diabetes melitus
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DIABETES MELLITUS
DIABETES MELITUS
Current issue perkembangan diabetes melitus
Konsep medik diabetes melitusPenatalaksanaan dan
Pencegahan diabetes melitus
Diabetes Melitus
Definisi :Suatu sindrom yang ditandai dengan adanya hiperglikemi kronis serta terganggunya metabolisme karbohidrat, lemak dan protein yang berkaitan dengan kurangnya jumlah atau kerja dari insulin secara relatif maupun absolut
Ref. : Peter H. Bennett; Definition, Diagnosis, and Classification of Diabetes Mellitus and Impaired Glucose Tolerance; Joslin’s Diabetes Mellitus; 13th ed.; 1994; hal. 193
DIABETES MELITUS
PENYAKIT MENAHUN TIDAK BISA DISEMBUHKAN
DIKENDALIKAN TIDAK BERGEJALA PENGOBATAN
DILALAIKAN TIDAK TERKENDALI KOMPLIKASI
AKUT DAN MENAHUN KEMATIAN
World View• 177 million worldwide• 4th leading cause of death by disease• India 33 million people with diabetes• China 23 million people with diabetes• Population of diabetes will double to triple
by 2025 • One out of every three Americans born
today will develop diabetes
Time magazine December 2003; CDC
BERAPA BANYAK DIABETISI?
Tergantung ras, umur, keturunan, pola hidup
Negara berkembang meledak, dibanding negara maju
Indonesia; rata-rata 4-5% 6 % Makassar 42 pengunjung26 DM
dengan hanya gula darah puasa.
150
221
300
100
150
200
250
300
350
Wo
rld
wid
e d
iab
etes
pre
vale
nc
e (
mill
ion
s)
2000 2010 2025
The worldwide pandemic oftype 2 diabetes
International Diabetes Federation Diabetes Atlas 2000; Amos et al. Diabet Med 1997;14 (Suppl 5):S1-S85.
U.S. Diabetes Prevalence Diabetes kills 1
American every 3 minutes New case diagnosed
every 40 seconds More deaths than AIDS
and breast cancer combined
Average life expectancy: 15 years less than non-diabetes population
18 Million
Two Worlds: Developed and Developing
0
50
100
150
200
250
300
350
developed developing world
1995 2000 2025
King H et al. Diabetes Care.1998; 21: 1414-1431
Estimatednumber of diabetics(millions)
120
80
40
0
2000
2025
120
80
40
0
2000
2025
DEVELOPED COUNTRIES
DEVELOPING COUNTRIES
Age Group (years)
20-44 45-64 >65
Mil
lio
ns
Mil
lio
ns
Number of people with IGT and diabetes in Indonesia (20-70 y age group)
IDF - Diabetes Atlas, 3rd Edition 2006
0
5
10
15
20
25
2007 2025
Diabetes
I G T
2.888
5.129
million
14.144
20.597
+ 77.6 %
rank no. 4 worldwide
rank no. 3 worldwide
+ 45.6 %
DM tipe 2: A silent killer
30% dari penduduk DMT2 tidak terdiagnosis
50% pasien baru diagnosis DMT2 sudah menderita komplikasi
65-80% pasien DMT2 meninggal o/k PKV
2-4X pasien DMT2 untuk mendapat PJK dan 2 X stroke
National Institute of Diabetes and Digestive and Kidney Diseases. http://diabetes.niddk.nih.gov/dm/pubs/statistics/index.htm#7 [Accessed 1 December 2005]Wingard DL et al. Diabetes Care 1993;16:1022-5
1995 1996 19991997 1998 2000 20022001
Year
0
5
10
20
15
25
30
Crude one-year mortality 1995 to 2002 in patients with and without diabetes
Mortality improvement was seen in both groups but a fatal outcome remained higher among patients with diabetes.
Diabetic
Non-diabetic
Norhammar A. Heart Jan, 2007
N = 70.88221%(14.873)had diabetes
• Overeating• Inactivity• Smoking• Diabetogenic drugs
• Pregnancy• Endocrine diseases• Diabetogenic drugs• Malnutrition in utero
Unknown Unknown
B- cell defectsInsulin resistance
Genetic factorsGenetic factors
Glucose toxicity
Hyperglycaemia
Worsening B-cell functions• ? Amyloid deposition• Malnutrition in utero
Impaired glucose tolerance
NIDDM
Environmental factorsEnvironmental factors
PatogenesisDM Tipe 2
Aksi / KerjaInsulin
Defisiensi Insulin
Hiperglikemi
DeFronzo RA.Diabetes.37:667,1988Saltiel J.Diabetes.45:1661-1669,1996Robertson RP.Diabetes.43:1085,1994Tokuyama Y. Diabetes 44:1447,1995
DiabetesMelitus
hypoX-jsk-7-99
IGT Postprandial Hyperglycemia Type 2
DiabetesPhase 1 Type 2
DiabetesPhase 2
Type 2DiabetesPhase 3
- 12 - 10 - 6 - 2 0 2 6 10 14Years from diagnosis
Bet
a ce
ll fu
nctio
n (%
)Stages of type 2 Diabetes in relationship to Stages of type 2 Diabetes in relationship to
--cell functioncell function
25
0
50
75
100
b-celldysfunction
(Expert Committee on the Diagnosis and Classification of Diabetes mellitus 2002)
Diabetes MellitusDiabetes Mellitus
IRIR Insulinresistance
Genetic susceptibility,obesity, Western
lifestyle
Type 2 diabetesMacrovascular
complication
Microvascular
complication
Diagnosis Diabetes melitus
Diagnosis DM
Hb A1C >6,5% Gula darah puasa > 126 mg/dL Gula darah 2 jam postprandial setelah
beban glukosa 75 gr >200 mg/dL Gula darah sewaktu disertai gejala klinis
khas >200mg/dL
ADA 2010
Diagnosis Pre Diabetes
Pemeriksaan gula darah puasa 100-125 mg/dL Glukosa Darah Puasa Terganggu (GDPT)
Pemeriksaan gula darah 2 jam post prandial pada TTGO 140-199 mg/dl Toleransi Glukosa Terganggu (TGT)
Risk factors for type 2 diabetes
• Umur >45 tahun• Obese• inaktifitas fisik• ibu/bapa diabetes• Sebelumnya sudah TGT atau GDPT• Pernah diabetes waktu hami (DM Gestasi) atau melahirkan bayi >4kg• Hipertensi (> 140/90 mm Hg)• HDL cholesterol < 35 mg/dl and/or trigliseride level > 250 mg/dl• Polycystic ovary syndrome• Hystory of vascular disease________________________________________________________* May not be correct for all ethnic groups.
