Slide 1

Lecture:
Early Detection and Standardized Diabetes
Management

30 minutes
 Slide 2

Early Detection and Standardized Diabetes Management

Lecture

Main Learning Points

• Understand the process from

screening to diagnosis and the
associated national guidelines
•Understand the importance of treating
diabetes and intensify treatment on
diabetes via blood glucose- and HbA1c
monitoring
•Understand the reason and need for
routine follow-up and reaching
individual targets to avoid complications
 Slide 3

Some Definitions before we start…

Common Definitions

Abbreviation Definition

NGT Normal Glucose Tolerance (Gula Darah Normal)

FPG Fasting Plasma Glucose (Gula Darah Puasa)

PPG Post-Prandial Plasma Glucose (Gula Darah Post Prandial)

IGT Impaired Glucose Tolerance (Toleransi Glukosa Terganggu)

IFG Impaired Fasting Glucose (Gula Darah Puasa Terganggu)

Average amount of glucose in the bloodstreams over a 3-month

HbA1c
period
 Slide 4

Classification of Diabetes

• Type 1 diabetes
• Absolute insulin deficiency due to the destruction of
pancreatic beta-cells
• Type 2 diabetes
• Type 2 is characterized by insulin resistance with relative
insulin deficiency to a predominately secretary defect
with insulin resistance
• Other specific types
• Gestational diabetes
• Glucose intolerance first detected in pregnancy that often
resolves after the birth of the baby

Diabetes Care 1997; 20: 1183-1197

 Slide 5

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 6

Type 2 diabetes is a progressive disease

HOMA: homeostasis model assessment

Lebovitz. Diabetes Reviews 1999;7:139–53 (data are from the UKPDS population: UKPDS 16.
Diabetes 1995;44:1249–58)
 Slide 7

Diabetes – elevated blood glucose due to

insufficient insulin secretion
Normal glucose and insulin Early Type 2 Diabetes Glucose
excursions and insulin excursions

Glucose Insulin Glucose Insulin

400 120 400 120

100 100
Glucose mg/dL

Glucose mg/dL
Insulin U/mL

Insulin U/mL
300 300
80 80

200 60 200 60

40 40
100 100
20 20

06:00 10:00 14:00 18:00 22:00 02:00 06:00 06:00 10:00 14:00 18:00 22:00 02:00 06:00

Breakfast
Time of Day Time of Day
Breakfast

Dinner
Lunch

Dinner
Lunch
 Slide 8

The Importance of treating Type 2 Diabetes

Type 2 diabetes is a progressive disease

Postprandial glucose

Diagnosis

Glucose Fasting glucose

Insulin Insulin resistance

Inadequate
β-cell function Insulin secretion
Microvascular changes
Macrovascular changes

Prediabetes
NGT Diabetes
(IFG/IGT)

Adapted from Type 2 Diabetes BASICS. International Diabetes Center 2000

 Slide 9

Classical Diabetes Symptoms

Polyuria • Excessive Urination at night

Polyphagia • Excessive Hunger

Polydipsia • Excessive Thirst

Unexplained weight
• Weight Loss even if food in-
loss
take is normal
 Slide 10

Other Diabetes Symptoms

Blurred Vision • Damaging blood vessels in the eyes

Numbness and/or • Numbness and tingling in hands, legs

Tingling and feet

Fatigue • Frequent fatigue regardless of

exercise

Itchy Skin • affects legs, feet, and hands

Impotence • Physical and Physiological

 Slide 11

4 Simple Steps from Screening to Diagnosis

1 2 3
Screen patients with Conduct 1st Blood Test Conduct 2nd Blood Test
diabetes risk factors (if required) and
establish Diagnosis

4
Inform Patient and
Initiate treatment
 Slide 12

Step 1: Risk Factors – PERKENI screening risk

factor guideline

Diabetes Associated
Unmodifiable Risk Modifiable Risk
Risk

• Race and Ethnic • Overweight (BMI >23) • Polycystic Ovary

• Family History of • Hypertension > Syndrome (PCOS) or
Diabetes 140/90 mmHg another clinical
• History of Gestational • Dyslipidemia (HDL < condition related to
Diabetes 35 mg/dl and/or insulin resistance
• History of delivery a triglycerides >250 • Metabolic Syndrome
baby more than mg/dl (IGT, IFG, History of
4.000g • Unhealthy Diet Coronary Artery
• History of low birth • Limited Physical Disease , stroke
weight <2.500g Activity and/or PAD)

Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

 Slide 13

Step 2: Conduct 1st Blood Test

Clinical Test
(+) Classic (-) Classical
Symptoms Symptoms

FBG ≥126 <126 FBG ≥126 100-125 <100

or or
RBG ≥200 <200 RBG ≥200 140-199 <140

Repeat FBG or RBG

2 Hour Post loading

Plasma Glucose

Diabetes Mellitus IGT IFG Normal

Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

 Slide 14

Step 3: Conduct 2nd Blood Test (if required) and

Establish Diagnosis

Clinical Test
(+) Classic (-) Classical
Symptoms Symptoms

FBG ≥126 <126 FBG ≥126 100-125 <100

or or
RBG ≥200 <200 RBG ≥200 140-199 <140

Repeat FBG or RBG

≥126 <126 2 Hour Post loading

Plasma Glucose
≥200 <200

PPG ≥200 140-199 <140

Diabetes Mellitus IGT IFG Normal

Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

 Slide 15

Step 4: Inform Patient and Initiate Treatment

Diabetes Mellitus IGT IFG

• Evaluation of Nutritional Status • Education

• Evaluation of Diabetes • Food Regulation
Complications • Physical Exercise
• Evaluation of Required Food • Ideal Body Weight
Regulation • OADs are unnecessary at
• Decision on medicines this stage

Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

 Slide 16

Cut-points: Diabetes, IGT and IFG

mg/dL
Fasting Plasma Glucose (FPG)

Diabetes

126

IFG (Impaired
Fasting Glucose

100
IGT (Impaired
Glucose Diabetes
NGT (Normal Tolerance)
Glucose
Tolerance)

140 200 mg/dL

2-hour Plasma
Glucose (PPG)
 Slide 17

Diagnosis of Type 2 Diabetes

KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

1. Classical symptoms of Diabetes (+) & Random plasma

glucose concentration ≥ 200 mg/dl
Or
2. Classical symptoms of Diabetes (+) & Fasting Plasma
Glucose ≥ 126 mg/dl.
Or
3. 2-hour post-OGTT ≥ 200 mg/dl.

Note:
• Classical symptom of diabetes (+), only need 1 abnormal BG
• No classical symptom of diabetes, need 2 x abnormal BG level in a different days
 Slide 18

Updated PERKENI Type 2 Diabetes Treatment

Algorithm

Diabetes STEP 1 STEP 2 STEP 3

Healthy life style Healthy life style

Note:
1. Therapy failed if
target of HbA1c <
7% is not achieved
within 2-3 months
for each step
2. In case of no HbA1c
test, the use of blood
glucose level is also
permitted. Average
blood glucose level
for a few BG test in
one day can be
converted to HbA1c
(ref: ADA 2010)
+
Mono therapy Healthy life style
+ Healthy life style
2 OAD Combination +
Alternative option, if : Combination 2 OAD
• No insulin is available +
• The patient is objecting insulin Basal insulin
• Blood glucose is still not optimally
controlled
Healthy life style
Insulin
+
Intensification*
3 OAD Combination

*Intensive Insulin: use of basal insulin together with insulin prandial

 Slide 19

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

1. American Diabetes Association Diabetes Care 2009;32 (Suppl 1):S1-S97

2. IDF Clinical Guidelines Task Force. International Diabetes Federation 2005. 3. PERKENI 2011 Konsensus .
 Slide 20

HbA1c correlation with blood glucose level

The relationship between A1C and eAG is described by the formula 28.7 X
A1C – 46.7 = eAG

David M. Nathan, Judith Kuenen, Rikke Borg, Hui Zheng, David Schoenfeld, and Robert J. Heine, for the A1c-Derived
Average Glucose (ADAG) Study Group. Diabetes Care 2008
 Slide 21

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.

Stratton IM et al. BMJ 2000;321:405–12

 Slide 22

The benefits of good blood glucose control are

clear

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

Deaths related
to diabetes

-21%
Source: UKPDS = United Kingdom Prospective Diabetes Study. Stratton IM
et al. BMJ. 2000;321(7258):405-412.
 Slide 23

Practical Monitoring Scheme

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009
 Slide 24

Practical Monitoring Scheme Cont…

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009
 Slide 25

Individualized Treatment based on several criteria

to control blood glucose

Inzucci SE, et al. Diabetologia. 2012

 Slide 26

Early Detection and Standardized Diabetes Management

Lecture

Summary Main Learning Points

• Diabetes is a progressive disease that • Understand the importance of treating

must be treated in order to avoid long- diabetes and reaching individual targets
term complications to avoid complications
• Good glycemic control according to • Understand the process from
PERKENI is: screening to diagnosis and the
• HbA1c <7% associated national guidelines
• FPG: <100 mg/dl • Understand the reason and need for
routine follow-up and intensify
• PPG: <140 mg/dl treatment on diabetes via blood
• Patient treatment need to be glucose- and HbA1c monitoring
individualized according to the
characteristics of each particular
patients