine ring)

Glyburide 5 16-24 Some (trans + cis 4’-OH groups)

(glibenclamide)

Third generation
Glimepiride 1-2 24 Yes (-OH on CH3 of R’ group)
40
Sulfonylureas (Cont’d)
Efficacy
– HbA1c: 1.5 – 1.7% reduction.
– FPG: 50 – 70 mg/dL reduction.
– PPG: 92 mg/dL reduction.

Adverse effects
–Hypoglycemia
–Hyponatremia (with tolbutamide and
chlorpropamide)
–Weight gain

41
Sulfonylureas (Cont’d)
Drug interactions

42
2. Short-acting Secretogogues

– Repaglinide
– Nateglinide

Pharmacological effect
–Stimulation of the pancreatic secretion of insulin
The insulin release is glucose dependent and is decreased at
low blood glucose
With lower potential for hypoglycemia (incidence 0.3%)
Should be given before meal or with the first bite of each
meal. If you skip a meal don’t take the dose!

43
 Secretogogues (Cont’d)
Adverse effect
–Incidence of hypoglycemia is very low about 0.3 %

Drug Interactions
– Inducers or inhibitors of CYP3A4 affect the action of repaglinide
– Nateglinide is an inhibitor of CYP2C9

44
3. Biguanides Metformin (Glucophage)

Pharmacological effect
–Reduces hepatic glucose production
–Increases peripheral glucose utilization

Adverse effects
– Nausea, vomiting, diarrhea, and anorexia

– Phenformin: another biguanide, was taken off the market because

it causes lactic acidosis in almost 50% of patients
– As a precaution → metformin should not be used in patients with
renal insufficiency, CHF, conditions that lead to hypoxia
45
4. Glitazones (PPARg Agonists)
PPARg Agonists:
Peroxisome proliferator-activated receptor g gonists
- Rosiglitazone - Pioglitazone

Pharmacological effect
–Reduces insulin resistance in the periphery (Sensitize
muscle and fat to the action of insulin) and possibly in the
liver
–The onset of action is slow taking 2-3 months to see the
full effect
–Edema and weight gain are the most common side
effects. (no hepatotoxicity) 46
5. a-Glucosidase Inhibitors
- Acarbose - Miglitol

Pharmacological effect
Prevent the breakdown of sucrose and complex
carbohydrates
The net effect is to reduce postprandial blood glucose rise
The effect is limited to the luminal side of the intestine with
limited systemic absorption. Majority eliminated in the feces.
Postprandial glucose conc is reduced.
FPG relatively unchanged.
Average reduction in HbA1c: 0.3-1.0%

47
 Pharmacotherapy :Type 2 DM

General considerations:

- Consider therapeutic life style changes (TLC) for

all patients with Type 2 DM
- Initiation of therapy may depend on the level of HbA1C
- HbA1C < 7% may benefit from TLC
- HbA1C 8-9% may require one oral agent
- HbA1C > 9-10% my require more than one oral agent

48
Pharmacotherapy :Type 2 DM
Obese Patients >120% LBW:

Metformin or glitazone

Add SU or short-acting insulin

secretagogue

Add Insulin or glitazone

49
Pharmacotherapy :Type 2 DM

Non-obese Patients <120% LBW:

SU or short-acting insulin
secretagogue

Add Metformin or glitazone

Add Insulin
50
Pharmacotherapy :Type 2 DM
Elderly Patients with newly diagnosed DM :

SU or short-acting insulin
secretagogue or a-glucosidase
inhibitor or insulin

Add or substitute insulin

51
 Pharmacotherapy :Type 2 DM
Early insulin resistance :

Metformin or glitazone

Add glitazone or metformin

Add SU or short-acting insulin

secretagogue or insulin
52
Clinical Trials: Diabetes Mellitus

1- Diabetes Prevention Program

• Population: Over-weight patients with impaired

glucose tolerance.

• Intervention: Low-fat diet and 150 min of exercise

per week.

• Results: Decrease the risk of progression to Type 2

DM by 58% 53
Pharmacotherapy :Type 1 DM

The choice of therapy is simple

All patients need Insulin

54
Insulin
Pharmacological effect:

Anabolic Anticatabolic
-Glucose uptake - Inhibits gluconeogenesis
-Glycogen synthesis
-Lipogenesis - Inhibits glycogenolysis
-Protein synthesis - Inhibits lipolysis
-Triglyceride uptake - Inhibits proteolysis
- Inhibits fatty acid oxidation

55
Insulin (Cont’d)
Strength

-The number of units/ml

e.g. U-100 , U-20, U-10

Source
- Pork: Differs by one a.a.
- Beef-Pork
- Human (recombinant DNA technology)
56
Insulin (Cont’d)
Onset and duration of effect

