Management of T2DM

dr. Andi Sulistyo Haribowo, SpPD

Dokter Spesialis Penyakit Dalam
RSU MITRA DELIMA
Kab. Malang
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Classification of Diabetes

Type 1 diabetes
-cell destruction
Type 2 diabetes
Progressive insulin secretory defect
Other specific types of diabetes
Genetic defects in -cell function, insulin action
Diseases of the exocrine pancreas
Drug- or chemical-induced
Gestational diabetes mellitus (GDM)

ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S11.

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Prediabetes: IFG, IGT, Increased A1C
Categories of increased risk for diabetes
(prediabetes)*

FPG 100125 mg/dL (5.66.9 mmol/L): IFG

OR
2-h plasma glucose in the 75-g OGTT
140199 mg/dL (7.811.0 mmol/L): IGT
OR
A1C 5.76.4%

*For all three tests, risk is continuous, extending below the lower limit of a range and becoming disproportionately
greater at higher ends of the range.

ADA. I. Classification and Diagnosis. Diabetes Care 2013;36(suppl 1):S13; Table 3.

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The continuum of glucose intolerance

Type 2 Disability
Normal IGT Complications
Diabetes Death

Preclinical Clinical
state disease Complications

Primary Secondary Tertiary

prevention intervention intervention
 Screening for Pre-diabetes
Who to screen

Patients overweight/obese/morbidly obese (BMI>25, >30, >40)

Hypertension
Gestational diabetes in the past (or infant >9 lbs)
Sedentary life style
Abnormal cholesterol (especially TG>250 mg/dl, HDL<35
mg/dl)
Age >45,
Race-African-American, Hispanic, Asian-American, Native
American, Pacific Islanders
Family history of diabetes
PCOS syndrome
Early age at menarche#
Antipsychotic medications (those for severe
schizophrenia/bipolar disorder)
Reduction in life expectancy in type
2 diabetes
Age at Marks & Krall Goodkin Panzram &
Diagnosis 1971 1975 Zabel-Langhennig
1981

10/15 (17) 27 -
15-19 16-17 23 -
20-29 12-14 16 -
30-39 10-11 11 -
40-49 8-9 10 7-8
50-59 6-7 6 5-6
60-69 4-5 5 3-4
70+ - - 3

Panzram G. Diabetologia 1987;30:123-31

 Hyperglycaemia and complications
Type 2 diabetes
60
Myocardial
% Incidence per 1000 patient-years

infarction
50
Microvascular
40 disease

30

20

10

0
<6 6-<7 7-<8 8-<9 9-<10 10+
Updated HbA1c (%)
UKPDS 35, BMJ 2000; 321: 405-12
Chronic Complications in Newly Diagnose Diabetes Mellitus
50% of patients had 1 complications

Stroke or TIA: 1%
Retinopathy: 21%
NEWLY
DIABETES
Hypertension: 35%

Plasma creatinine
>120mol/l: 3%
Abnormal ECG : 18%

Intermittent
Claudicasio: 3%
Erectal Dysfuntion : 20%

Foot skin ischemia : 6%

Pedal pulse (-) : 13%
UKPDS 6, Diabetes Res. 1990 Jan;13(1):1-11. J Hypertens 1993 Jun;11(6):681.
Acta Medica Iranica, 44(6): 415-419; 2006 International Journal of Diabetes Mellitus, 2010 April; 2(1):61-3
 Initial evaluation

Classify diabetes
Detect complication
Previous treatment and glycemic
control

Management plan
An integrated approach is needed

To correct The glucotriad:

FPG, ppPG increment peaks
HbA1C
Comorbidities of the metabolic
syndrome: obesity, hypertension,
hypercoagulation

To prevent Macrovascular disease

Microvascular disease
Diabetic nephropathy
Deterioration of -cell function and
insulin sensitivity
Intervention to effect better control
means fewer complications
EVERY 1% Reduced Risk*
reduction in HBA1C
- 21%
Deaths from diabetes

- 14%
Heart attacks

- 37%
Microvascular complications
1%
- 43%
Peripheral vascular disorders
*p<0.0001
UKPDS 35 BMJ 2000;321:405-412
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Barriers and limitation to Goal

Ineffective diet/exercise initiatives

Lack of efficacy of pharmacological
agents
Adverse events
Poor compliance
Conservative management
Sub-optimal healthcare systems
Natural progression of disease
Lifestyle Intervention

Medical nutrition counseling

Exercise recommendations
Diabetes education
 Medical nutrition therapy

Weight loss 7% decrease insulin

resistance
Saturated fat less then 7% of total
calories intake
Minimize intake of tras fatty acid
Carb counting is usefull for patients
received insulin
Glycemic index and glycemic load
are considered
Clinical trials/outcome studies of MNT
have reported decreases in A1C at
36 months ranging from 0.25 to 2.9%
 Diabetes self-management
education

People with diabetes should receive

DSME according to national standards
when their diabetes is diagnosed and
as needed thereafter.
 Physical activity

People with diabetes should be advised to

perform at least 150 min/week of
moderate-intensity aerobic physical
activity (5070% of maximum heart rate).
In the absence of contraindications,
people with type 2 diabetes should be
encouraged to perform resistance training
three times per week.
Pharmacotherapy in
Type-2 Diabetes
The New Paradigm of (Type 2) Diabetes
Treatment

