Dr Budi Enoch SpPD

22 Maret 2014
 A group of metabolic diseases
 Characterized by hyperglycemia
 Resulting from defects in insulin
secretion , insulin action, or both
 By the year 2030,
350 million people
will have
type 2 diabetes
(21,3 million from
Indonesia- top 4)
 2020 : Penduduk Indonesia diatas usia 20
tahun 178.000.000 orang dimana 7.000.000
orang (4%) adalah penderita DM tipe 2
 Berdasarkan hasil Riset Kesehatan Dasar
(Riskesdas) 2007, angka prevalensi diabetes
mellitus tertinggi terdapat di provinsi
Kalimantan Barat dan Maluku Utara
(masing-masing 11,1 persen), diikuti Riau
(10,4 persen) dan NAD (8,5 persen).
 NDDM : resiko CHD 2 – 4 kali lebih tinggi
dibanding non DM2
 Biaya perawatan DM, 10% dari total ongkos
perawatan kesehatan1
 Penyakit CV mengkonsumsi proporsi biaya
terbesar dari ‘direct costs2’

1. International Diabetes Federation, Diabetes Atlas, 4th Edition;

2. Diabetes - The Policy Puzzle. FEND 2003
  DM  is a syndrome with
disordered metabolism and
inappropriate hyperglycemia due to
either a deficiency of insulin
secretion or to a combination of
insulin resistance and inadequate
insulin secretion to compensate
 Both the tissue resistance to insulin and the
impaired β cells response to glucosa appear to
be further aggravated by increased
hyperglycemia (glucosa toxicity), and both
defect are ameliorated by treatment that
reduces the hyperglycemia toward normal
 Obese type 2 :
- most common (diabesiti)
- insensitivity to endogenous insulin
 Non obese type 2 :
- show an absent or blunted early phase of
release in response to glucose
- generally respond to appropriate therapeutic
supplements of insulin
 1 dari setiap 7 dollar biaya perawatan kesehatan
digunakan untuk orang dengan diabetes
 Biaya perawatan kesehatan untuk orang dengan
diabetes setiap tahun berlipat 3,6 kali lebih besar
daripada biaya perawatan kesehatan pada orang
tanpa diabetes
 Biaya langsung untuk kasus positif: 85 milyar
dollar
 Perkiraan biaya secara keseluruhan: 92 – 100 milyar
dollar
 % of Total

Routine follow-up 32.5

Acute Metabolic Conditions 6.2

Chronic complications 61

ADA Diabetes Caro 21: 296, 1968

 obesity Impaired diabetes Uncontrolled
glucosa hyperglycae
tolerance mia

pp

n
120
mgr%

-20 -10 0 +10 +20 +30

Years of diabetes
 obesity Impaired diabetes Uncontrolled
glucosa hyperglycae
tolerance mia
Relative β cells function

Insulin resistance

100%

Decline β cell Insulin level

function

-20 -10 0 +10 +20 +30

Years of diabetes
 Diabetic Stroke
Retinopathy 2 to 4 fold increase in
cardiovascular
Leading cause mortality and stroke3
of blindness
in working age
Cardiovascular
adults1 Disease

8/10 diabetic patients

Diabetic
Nephropathy die from CV events4

Diabetic
Neuropathy
Leading cause of
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.
3 Kannel WB, et al. Am Heart J 1990; 120:672–676. 4Gray RP & Yudkin JS. In Textbook of Diabetes 1997.
5Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
 DIAGNOSIS DM
Hanya dapat ditegakkan dengan
PEMERIKSAAN GLUKOSA DARAH

HARUS DIPERHATIKAN :
Metode enzimatik
Bahan pemeriksaan plasma vena
(atau darah kapiler)
Dilakukan di lab. terpercaya
 PENGGUNAAN PEMERIKSAAN
KADAR GLUKOSA DARAH

1. SKRINING :
Pada individu tanpa gejala,
tetapi berisiko tinggi
Dianjurkan dilakukan saat “Check Up”

2. DIAGNOSIS :
Pada individu yang bergejala
klasifikasi
 Obese vs Non-obese
 Juvenile Onset vs Adult Onset
 IDDM vs NIDDM
 Primary vs Secondary
 Type 1 vs Type 2
 ???
 A. Clinical Classification
1. Diabetes Mellitus
IDDM
NIDDM – Obese
– Non-obese
Secondary Diabetes
MRDM
2. Gestational Diabetes
3. Impaired Glucose Tolerance

 B. Statistical Risk Classification

(WHO, 1985; PERKENI, 1993)
 Etiologic Clasification
I. Type 1 (ß-cell destruction leading to absolut
deficiency)
A. Immune mediated
B. Idiopathic

II. Type 2
• Predominantly insulin resistance + relative
insulin deficiency
• Predominantly secretory defect + insulin
resistance

III. Other specific types

IV. Gestasional diabetes mellitus

The Expert Committee,1997; WHO 1999; PERKENI 2006

Kadar glukosa darah sewaktu* dan puasa* sebagai
patokan penyaring dan diagnosis DM (mg/dl)

Bukan Belum pasti DM

Kadar gula darah DM DM
Sewaktu
plasma vena < 110 110 - 199 >200
darah kapiler < 90 90 - 199 > 200

