Manajemen Diabetes Mellitus Slide Lama Upload

DM

1. Slide 1
Early Detection and Standardized Diabetes
Management
Lecture:
30 minutes

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 2

3. 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)
HbA1c
Average amount of glucose in the bloodstreams over a 3-month
period

4. 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

5. 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

6. Slide 6
Type 2 diabetes is a progressive disease
Lebovitz. Diabetes Reviews 1999;7:139–53 (data are from the UKPDS population: UKPDS 16.
Diabetes 1995;44:1249–58)
HOMA: homeostasis model assessment

7. Slide 7
Diabetes – elevated blood glucose due to
insufficient insulin secretion
Normal glucose and insulin
excursions
Early Type 2 Diabetes Glucose
and insulin excursions
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Glucose Insulin
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Glucose Insulin

8. Slide 8
The Importance of treating Type 2 Diabetes
Type 2 diabetes is a progressive disease
Adapted from Type 2 Diabetes BASICS. International Diabetes Center 2000
Diagnosis
Insulin
Glucose
Prediabetes
(IFG/IGT)
NGT Diabetes
Macrovascular changes
Microvascular changes
Inadequate
β-cell function
Postprandial glucose
Fasting glucose
Insulin resistance
Insulin secretion

9. Slide 9
Classical Diabetes Symptoms
Polyuria
Unexplained weight
loss
Polydipsia
Polyphagia
•Excessive Urination at night
•Excessive Hunger
•Excessive Thirst
•Weight Loss even if food in-
take is normal

10. Slide 10
Other Diabetes Symptoms
Blurred Vision
Numbness and/or
Tingling
Fatigue
Itchy Skin
Impotence
•Damaging blood vessels in the eyes
•Numbness and tingling in hands, legs
and feet
•Frequent fatigue regardless of
exercise
•affects legs, feet, and hands
•Physical and Physiological

11. Slide 11
4 Simple Steps from Screening to Diagnosis
Conduct 1
st
Blood Test
2
Conduct 2
nd
Blood Test
(if required) and
establish Diagnosis
3
Screen patients with
diabetes risk factors
1
Inform Patient and
Initiate treatment
4

12. Slide 12
Step 1: Risk Factors – PERKENI screening risk
factor guideline
Unmodifiable Risk Modifiable Risk
Diabetes Associated
Risk
•Race and Ethnic
•Family History of
Diabetes
•History of Gestational
Diabetes
•History of delivery a
baby more than
4.000g
•History of low birth
weight <2.500g
•Overweight (BMI >23)
•Hypertension >
140/90 mmHg
•Dyslipidemia (HDL <
35 mg/dl and/or
triglycerides >250
mg/dl
•Unhealthy Diet
•Limited Physical
Activity
•Polycystic Ovary
Syndrome (PCOS) or
another clinical
condition related to
insulin resistance
•Metabolic Syndrome
(IGT, IFG, History of
Coronary Artery
Disease , stroke
and/or PAD)
Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

13. Slide 13
Step 2: Conduct 1
st
Blood Test
Clinical Test
(+) Classic
Symptoms
(-) Classical
Symptoms
FBG
RBG
≥126
≥200
<126
<200
FBG
RBG
≥126
≥200
<100
<140
100-125
140-199
Diabetes Mellitus IGT IFG Normal
Repeat FBG or RBG
2 Hour Post loading
Plasma Glucose
Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2
Included in the
Binder
or or

14. Slide 14
Step 3: Conduct 2
nd
Blood Test (if required) and
Establish Diagnosis
Clinical Test
(+) Classic
Symptoms
(-) Classical
Symptoms
FBG
RBG
≥126
≥200
<126
<200
FBG
RBG
≥126
≥200
<100
<140
100-125
140-199
Diabetes Mellitus IGT IFG Normal
Repeat FBG or RBG
2 Hour Post loading
Plasma Glucose
≥126
≥200
<126
<200
PPG ≥200 140-199 <140
Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2
Included in the
Binder
or or

15. Slide 15
Step 4: Inform Patient and Initiate Treatment
Diabetes Mellitus IGT IFG
•Evaluation of Nutritional Status
•Evaluation of Diabetes
Complications
•Evaluation of Required Food
Regulation
•Decision on medicines
•Education
•Food Regulation
•Physical Exercise
•Ideal Body Weight
•OADs are unnecessary at this
stage
Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

16. Slide 16
Cut-points: Diabetes, IGT and IFG
mg/dL
2-hour Plasma
Glucose (PPG)
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(
F
P
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)
mg/dL
140 200
100
126
NGT (Normal
Glucose
Tolerance)
Diabetes
IFG (Impaired
Fasting Glucose
IGT (Impaired
Glucose
Tolerance)
Diabetes

17. 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
2. Classical symptoms of Diabetes (+) & Fasting Plasma
Glucose ≥ 126 mg/dl.
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
Or
Or

18. Slide 18
Updated PERKENI Type 2 Diabetes Treatment
Algorithm
Diabetes STEP 1 STEP 2 STEP 3
Healthy life style Healthy life style
+
Mono therapy
Healthy life style
+
2 OAD Combination
Healthy life style
+
Combination 2 OAD
+
Basal insulin
Insulin
Intensification*
*Intensive Insulin: use of basal insulin together with insulin prandial
Healthy life style
+
3 OAD Combination
Alternative option, if :
• No insulin is available
• The patient is objecting insulin
• Blood glucose is still not optimally
controlled
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)

19. 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
FPG
<130 mg/dL
HbA
1c
< 7.0%
PPG
<180 mg/dL
FPG
<110 mg/dl
HbA
1c
< 6.5%
PPG
<145 mg/dL
IDF
2
ADA
1
PERKENI
3
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 .
FPG
<100 mg/dl
HbA
1c
< 7%
PPG
<140 mg/dl

20. HbA1c correlation with blood glucose level
Slide 20
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
The relationship between A1C and eAG is described by the formula 28.7 X
A1C – 46.7 = eAG

21. Slide 21
Risk of Complications increases as Hb1Ac
increases and that’s why diabetes must be treated
Stratton IM et al. BMJ 2000;321:405–12
0
20
40
60
80
5 6 7 8 9 10 11
Myocardial infarction
Microvascular disease
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.
I
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12697 154 183 212 240 269
Mean HbA1c (%)
Mean mg/dl

22. Slide 22
The benefits of good blood glucose control are
clear
Good control is
≤ 7.0% HbA
1c
HbA
1c measures
the average
blood glucose
level over the
last three
months
Source:UKPDS = United Kingdom Prospective Diabetes Study. Stratton IM
et al. BMJ. 2000;321(7258):405-412.
Deaths related
to diabetes
Microvascular
complications
Myocardial
infarction
-14%
-37%
-21%
HbA
1c
-1%

23. Slide 23
Practical Monitoring Scheme
Source:Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009

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

25. Slide 25
Individualized Treatment based on several criteria
to control blood glucose
Inzucci SE, et al. Diabetologia. 2012

26. Early Detection and Standardized Diabetes Management
Lecture
Main Learning Points
• Understand the importance of treating
diabetes and reaching individual targets
to avoid complications
• Understand the process from
screening to diagnosis and the
associated national guidelines
• Understand the reason and need for
routine follow-up and intensify
treatment on diabetes via blood
glucose- and HbA1c monitoring
Summary
• Diabetes is a progressive disease that
must be treated in order to avoid long-
term complications
• Good glycemic control according to
PERKENI is:
• HbA1c <7%
• FPG: <100 mg/dl
• PPG: <140 mg/dl
• Patient treatment need to be
individualized according to the
characteristics of each particular
patients
Slide 26