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Baik Sedang
Buruk
Type 2 Disability
Normal IGT Complications
Diabetes Death
Preclinical Clinical
state disease Complications
26 Live to Eat !
Dual defect of type 2 diabetes
moving targets
Insulin Type 2 b-cell
Resistance Diabetes Dysfunction
b-cell Failure
Insulin
Concentration
Insulin
Resistance
Euglycaemia
Normal IGT ± Obesity Diagnosis of Progression of
(pre diabetes) type 2 diabetes type 2 diabetes
DeFronzo R et al. Diabetes Care 1992;15:318-68
Natural History of Type 2 Diabetes
Type 2
30% 50%
diabetes
Heart attacks
Microvascular complications
1%
Peripheral vascular disorders
*p<0.0001
UKPDS 35 BMJ 2000;321:405-412
Treatment algorithm for type 2
diabetes
Aim Diet, exercise, health education
Sulphonylurea or metformin
Glucosidase Inhibitors
Glitinides
Thiazolidinediones
Oral combinations
Insulin
Glucose Biguanides
production Thiazolidinediones
INTESTINE
-glucosidase inhibitors
GLUCOSE
PRODUCTION PERIPHERAL GLUCOSE
UPTAKE & UTILIZATION
LIVER
Glucose
MUSCLE
Biguanides
Thiazolidinediones
ADIPOSE TISSUE
Thiazolidinediones
INSULIN SECRETION Biguanides
Sulphonylureas
Meglitinides
PANCREAS Modified: Ann Intern Med 1999;131:281
Choice of agents in current use
Glipizide
Acarbose
Gliclazide
Miglitol
Glimepiride Sulphonylureas Voglibose
Glibenclamide
Meglitinides
Rosiglitazone Repaglinide
Pioglitazone Nateglinide
SULFONYLUREA
GENERASI I
Tolbutamid GENERASI II
Acetoheksamid Glibornurid
Tolazamid Glipizid
Carbutamid Glisoxepid
Glikodiasin Glibenclamid
Khlorpropamid Gliclasid
Gliquidon
GENERASI III
Glinid (repaglinid dan nateglinid)
Comparison between
1st generation SU Vs 2nd generation SU
2 Oral 3 Oral
Oral agent agents agents
Add
insulin
Adapted from Mudaliar S et al. In: Ellenberg and Rifkin’s Diabetes Mellitus, 6th ed. New York, NY:
Appleton and Lange; 2003:531-557.
Proposed Algorithm of
Therapy for Type 2 Diabetes
Inadequate non-
pharmacologic
therapy
• Severe symptoms
• Severe
hyperglycaemia Oral agent 2 Oral 3 Oral
• Ketosis agents agents
• Pregnancy
Baik Sedang
Buruk
Krall LP, Beaser RS, Joslin Diabetes Manual, 12th edition, 1988
Target BG levels
Time Ideal normal Target levels
level (mg%) (mg%)
Before breakfst 70-105 70-120
Before Lunch, 70-110 70-140
Supper, Bed
time snack
75
Breakfast Lunch Dinner
Plasma Insulin µU/ml)
50
25
• Hospital monitoring
Blood glucose in critically ill patients,
perioperative setting
• Self monitoring (out patient setting)
Self monitoring of BG control
Indications
T1 and T2DM (insulin treated patients)
Aims
To full fill the target of control good,
fair / acceptable BG control)
Avoid hypoglicemia
Insulatard Insulatard
Mixtard Mixtard
(30% reg + 70% intermediate) (30% reg + 70% intermediate)