Puasa
plasma vena < 110 110 - 125 >126
darah kapiler < 90 90 - 109 > 110

* metoda enzimatik Konsensus pengelolaan DM tipe 2.PERKENI.2002

 Management of Type 2 DM
1 2

3 4
 Diagnosis

Pilar Pengobatan
I II III IV

edukasi Aktifitas nutrisi obat

fisik

Edukator Dokter
 PANEL PENGELOLAAN DM &
JADWAL PEMERIKSAAN

NAMA PEMERIKS AWAL TGT KEBUT 3 BLN 1 TH

Glukosa puasa v v v v
Glukosa 2 JamPP v v v v
Hematologi rutin v
Urine Rutin v
HbA1c v v v
Mikroalbumin v v
Kreatinin v v
 PANEL PENGELOLAAN DM &
JADWAL PEMERIKSAAN

NAMA PEMERIKS AWAL TGT KEBUT 3 BLN 1 TH

Albumin/Globulin v v
GPT v v
Cholesterol Total v v
Cholesterol HDL v v
Cholesterol LDL v v
Trigliserida v v
Fibrinogen v v
 KRITERIA PENGENDALIAN DM

NAMA PEMERIKS Baik Sedang Buruk

Glukosa puasa 80 – 109 110 – 125 > 126

Glukosa 2jampp 80 – 144 145 – 179 > 180
HbA1c (%) < 6.5 6.5 – 8 >8
Cholesterol Total < 200 200 – 239 > 240
Cholesterol LDL < 100 100 – 129 > 130

Cholesterol HDL > 45 35 – 45 < 35

Trigliserida < 150 150 – 199 > 200
IMT (kg/m2) 18.5 – 22.9 23 – 25 > 25
Tekanan Darah < 130/80 130-140/80-90 > 140/90
 glycated hemoglobin (hemoglobin A1c, HbA1c, A1C, or
Hb1c; sometimes also HbA1c) is a form of hemoglobin
that is measured primarily to identify the average plasma
glucose concentration over prolonged periods of time
 It is formed in a non-enzymatic glycation pathway by
hemoglobin's exposure to plasma glucose
 Normal levels of glucose produce a normal amount of
glycated hemoglobin.
 The 2010 American Diabetes Association Standards of
Medical Care in Diabetes added the A1c ≥ 48 mmol/mol
(≥6.5%) as another criterion for the diagnosis of diabetes
 higher amounts of glycated hemoglobin, indicating poorer
control of blood glucose levels
 PERKENI 2010 < 7
 IDF (International Diabetes Federation ) < 6,5
 AACE (American Association Clinical
Endocrinologist) < 6,5
 EASD (Europian Association for the Study of
Diabetes) < 7
 ADA (American Diabetic Association) < 7
 HbA1c goal Individual targeted HbA1c

•Short duration of diabetes

•Long life expectancy
6,5 – 7%
•No significant CVD
•Major focus on primary prevention of complications
•Reduced risk for microvascular complication
Justification •Reduced risk for macrovascular complication in the long
run
•History of hypoglycemia
•Limited life expectancy
7,0 – 8%
•Advanced microvascular or macrovascular complications
•Extensive co-morbid conditions

Diabetes Care 2010;33(Suppl 1):S11-S61

  Nopember 1986 sampai Nopember 2008
 27.965 pasien yang diterapi intensif dari terapi oral
mono sampai kombinasi terapi dan 20.005 pasien yang
merubah kombinasi terapi sampai insulin

Currie et al. Lancet 2010;375(9713):481–9

 Adjusted hazard ratios for all-cause mortality by HbA1c deciles in people given
oral combination and insulin-based therapies

Metformin plus sulphonylureas Insulin-based regimens

Currie et al. Lancet 2010;375(9713):481–9

 Epidemiological evidence from the general population
suggests that cardiovascular risk starts to increase
above a blood pressure of 115/75 mmHg and then it
doubles for every 20 mmHg rise in systolic pressure,
and for every 10 mmHg rise in diastolic blood pressure
 Current guidelines and position statements show a
remarkable consistency in setting a target blood
pressure level at 130/80 mm Hg
 recent data support the use of ACE inhibitors or ARBs
as first-line anti-hypertensive agents in patients with
dysglycaemia
 LDL goal in high-risk T2D patient is <1.8
mmol/L,
 all T2D <2.5 mmol/L and T1D >30%
reduction
 Statin therapy is the basis, fibrates do not
improve the prognosis.
 Aspirin should be used with care, paying
attention to the risk of bleeding, and not
used on every T2D patient.
 PERHITUNGAN BERAT BADAN
RUMUS BROCCA IMT

BB IDEAL (Bbi) 90% X (TB-100) KG BB(KG)/TB2(M2)

BB NORMAL BBI +/- 10 % 18,5-22,5

KURUS < BBI – 10% < 18,5

GEMUK > BBI + 10 % > 23

kondisi Penambahan energi

Bb lebih 10 %

Bb gemuk 20 %

Bb kuran 30 %

Stres metabolik 10-30%

Hamil trimester i dan ii 300 kalori

Hamil trimester III 500 kalori

Physical Activity

z To control diabetes the

recommendation is to increase
physical activity, preferably every
day for 20-60 minutes.
z < 20 min : no effect
z > 60 min : prone to injury
and disease attack
z MHR (Maximum Heart Rate)  220 –
Age

z THR (Target Heart Rate)  60 – 70 %

MHR (80%)
 Diabetes is a progressive disease that must be treated
in order to avoid long-term complications
 Good glycemic control according to PERKENI is
- HbA1c < 6,5%
- FPG < 130 mgr%
- PPG < 140 mgr%
 Patient treatment need to be individualized according
to the characteristics of each particular patient