Diabetes care 2002;25 suppl1: S22
Diabetes care 2004;27:S12
Classification of Diabetes Mellitus
Type 1 diabetes Immune-mediated Idiopathic
Type 2 diabetes Gestational
Diabetes Mellitus (GDM)
Other Specific Types Genetic defects/syndromes Diseases of the exocrine
pancreas Endocrinopathies Drug-induced Infections Uncommon immune-
mediated
Manifestasi klinis
3 P (Poliuri, Polifagi, Polidipsi) BB turun Gatal-gatal Lesu, loyo Kesemutan Impotensi Luka sukarsembuh
Tujuan pengobatan DM tipe 2:
Menekan/mengurangi gejala klinik hiperglikemia
Mencegah onset / progresivitas komplikasi vaskuler diabetik dengan kontrol metabolik jangka lama
Charbonnel V Therapeutique des Entretitiens1997;187-192
Targets for Glycemic Control
* Treatment goals and strategies must be tailored to the patient, with consideration given to individual risk factorsTo achieve an A1C 7.0%, patients should aim for
FPG, preprandial and postprandial PG targets
Target A1C (%)
FPG/preprandial (mg/dl)
2h-postprandial
(mg/dl)
Target for most patients
<7 80 - 130 100 - 180
Normal range (if it can be safely achieved)
< 6.0 80 – 110 100 - 140
DIABETISI
PENYAKIT JANTUNG KORONER
GAGAL GINJAL
KEBUTAAN
STROKE
LUKA KAKI
TBC PARU
KENDALIKAN GULA DARAH
LEMAK DARAH
ROKOK
HIPERTENSI
OLAHRAGA
BERAT BADAN
DIET
TABLET
INSULIN
PERIORITAS PENGOBATAN
Kendalikan glukosa darah
Kendalikan sindroma metabolik: Obesitas,dislipidemia,hipertensi, intoleransi glukosa, hiperinsulinemia
Gangguan mikrovaskul
er
Gangguan makrovaskul
er
OBAT OBAT ANTI DIABETES
Tablet: Kerja pendek:3 kali perhari: Novonorm, Starlix, Glucobay, Glucophage
Kerja sedang 2 kali perhari Glibenklamid, Daonil,Gluronerm
Kerja lama 1 kali perhari Glucotrol XL, Diamicron MR
Suntik insulin: Kerja pendek : Actrapid, Humulin R, novorapid, apidra
Kerja sedang : Insulitard, Humulin N, Kerja lama Lantus,levemir
Kombinasi humalo mix, novomix
Mikroangiopati diabetik
Makroangiopati diabetik
Koma diabetik
Koma hiperglikemik
Koma hipoglikemik
Major clinical manifestations of atherothrombosis
Adapted from: Drouet L. Cerebrovasc Dis 2002; 13(suppl 1): 1–6.
Transient ischemic attack
Angina:• Stable• Unstable
Ischemicstroke
Myocardial infarction
Peripheral arterialdisease:• Intermittent claudication• Rest Pain• Gangrene• Necrosis
Hiperglikemia
Glycation
Osmotic Effect
Oxidants Cytokines
AGES
Polyol Pathway
Tissue damage
Endothelial Cell Dysfunction
Chronic Complication (Atherosclerosis,etc)
DAG-PKC Pathway
DAG = Diacyl glycerol PKC = Proteinkinase
PENCEGAHAN DM
Pencegahan primerPencegahan sekunderPencegahan tertiair
Pencegahan Primer Pola hidup olahraga, diet, stress
Exersice intensif mengurangi DM Obat-obat : glucobay, metformin,
pioglitazone. Obat penurun berat badan
Pencegahan sekunder
Edukasi Diet Olahraga Obat anti diabetes ( oral atau insulin) Kontrol teratur
Normal
prediabetes
Diabetes
TGT, GDPT
Hiperglikemia
Komplikasi
Kronis Akut
P. Primer
P.Sekunder
P.Tertier
Koma diabetik Jantung, kaki, otak, mata, ginjal
Sulaemana Mosquue Istambul
St Sophia- Istambul