4 penggunaan insulin pada pasien rawat jalan

8/18/2019 4 Penggunaan Insulin Pada Pasien Rawat Jalan

1/53

Insulin for outpatient setting


2/53

Presentation Point of View

1. Rationality of Insulin Therapy for Type 2 DM

2. What is Analogue Insulin?

3. How & strategy of Insulin treatent ?!. "arrier of using insulin

#. Ta$e Hoe Message


3/53

Diabetic

retinopathy

%eaing 'ause

of (linness

in wor$ing)age

aults1

Diabetic

nephropathy

%eaing 'ause of

en)stage renal isease2

Cardiovascular disease

Stroke

1.2) to 1.*)folin'rease in stro$e3

Diabetic

neuropathy

%eaing 'ause of

non)trauati' lower

e+treity aputations#

,#- ia(eti' patients

ie fro / e0ents!

Type 2 Diabetes is NOT a Mild

Disease

1

Fong DS, et al. Diabetes Care 2!"e 2# $Suppl% 1&'S(()S12%

2

Molitch M*, et al. Diabetes Care 2!" 2# $Suppl% 1&'S(+)S(%!-annel ./, et al % Am Heart J 1((" 12'#02)#0#% +ray 3 4 5udkin 6S% 7n Textbook of Diabetes 1((0%8May9ield 6:, et al. Diabetes Care 2!" 2# $Suppl% 1&'S0)S0(%

Microvascular Macrovascular

Diabetic Foot

*rectile Dys9unctionThe ;ost secretive

Co;plication o9 DM


4/53

7ncidence ates o9 M7 and Microvascular

*ndpoints by Mean


5/53

Disappointing Outco;es 9ro; ecent Ma=or

Trials o9 7ntensive lycae;ic Control

&a

C7& vs% control

Macro@vascular

Micro@vascular

Mortality

:CCODb

)1%1 )1 $@ 22 to +& N 22 $1 to +#&

:DA:NC*c )% )# $)# to 1#& )1+ $)! to )2!& 0 $)# to 10&

aAverage diference between intensive and conventional glycaemic interventions at stu

bAction to Control Cardiovascular Risk in Diabetes Study;cAction in Diabetes and Vascular Disease:Pretera and Diamicron !odi"ed Release Controlled #valuation. $R: not re%orted.

ACC&RD study. $ #ngl ' !ed. ())*; +,*: (,-,,/; ADVA$C# study. $ #ngl ' !ed.

7ntensive B $:1c #%!@#%+>& vs% Standard B $:1c 0%+>&

$7ntensive B :1c #%8> vs% Standard B :1c 0%!>&

/ene9icial *99ect' in ess Disease Duration $:CCOD&, ithout Macrovascular Disease

$:DA:NC*&%


6/53

oal Aalues 9or lycae;ia in

Ma=or uidelines

7DF :sia@3aci9ic$28&

7DF global$28&

:D:B*:SD $2&

) E0%>

3las;aglucose

F3 +%+)#%1 ;;olB$)11 ;gBd&

Non@9asting glucose+%+)% ;;olB

$)1+8 ;gBd&

E#% ;;olB $11 ;gBd&pre@break9ast orevening ;eal

F3 !%()0%2 ;;olB$0)1! ;gBd&

3eak 33 E1% ;;olB$1 ;gBd&

2P3: 4asting %lasma glucose 5%re%randial ca%illary glucose6PP3: %ost%randial %lasma glucose

AsianPaci"c 7y%e ( Diabetes Policy 3rou% ()),; 8nternational Diabetes 2ederation ()),;American Diabetes Association. Diabetes Care. ())*;+9 5Su%%l 96:S9(S,-;

$atan D! et al. Diabetologia. ())*;,9:*99.


7/53

-riteria 3engendalian DM

/aik Sedang /uruk

lukosa Darah 3uasa $;gBd& @1( 11@128 12#

lukosa Darah 2 =a; 33 $;gBd& @1++ 1+8@10( 1

:1c $>& E#,8 #,8@ -olesterol Total $;gBd& E2 2@2!( 2+

-olesterol D $;gBd& E1 1@12( 1!