Changing the properties of insulin

preparation can alter the onset and duration of
action
-Lispro: (Monomeric) absorbed to the
circulation very rapidly
-Aspart: (Mono- and dimeric) absorbed to the
circulation very rapidly
-Regular: (Hexameric) absorbed rapidly but
slower than lispro and aspart
57
Insulin (Cont’d)
Onset and duration of effect
-Lent insulin: Amorphous precipitate of insulin
and zinc and insoluble crystals of insulin and
zinc. Releases insulin slowly to the circulation
-NPH: R-insulin + Protamine zinc insulin.
Releases insulin slowly to the systemic
circulation
-Insulin glargine: Prepared by modification of
the insulin structure. Precipitate after S.C.
injection to form microcrystals that slowly
release insulin to the systemic circulation (N.B.
cannot be mixed with other insulins)
58
Insulin (Cont’d)
Onset and duration of effect
-Rapid-acting insulin
- e.g. Insulin lispro and insulin aspart
-Short-acting insulin
- e.g. Regular insulin
-Intermediate-acting insulin
- e.g. NPH and Lente insulin
-Long-acting insulin
- e.g. Insulin Glargine
-Mixture of insulin can provide glycemic control over
extended period of time
- e.g. Humalin 70/30 (NPH + regular)

59
Insulin (Cont’d)
Adverse effects
-Hypoglycemia
- Treatment:
- Patients should be aware of symptoms of hypoglycemia
- Oral administration of 10-15 gm glucose
- IV dextrose in patients with lost consciousness
- 1 gm glucagon IM if IV access is not available

-Skin rash at injection site

- Treatment: Use more purified insulin preparation
-Lipodystrophies (increase in fat mass) at injection site
- Treatment: rotate the site of injection

60
 Insulin (Cont’d)
Drugs interfering with glucose tolerance
The most significant interactions are with drugs that alter
the blood glucose level:
-Diazoxide
-Thiazide diuretics
-Corticosteroids
-Oral contraceptives
-Streptazocine
-Phenytoin
All these drugs increase the blood glucoseconcentration.
Monitoring of BG is required

61
Insulin (Cont’d)
Methods of Insulin Administration
Insulin syringes and needles

Pen-sized injectors

Insulin Pumps

62
Pharmacotherapy :Type 1 DM

The goal is:

To balance the caloric intake with the
glucose lowering processes (insulin and
exercise), and allowing the patient to live
as normal a life as possible

63
Pharmacotherapy :Type 1 DM

- The insulin regimen has to mimic the physiological

secretion of insulin

- With the availability of the SMBG and HbA1C tests

adequacy of the insulin regimen can be assessed

- More intense insulin regimen require more intense

monitoring

64
Pharmacotherapy :Type 1 DM

Example:

1- Morning dose (before breakfast):

Regular + NPH or Lente
2- Before evening meal:
Regular + NPH or Lente
Require strict adherence to the timing of meal and
injections

65
Pharmacotherapy :Type 1 DM

Modification
- NPH evening dose can be moved to bedtime
- Three injections of regular or rapid acting insulin before
each meal + long acting insulin at bedtime (4 injections)
- The choice of the regimen will depend on the patient

66
Pharmacotherapy :Type 1 DM

How much insulin ?

- A good starting dose is 0.6 U/kg/day
- The total dose should be divided to:
- 45% for basal insulin
- 55% for prandial insulin
The prandial dose is divided to
- 25% pre-breakfast
- 15% pre-lunch
- 15% pre-supper
67
Pharmacotherapy :Type 1 DM

Example: For a 50 kg patient

- The total dose = 0.6X50 = 30 U/day
- 13.5 U for basal insulin (45% of dose)
- Administered in one or two doses
- 16.5 U for prandial insulin (55% of dose)
The 16.5 U are divided to:
- 7.5 U pre-breakfast (25%)
- 4.5 U pre-lunch (15%)
- 4.5 U pre-supper (15%)
68
Pharmacotherapy :Type 1 DM

Monitoring
- Most Type 1 patients require
0.5-1.0 U/kg/d
- The initial regimen should be modified based
on:
- Symptoms
- SMBG
- HbA1C
69
Pharmacotherapy :Type 1 DM

Monitoring

70
Pharmacotherapy :Type 1 DM
Insulin Pump Therapy
- This involves continuous SC administration of
short-acting insulin using a small pump
- The pump can be programmed to deliver basal
insulin and spikes of insulin at the time of the
meals
- Requires intense SMBG
- Requires highly motivated patients because failure
to deliver insulin will have serious consequences
71
Pharmacotherapy :Type 1 DM
Insulin Pump