Treatment Driven by Target ( A1C < 7%)

Early Combinations ( including with insulin )
Aggressive Insulin Treatment

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 Targets for Glycemic (blood sugar)
Control In Most Non-Pregnant Adults
ADA AACE
A1c (%)
<7* 6.5
Fasting (preprandial) plasma
glucose 70-130 mg/dL <110 mg/dL

Postprandial (after meal)

plasma glucose <180 mg/dL <140 mg/dL

American Diabetes Association. Diabetes Care. 2011;34(suppl 1) *<6 for certain individuals
Implementation Conference for ACE Outpatient Diabetes Mellitus Consensus Conference Recommendations: Position Statement
at http://www.aace.com/pub/pdf/guidelines/OutpatientImplementationPositionStatement.pdf. Accessed January 6, 2006.
AACE Diabetes Guidelines 2002 Update. Endocr Pract. 2002;8(suppl 1):40-82.

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 UKPDS : Hasil dari Pengobatan Diabetes
tipe 2
3 tahun :
48-55% memiliki HbA1c<8%
41-46% memiliki HbA1c<7%
6 tahun :
35-38% memiliki HbA1c<8%
25-27% memiliki HbA1c<7%
9 tahun :
16-21% memiliki HbA1c<8%
10-18% memiliki HbA1c<7%
KESIMPULAN :
Sejalan dengan waktu pasien diabetes tipe 2 akan
memerlukan terapi insulin/kombinasi dengan insulin
Prof. Z.T Bloomgarden
11th AFES Congress, Bali, Nov 2001 43
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 Type 2 Diabetes Anti-Hyperglycemic Therapy:
General Recommendations
Healthy eating, weight control, increased physical activity
Initial Drug Monotherapy Metformin
Efficacy ( HbA1c) High
Hypoglycemia Low risk
Weight Neutral / loss
Side effects GI / lactic acidosis
Cost Low
Consider initial dual If needed to reach individualized HbA target after ~3 months, proceed to two-drug combination
Begin with
combination therapy these options if(order not meant to denote any specific preference):
1c

when A1c >9% metformin contraindicated

Metformin + Metformin + Metformin + Metformin +
Metformin +
Sulfonylurea Thiazolidinedio
GLP-1-R Insulin (usually
Two-Drug Combinations* High ne DPP-4 Inhibitor
Agonists basal)
Efficacy ( HbA1c) Moderate High Intermediate
High Highest
Hypoglycemia risk Low risk Low risk
Weight Low risk High risk
Gain Gain Neutral
Side effects Loss Gain
Hypoglycemi Edema, FH, Rare
Cost GI Hypoglycemia
a FXs High
High Variable
Low High
Consider initial
insulin therapy If needed to reach individualized HbA1c target after ~ 3 months, proceed to two-drug combination
(order not meant to denote any specific preference):
when A1c>10-12%
Metformin + Metformin + Metformin + Metformin +
Metformin +
Three-Drug Combinations Sulfonylurea Thiazolidinedion DPP-4 Inhibitor GLP-1-R Insulin (usually
+
TZD eSU+ +SU
Agonists
SU
+ basal)
TZD
+

DPP-4-I DPP-4-I TZD TZD DPP-4-I

or or or or or
GLP-1 RA GLP-1 RA Insulin Insulin GLP-1 RA
or or or or or
Insulin Insulin
or or

If combination therapy that includes basal insulin has failed to achieve HbA1c target after 3-6
More Complex months, proceed to a more complex
Insulin Strategies insulin strategy, usually in combination with one or two non-insulin agents
Insulin (multiple daily doses)
Diabetes Care 2012;35:1364-79.
Diabetologia 2012;55:1577-96.
 Lesson from the recent guidelines

Single OAD:
Used as first line drug for A1C level 6.5-7.5%
First choice: Met, TZD,DPP IV, AGI (depend on clinical
presentation of patients)
SU ??
Combination OAD:
Used for first line for A1C level 7.6-9.0%
Metformin is always used for any combination with other
OAD
Triple drug combination still usage
Insulin:
Can be combined with OAD at any level of A1C if target A1C can not
achieved by OAD only
Used as first line drug in: drug naive patient with symptom of metabolic
decompensated or patient failure in OAD
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THANK
YOU
Curiculum Vitae : dr. Andi Sulistyo H,
Sp.PD
Tempat/Tgl Lahir :Malang, 28 Mei 1978
Pendidikan :
1. S1 dan Dokter Fakultas Kedokteran Universitas Brawijaya Malang
2. Dokter Spesialis Penyakit Dalam, Fakultas Kedokteran Universitas
Brawijaya Malang
. Pengalaman Organisasi :
1. Sie Minat & Bakat Senat Mahasiswa Fakultas Kedokteran Universitas
Brawijaya Th 1996-1997
2. Pengurus PAPDI Cab. Malang ( Sie Informasi & Komunikasi ) Th 2012 -
Sekarang
. Pengalaman Bekerja :
1.Dokter Spesialis Penyakit Dalam Dinas Kesehatan Kota Malang 2003 2015
2. Dokter Spesialis Penyakit Dalam RSUD Kota Malang 2015 Sekarang
3. Dokter Spesialis Penyakit Dalam RSU Mitra Delima 2010 Sekarang
4. Dokter Spesialis Penyakit Dalam RSU Prasetya Husada Karangploso 2010 -
Sekarang