-olesterol


8/53

egacy *99ect o9 *arlier lucose Control

After median 8.5 years posttrial follo!"p

:ggregate *ndpoint 1((0 20

:ny diabetes related endpoint ###$ 12> (>

P$ %2( %+

Microvascular disease ###$ 28> 2+>

P: %(( %1

Myocardial in9arction RRR: 1#> 18>

P: %82 %1+

:ll@cause ;ortality RRR: #> 1!>

P: %++ %0

### % #elati&e #isk #ed"'tion( P % )o* #ank

G-3DS % N *ng 6 Med% 2" !8(


9/53

Therapy 9or lycae;ia at 8 5ears

-

2-

!-

-

*-

1-

ConventionalHH 7ntensiveH

riginal ranoisation

4 r o p o r t i o n o

f p a t i e n t s

Diet alone

ral onotherapy

o(ine oral

ral 5 insulin

"asal insulin

"asal 5 solu(le

,,-

G-3DS % N *ng 6 Med% 2" !8(

6Co;bination OralIB7nsulin #+ >

66Co;bination Oral IB7nsulin +# >


10/53

3engelolaan


11/53

Strategy to 3revent the Deterioration

o9 Type 2 Diabetes

5ears 9ro; Diagnosis

ebovit?


12/53

7nsulin


13/53

O:D '8egagalan se$uner sesuah (e(erapa

tahun

AD&P7: Kahn SE et al. N Engl J Med 2006;355:2427-43.

8.0

7.6

7.2

6.8

6.4

6.0

0

0 2 3 4 5

7ime 5ears67ime 5ears6

< b A

< b A 9 c 9 c

! "

#

! "

#

$osiglita%one&etfor'in(l)*en+la'i,e

AD&P7AD&P7

studystudy


14/53

(ears fro) rando)isation

20

40

*0

0

+ r

e , ! i r i n " a d d i t i o n a l

i n s ! l i n

&%lor'ro'a)ide

"li'iide

a/in"ins!lin

ef!sin"ins!lin

1 2 4 53 *

15 152 12* 121143 11*15 150 13 132 12 123

n!)er of'atients6ear

7ri"%t et al. Diabetes Care. 2002;25:330-3*.

O: :*NT F:7G* 7N

G-3DS

O


15/53

1#

:DO3T T7:

Cu;ulative 7ncidence o9 Monotherapy

JFailureK

-ahn' N*6M% 2#" !88'2+20@ +!


16/53

1

7nsulin Gse in the Gnited States e;ains o

Despite 3oor lyce;ic Control

8oer"er J et al. Diabetes Care. 200;31:1- *.

9ral a"ents ins!lin

Ins!lin onl6iet onl6 9ral a"ents


17/53

Choosing 7nsulin 9or your 3atientL


18/53


19/53

Saat diagnosis'

aya hidup

I

Met9or;in

aya hidup I

Met9or;in I

7nsulin basal

aya hidup I

Met9or;in I

Sul9onilurea

aya hidup I

Met9or;in I

7nsulin intensi9

aya hidup I

Met9or;in I

3ioglita?on

aya hidup I

Met9or;in I

3@1 agonis

aya hidup I

Met9or;in I

3ioglita?on I

sul9onilurea

aya hidup I

Met9or;in I

/asal insulin

+ell &alidated

'ore t,erapies

)ess !ell

&alidated 'ore

t,erapies

Tahap 1 Tahap 2 Tahap !

9athan DM et al: Diabetes Care 32;1


20/53


1. Rationality of Insulin Therapy for Type 2 DM

2. What is Analogue Insulin?

3. How & >trategy of Insulin Treatent!. "arrier of using insulin

#. Ta$e Hoe Message


21/53

>earah 4er$e(angan

insulin

1


22/53

-ele;ahan


23/53

-ele;ahan


24/53

Str!&t!ral esi"n 8!)an Ins!lin

Thr

Glu

Lys

ValPhe

Asn

Glu

Leu

Gln

Tyr

LeuSerCysIleSerCys

Cys

Gln

Glu

Val

Ile

Gly

Tyr

CysAsn

Lys

ThrTyr

Phe Phe

ArgGly

GluGly

Cys

Val

Leu

Tyr

Leu

Ala

Val

Leu

His

SerGly

Cys

Asn Gln LeuHis=9

A(9

A9

=(/

C14 fatt y acid chain

(M yristic acid )