72
Surgery

Islet transplantation has been investigated as

a treatment for type 1 diabetes mellitus in
selected patients with inadequate glucose
control despite insulin therapy.
Observations in patients with type 1 diabetes
indicate that islet transplantation can result in
insulin independence with excellent metabolic
control
Ref. Shapiro A.M. J., et al. N Engl J Med 2000; 343:230-238, Jul 27, 2000
Diabetes Mellitus Complications

1. Hypoglycemia
- Cause: Missing meals or excessive exercise or too
much insulin
- Symptoms: Tachycardia, palpitation, sweating,
nausea, and vomiting. Progress to mental confusion,
bizarre behavior and coma
- Treatment: Candy or sugar
IV glucose
Glucagon 1 gm IM
- Identification: MedicAler bracelet
74
Diabetes Mellitus Complications

2. Diabetes retinopathy

- Microaneurysm
- Hemorrhage
- Exudates
- Retinal edema
- other

75
Diabetes Mellitus Complications

3. Diabetes nephropathy
- 30-40 % of all type 1 DM patients develop nephropathy
in 20 years
- 15-20 % of type 2 DM patients develop nephropathy
- Manifested as:
- Microalbuminuria
- Progressive diabetic nephropathy leading to end-
stage renal disease

76
Diabetes Mellitus Complications

Diabetes nephropathy (Cont’d)

- All diabetic patients should be screened annually for
microalbuminurea to detect patients at high risk of
developing progressive diabetic nephropathy
- Tight glycemic control and management of the blood
pressure can significantly decrease the risk of developing
diabetic nephropathy.
- ACE-inhibitors are recommended to decrease the
progression of nephropathy
77
Diabetes Mellitus Complications

4. Diabetes neuropathy

Autonomic neuropathy:
- Manifested by orthostatic hypotension, diabetic diarrhea,
erectile dysfunction, and difficulty in urination.
78
Diabetes Mellitus Complications

5. Peripheral vascular disease and foot ulcer

Incidence of gangrene
of the feet in DM is 20
fold higher than control
group due to:
- Ischemia
- Peripheral neuropathy
- Secondary infection

79
 Treatment of DM During Pregnancy

All women with T1D, T2D, or previous GDM should

receive preconception care to ensure adequate nutrition
and glucose control before conception, during pregnancy,
and in the postpartum period
Use insulin to treat hyperglycemia in T1D and T2D and
when lifestyle measures do not control glycemia in GDM
Basal insulin: NPH or insulin detemir
Prandial insulin: insulin analogs preferred, but regular
insulin acceptable if analogs not available
Penatalaksanaan DM selama
bulan Ramadhan dan
pandemic COVID
Stratifikasi risiko pasien DM dan COVID

Diabet. Med. 37, 1094–1102 (2020)

Diabetes dan COVID

Pada
kondisi
COVID,
kadar gula
harus tetap
dikontrol
Di bulan Ramadhan, jika penderita DM (non-
Covid) tetap ingin berpuasa, perlu diingat bahwa:

● Pasien diabetes yang akan menjalani puasa Ramadan, memiliki berbagai

risiko yang tak diinginkan, seperti: dehidrasi, hipoglikemi, hiperglikemi,
ketoasidosis dan thrombosis
● Meskipun demikian sebagian besar pasien diabetes (83-89%) tetap ingin
menjalankan puasa Ramadhan meskipun mempunyai risiko yang tinggi.
● Tenaga Kesehatan hendaknya dapat membantu pasien diabetes yang
ingin
menjalankan puasa Ramadhan guna mengurangi terjadinya risiko yang tidak
diinginkan, dengan memberikan edukasi khusus Ramadhan pada pasien.
● Terbukti dari suatu penelitian bahwa edukasi khusus Ramadhan pada pasien
diabetes memperbaiki kepatuhan pasien pada rekomendasi yang dianjurkan
dalam menjalani puasa Ramadan.
Petunjuk Umum
 Nutrisi dan Cairan
●
Kebutuhan kalori harian dalam jumlah 1200-2000 kalori didistribusikan untuk sahur (30-40%)
dan berbuka (40-50%), ditambah 1-2 camilan sehat (10-20%)
●
Komposisi nutrisi terdiri dari karbohidrat (40-50%), sebaiknya dengan indeks glikemik rendah
sehingga energi dapat dilepaskan secara perlahan; protein 20-30% berupa kacang-kacangan,
ikan, unggas atau daging; lemak 30-35% berupa lemak monosaturasi dan lemak tak jenuh
ganda; lemak jenuh harus dibatasi < 10% dari total asupan kalori harian; dan asupan serat yang
cukup dari buah, sayur
●
Mempertahankan tingkat hidrasi dengan minum cukup air sebanyak 30-50 cc/kg/berat
badan, (disesuaikan dengan kondisi ginjal dan jantung pasien). Hal ini dilakukan untuk
mencegah dehidrasi dan menurunkan risiko thrombosis
●
Makan sahur disarankan seakhir mungkin sebelum memulai puasa.
●
Makanan yang mengandung banyak gula, minuman manis, sirup, jus kalengan, atau jus
segar dengan tambahan gula harus dihindari setelah berbuka puasa dan di antara waktu
makan
●
Hindari minuman berkafein karena bersifat diuretik yang dapat menyebabkan dehidrasi

Perkeni, 2022
Penyesuaian penggunaan Obat (1)

Perkeni, 2022
Penyesuaian penggunaan Obat (2)

Perkeni, 2022
 Kolaborasi tenaga kesehatan

● Penanganan penyakit diabetes memerlukan kolaborasi tenaga

kesehatan, dalam hal ini dokter sebagai penentu diagnosis dan
farmasis mendampingi, memberikan konseling dan bekerja
sama erat dengan pasien untuk mencapai tujuan terapi
● Farmasis dapat terlibat langsung pada terapi pasien
diabetes
melitus untuk:
○ Mencegah masalah terapi obat (konseling dan edukasi,

serta pemantauan terapi obat)

○ Deteksi dini masalah terapi obat

○ Identifikasi masalah terapi obat

○ Memberikan solusi masalah terapi obat

Tantangan di era pandemic COVID-19

Pasien tidak mau datang

ke faskes/RS atau
apotek

Pengobatan terputus atau

kondisi diabetes tidak
terpantau

Perburukan DM dan
peningkatan risiko
komplikasi

Perburukan DM dapat
Poin Edukasi untuk pasien
DM
Pentingnya menjaga agar kadar gula darah tetap pada rentang normal, karena Diabetes yang
tidak terkontrol akan meningkatkan risiko komplikasi dan keparahan Covid-19 jika terkena

Pentingnya kepatuhan dan ketepatan penggunaan obat (oral/insulin)  perlu

meningkatkan
upaya edukasi utk meningkatkan kepatuhan dan ketepatan penggunaan obat

Pentingnya perbaikan life style (diet, olah raga, kurangi stress,

dll) Pentingnya pemantauan kadar gula darah mandiri

Pentingnya memantau efek obat yang tidak diinginkan yang dapat

mengurangi kepatuhan dan
outcome terapi  komunikasikan dengan dokter/Apoteker untuk
mendapat pengatasan
Pemantauan glukosa darah mandiri (PDGM)
● Apapun terapinya, target pengendalian DM yang mudah diukur adalah
kadar
glukosa darah
● PDGM adalah pemeriksaan glukosa darah berkala yang dilakukan
dengan menggunakan glucometer oleh penyandang sendiri dan/atau
keluarganya
● Penyandang DM bisa memiliki sendiri alat glucometer di rumah
setelah mendapatkan edukasi dari tenaga Kesehatan terlatih, atau
melakukan
pemeriksaan di Apotek
● Apoteker dapat membantu pasien untuk memahami hasil
PDGM dan menyarankan tindakan yang sesuai :
○ Mengecek kepatuhan minum obat/menggunakan obat,
○ memastikan ketepatan penggunaan obat,
○ menganalisis kemungkinan ada drug-related problem,
○ Menyarankan diet, olahraga, dll, atau
○ merujuk ke dokter jika diperlukan penyesuaian regimen
 Take Home Messages
●
Diabetes Mellitus merupakan penyakit kronis yang banyak dijumpai
●
Kontrol DM yang baik dapat mencegah komplikasi dan memelihara
kualitas hidup
●
Manajemen DM adalah melalui terapi obat dan non-obat yang
dijalankan secara proporsional
●
Pada bulan Ramadhan juga perlu ada perhatian khusus terhadap
penatalaksanaan DM bagi yang ingin tetap berpuasa, terutama terkait
dengan aktivitas, makanan, dan penyesuaian penggunaan obatnya
Terima Kasih 
Contoh Soal Ujian :
Pasien wanita berusia 25 tahun periksa ke dokter dan
pasien tersebut melakukan cek gula darah. Diketahui
pasien tengah hamil 6 bulan dan gula darah puasa yang
tinggi. Dokter mendiagnosis wanita tersebut DM
Gestasional. Terapi farmakologis yang tepat apa yang
anda rekomendasikan kepada pasien?
a. insulin
b. glyburide
c. acarbose
d. empafliglozin
e. metformin