Thr

4ro

:sp

>evemir 58nsulin Detemir6$ovoRa%id 58nsulin As%art6

Pro


25/53

MakanMakan

3agi3agiMakanMakan

SiangSiangMakanMakan

Mala;Mala;Sebelu; tidurSebelu; tidur

eve;ireve;ir

NovoapidNovoapid

7nsulin endogen7nsulin endogen

@@@@@@@@

@@@@@@@@

Pro"l 8nsulin Analog sangat miri% dengan 8nsulin #ndogen

NovoMiNovoMi


26/53

Efektivitas :Superior mengendalikan ! " jam pp

Superior mengendalikan ! puasaSuperior mengendalikan H#$%c

&eamanan 'isiko Hipoglikemi le#ih minimal

leksi#ilitas aktu pen*untikan le#ih fleksi#el

(tidak menunggu +, menit)

Profil far)a/o/ineti/ analo" 6an" lei% )iri' ins!lin

ala)i# se%in""a )en"%asil/an : =fe/ti@itas# ea)anandan le!ibilit" lei% ai/ diandin" %!)an Ins!lin

Analo" @s 8!)an Ins!lin


27/53

Dose to Dose $1'1&Sebelu;nya :ctrapid # unit ! sehari Novoapid # unit ! sehari

Mitard 1+ unit ;ala; dan 1# unit siang NovoMi 1+ unit ;ala; dan 1# unit siang

7nsulatard 1+ unit ;ala; eve;ir 1+ unit ;ala;

Pasien s!da% )en""!na/an 8!)anIns!lin


28/53

3resentation 3oint o9 Aie

1. Rationality of Insulin Therapy for Type 2

DM

2. What is Analogue Insulin?3. How & >trategy of Insulin Treatent ?

!. "arrier of using insulin

#. Ta$e Hoe Message


29/53


30/53

lyce;ic Control' eco;;ended goals

.. (lo*al gui,eline for t)pe 2 ,ia*etes +lini+al gui,elines tasfor+e !russels: I/12005#(lo*al gui,eline for t)pe 2 ,ia*etes +lini+al gui,elines tasfor+e !russels: I/12005#

2.2. athan /&athan /& et al. Diabetologiaet al. Diabetologia 2006;4:7-2.2006;4:7-2.

3.3. http:.aa+e.+o'pu*o,i'ple'entationroa,'ap.p,f http:.aa+e.+o'pu*o,i'ple'entationroa,'ap.p,f

Measure;ent Nor;al 7DF1 :D:B*:SD2 ::C*! 3*-*N7

:1cH C- C.#- C,- C.#- C.#-

Fasting luc C1 C11


31/53

Insulin 'an (e initiate anytie

8nade?uate8nade?uate>i4estyle>i4estyle

@@9 &AD9 &AD

@ ( &AD @@

+ &AD+ &AD

8nitiate 8nsulin

ts of nor'al gl)+e'i+ status1

insulin +an *e initiate, earlier1 as soon as is re?uire,.

7ndication; 3er;anent Not per;anentT1DM Infe'tion

AD failure 4regnan'y

AD ontra Ini'ation Hospitalie

Dia(eti' 8etoa'iosis 4erioperati0e


32/53

Strategy o9

7nsulin Treat;ent L


33/53

1%79 Fasting / is ele0ate: start for (asal insulinwith long a'ting insulin %e0eirB

2. If 3randial / is ele0ate: start for pranial@(olus insulin with rapi a'ting insulin9o0oRapiB

3. If Fasting and 3ost 3randial are ele0ate ;

) ral agent with (asal insulin ) prei+ insulin 9o0oMi+B ) (asal@(olus as in ultiple aily ine'tion MDIB


34/53

Treatent "ase on Type of Hypergly'eia

=asal=asalPrandialPrandial

Prandial 8nsulin

5$ovoRa%id6

=asal 8nsulin 5>evemir6

7reat 4asting y%erglyc. "rst

Continue oral agent

S!=3 is im%ortant

C&$C#P7=ASA> PRA$D8A> C&$C#P7

Entu$ enFsipleF$an terapi guna$an 9o0oMi+

3- ; 4ranial Insulin & ,- ; "asal InsulinB


35/53


36/53

Strate"ies for initiation Cintensifi&ation of ins!lin t%era'6 in'atients wit% t6'e 2 diaetes )ellit!s

Basal oncedail* start-

.remi/ oncedail* start-

0ncreasingneed tocover ..!isease

progression

Basal #olus

therap*(1 .randial

0nsulin)

0ntensification

.remi/ t2ice3dail*

Basal #olus

therap*(1 .randial

0nsulin)

0ntensification

.remi/ three3times dail*

-continue 2ith appropriate 4$!


37/53

eco;;endation


38/53

GFi the Fasting First

>tart with (asal insulin


39/53

Saat diagnosis'

aya hidup

I

Met9or;in

aya hidup I

Met9or;in I

7nsulin basal

aya hidup I

Met9or;in I

Sul9onilurea

aya hidup I

Met9or;in I

7nsulin intensi9

aya hidup I

Met9or;in I

3ioglita?on

aya hidup I

Met9or;in I

3@1 agonis

aya hidup I

Met9or;in I

3ioglita?on I

sul9onilurea

aya hidup I

Met9or;in I

/asal insulin

+ell &alidated

'ore t,erapies

)ess !ell

&alidated 'ore

t,erapies

Tahap 1 Tahap 2 Tahap !

9athan DM et al: Diabetes Care 32;1


40/53

hoose the insulin (asal

analogue as a starter


41/53


42/53

9evemir sekali sebelum tidur.


43/53

Time of day (hours)

400

300

200

100

0

06.00 06.0010.00 14.00 18.00 22.00 02.00

P l a s m a g l u c o s e

( m g / d l )

NormalMeal Meal Meal

20

1

10

0

Plasma

glucos

e(mmol

/l)

Suntikkan 9) iu >evemir sekali sebelum tidur.Atur dosisnya 5@+ atau +6 setia% + ari sd.

3DP menca%ai target 3DP *)99) mgd>5Perkeni ())06

!y"erglycaemia due #o a$ i$crease i$ fas#i$g glucose

T2%M

Fi$ t%e Fastin" First

4rofile T2DM

D4: en'apai target


44/53

:9ter 9asting glucose has

been controlled, then hatLCek 33, i9 it is high goes to

/asal ) /olus or sitch to3re;i


45/53

MakanMakan

3agi3agiMakanMakan



eve;ireve;ir

NovoapidNovoapid

7nsulin endogen7nsulin endogen

@@@@@@@@

@@@@@@@@

Regimen =asal =olus

*7M*N /:S:@/OGS

-elebihan '

1% Sangat ideal, dapat ;enghasilkan terapi yang

;enyerupai pro9il insulin endogen

2% Sangat ;udah ;engatur dosis insulin basal ;aupunbolusnya

-ele;ahannya '

1% 3asien tidak ;enyukainya karena + suntik

2% 3asien harus ;enggunakan 2 =enis insulin $berisiko

pasien salah suntik& dan biaya terapi lebih ;ahal

Suntikkan 9) iu >evemir sekali sebelum tidur.7ambakan 8neksi $ovoRa%id di setia% makan


46/53

Time of day (hours)

400

300

200

100

0

06.00 06.0010.00 14.00 18.00 22.00 02.00

P l a s m a g l u c o s e

( m g / d l )

NormalMeal Meal Meal

20

1

10

0

Plasma

glucos

e(mmol

/l)

Atur dosisnya 5@+ atau +6 setia% + ari sd.3DP menca%ai target 3DP *)99) mgd>

5Perkeni ())06

!y"erglycaemia due #o a$ i$crease i$ fas#i$g glucose

T2%M

7ambakan 8neksi $ovoRa%id di setia% makan5(0 iu6 untuk mengendalikan 3ula dara ( am

PP menca%ai target E 9*) mgd> 5Perkeni())06

Basal G Bol!s Don&e't den"anEe@e)ir -


47/53

MakanMakan

3agi3agiMakanMakan



7nsulin endogen7nsulin endogen @@@@@@@@

Regimen Premi

NovoMi 2 sehari $;ulai ! iu&NovoMi 2 sehari $;ulai ! iu&

NovoMi 1 sehari $;ulai 12 iu&NovoMi 1 sehari $;ulai 12 iu&

NovoMi ! sehari $;ulai ! iu&NovoMi ! sehari $;ulai ! iu&

*7M*N 3*M7

-elebihan '

7 Sangat disukai pasien karena cukup ;enggunakan 1

=enis insulin dan 1 =enis pen $Data Diabcare 2, pada

12( pasien 7ndonesia ;enun=ukkan pre;i palingbanyak digunakan&

-ele;ahannya '

7 3engaturan dosis kurang 9leksibel


48/53



DM

2. What is Analogue Insulin?3. How & >trategy of Insulin treatent ?


#. Ta$e Hoe Message


49/53

Ken,ala ,ala' terapi Insulin

DrugDrug

addiction Laddiction L

*pensive P*pensive P8t urts8t urts

FF

8 donGt want8 donGt want

it.Fit.F


50/53


9.HSekali mulai tera%i insulinI tidak bisa di stop lagi J !@ersepsi )ang salah1 seperti Ae+an,uanB o*at #

= erian insulin ,engan Aper+o*aanB Canga pen,e :“Cobalah suntik insulin selama 1 bulan saja, lalu kita evaluasilagi”

(.H Suntik insulin sangat merepotkanJ

! @asien 'erasa ti,a sanggup sunti sen,iri#

< /e'onstrasian epa,a pasien *etapa simple n)a suntian

insulin< erian insulin D hari untu 'engurangi eti,an)a'anan

@olons) F1 Ga+son $. Clinical Diabetes 2004;22:47-50.


51/53

+. H+. HKegagalan terapi adalah kesalahan sayaKegagalan terapi adalah kesalahan sayaJJ !suntian insulin se*agai!suntian insulin se*agai huu'anhuu'an arenaarena egagalan pri*a,iegagalan pri*a,i66

Jelaskan baha insulin dipe!lukan ka!ena Jelaskan baha insulin dipe!lukan ka!ena pe!jalanan pen"akit DM pe!jalanan pen"akit DM "g "g p!og!esi#, p!og!esi#, bukan ka!ena kegagalan pasienbukan ka!ena kegagalan pasien mengelola pen"akitn"a$mengelola pen"akitn"a$

4.4. HHFamili saya disuntik insulin sebelum diamputasiFamili saya disuntik insulin sebelum diamputasi

kakinyakakinyaJJ !Insulin ,i*erian *ila!Insulin ,i*erian *ila /ia*etes su,ah *erat/ia*etes su,ah *erat##

Jelaskan baha suatu saat insulin dipe!lukan ka!ena Jelaskan baha suatu saat insulin dipe!lukan ka!ena pe!jalanan pe!jalananalamiah pen"akit DMalamiah pen"akit DM "g p!og!esi# "g p!og!esi#

,.,. HH Saya tidak berani suntik insulin sendiri, karenaSaya tidak berani suntik insulin sendiri, karena

nyeri nyeri ....!! ”” !!nDietasnDietas terha,ap sunti insulin#terha,ap sunti insulin#

%ho patient that insulin injection is%ho patient that insulin injection is less painful than BGless painful than BGmonitoringmonitoring ith a glucose mete! ith a glucose mete!

@olons) F1 Ga+son $.@olons) F1 Ga+son $.

Clinical DiabetesClinical Diabetes

2004;22:47-50.2004;22:47-50.



52/53



DM

2. What is Analogue Insulin?3. How & >trategy of Insulin treatent ?


#. Ta$e Hoe Message


53/53

=ae Fo'e &essages

. /& tipe 2 a,alah pen)ait roni )ang %rogresi4

2.2. = =erapierapi /& Hperlu/& Hperlu HHtimingtimingJ yg te%atJ yg te%at untu 'en+apai targetuntu 'en+apai target

3.3. ila target *elu' ter+apai1 harus 'eningat eila target *elu' ter+apai1 harus 'eningat e langahlangah *eriutn)a*eriutn)a

4.4. =erapi Insulin sering ,iperluan untu 'en+apai target glie'i =erapi Insulin sering ,iperluan untu 'en+apai target glie'i

5.5. =itrasi ,osis =itrasi ,osis insulininsulin ,ilauan sesuai algorit'e,ilauan sesuai algorit'e !!perluperlu S&(# sehingga risioS&(# sehingga risio

hipoglie'ia ,apat ,iteanhipoglie'ia ,apat ,itean0. #dukasi sangat penting se*elu' sela'a terapi insulin

7. &ulailah ,engan 'engen,alian gula ,arah puasa1

Setelah (/@ 'en+apai target !80-0 'g,# sela'a 3 *ulan na'un F*+ 'asihtinggi1 segeralah 'ena'*ahan pen)untian *olus !terapi *asal-*olus# atau'engganti terapi ,engan pre'iD insulin !untu perti'*angan )ang le*ih si'pel

untu pasien#

Setelah 3 *ulan 'enggunaan pre'iD 2 D sehari ti,a Cuga 'en+apai target F*+segeralah 'eningatan pre'iD 'enCa,i 3 D sehari atau 'enggunaan terapiasal-olus &/I

4 penggunaan insulin pada pasien rawat jalan

Documents