diagnosis manajemen dm tipe 2 dr bowo pdf
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dm tipe 2TRANSCRIPT
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CV: dr. R Bowo Pramono SpPD KEMD Lahir TEGAL 27-jan 1959 Istri: dr. Astuti SpS, 2 putri Dokter Umum: FK UGM 17-01-1985 SPPD : FK UGM 24-11-1997 KEMD : 14-05-2008Pekerjaan: 1987-2002 PKM Kedung Waringin Bekasi 1999-2004 RSU Selong Lombok Timur 2004-2010 RS DR Sardjito/FK UGM 2006-2013 Sekretaris Bagian Penyakit Dalam FK UGM 2007-2011 Sekretaris PAPDI Cabang Yogyakarta
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DIAGNOSIS & MANAJEMEN DM TIPE 2
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DIAGNOSIS:
DIAGNOSED FASTINGBG/mg%
POSTPRANDIALBG/mg%
RANDOMBG/mg%
NODIABETES
80 -
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Prinsip Dasar Terapi Diabetes Mellitus
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PENGATURAN MAKAN
2
LATIHANJASMANI
OBAT HIPOGLIKEMIK
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3
PENYULUHAN
CANGKOK PANKREAS
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Correlation between HbA1c level and mean plasma glucosa levels on multiple testing
over 2-3 months
HbA1c Mean plasma glucose (mg/dL)
6 135
7 170
8 205
9 240
10 275
11 310
12 345
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1%
Hasil dari UKPDS: Kontrol yang baik pada DM T2 mampu menurunkan resiko
komplikasi
Kematiankarenadiabetes
Infarkmiokard
Komplikasimikrovaskuler
Gangguanpembuluhdarahperifer
21%
14%
37%
43%
Menurunkanresiko*Penurunan1%HbA1c
*p
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PRINSIP PENGOBATAN DIETKebutuhan kalori sesuai : kelamin, umur , berat badan, aktifitas fisik, pekerjaan, kehamilan, menyusui, komplikasi
3 kali makan utama dan 3 kali makan kecil
Jumlah dan waktu makan harus tepat
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JADWAL MAKAN DIABETES
Komposisi diet: 60-70 % hidrat arang 20-25 % lemak 10-15 % protein
6.30 9.30 12.00 15.00 19.00 21.00
20% 10% 25% 10% 25% 10%
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PRINSIP OLAHRAGA PADA DIABETES
Pilih olahraga yang disenangi
Melibatkan otot-otot besarFrekuensi : Teratur 3-5 kali perminggu
Intensitas : Ringan sampai sedang
Durasi : 30 60 menit / 5 X30 menit /minggu
Tipe : Aerobik (jalan, joging, ber sepeda)
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Program Latihan Teratur (3-4 kali seminggu) 20- 40 menit didahului
pemanasan 5-10 mnt dan cool-down 10 mnt
CRIPE:Continous
RythmisInterval
ProgresifEndurance
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Treatment options for type 2 diabetes
Sulfonylureas 1st generation e.g. chlorpropamide,
tolbutamide 2nd generation e.g. glyburide,
gliclazide, glipizide, gliquidone 3rd generation e.g. glimepiride Modified release
Glinides/meglitinides Non-sulfonylureic e.g. repaglinide Amino acid derivatives e.g. nateglinide
Biguanides e.g. metformin
Thiazolidinediones e.g. rosiglitazone, pioglitazone
-glucosidase inhibitors e.g. acarbose
Insulin regular intermediate/long acting pre-mixed analogs
rapid acting long acting
Fixed-dose oral antidiabetic drug combinations e.g. glyburide/metformin,
glipizide/metformin, rosiglitazone/metformin
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MetforminHow it works Decreases hepatic glucose output
Lowers fasting glycemiaExpected HbA1creduction
~ 1.5%
Adverse events GI side effects Lactic acidosis (quite rare)
Weight effects Weight stability or modest weight loss
CV effects Unconfirmed beneficial effect demonstrated in UKPDS
Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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SulfonylureasHow they work Enhance insulin secretion
Expected HbA1creduction
~ 1.5%
Adverse events Hypoglycemia (but severe episodes are infrequent)
Weight effects ~ 2 kg weight gain common when therapy initiated
CV effects UGDP suggested potential cause of increased CVD mortality; not substantiated by UKPDS
Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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INCREASED INSULIN SECRETIONSulfonylurea Length of
actionBegins ofaction
Daily dose(mg)
Route of excretion
Glibenclamide 16 24h 2 4h 1,25 15 R = 50%, B = 50%
Gliclazide 10 24h 2 4h 40 320 R = 70%, B = 30%
Glipizide 6 24h 2 4h 2,5 40 R = 80%, B =20%
Chlorpramide 24 72h 2 4h 100 500 Renal
Tolbutamide 6 10h 2 4h 100 1000 Renal
Glimepiride 24h 2 4h 1 - 6 R = 40%, B =60%
gliquidon 18 - 24h 2 - 4h 30 - 120 R = 5%, B = 95%
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GlinidesHow they work Stimulate insulin secretion (but
differently from sulfonylureas)Expected HbA1creduction
~ 1.5% (repaglinide)
Adverse events Hypoglycemia (may be less frequent than some sulfonylureas)
Weight effects ~ 2 kg weight gain common when therapy initiated
CV effects None mentioned in ADA recommendations
Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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Dipeptidyl Peptidase IV InhibitorsHow they work Inhibit degradation of endogenous
GLP-1
Expected HbA1creduction
~0.8%
Adverse events MinimalWeight effects Neutral
CV effects Unknown
Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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-Glucosidase InhibitorsHow they work rate of digestion of polysaccharides in
proximal small intestine (primarily lowering PPG levels without causing hypoglycemia)
Expected HbA1creduction
0.50.8%
Adverse events Increased gas production GI symptoms
Weight effects Weight neutralCV effects Unconfirmed report of reduction of
severe outcomes in one clinical trial
Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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Thiazolidinediones
How they work Increase sensitivity of muscle, fat, and liver to endogenous and exogenous insulin
Expected HbA1creduction
0.51.4%
Adverse events Weight gain and fluid retention
Weight effects Increase in subcutaneous adiposity Redistribution from visceral deposits
CV effects New / worsened CHF or peripheral edema (due to fluid retention)
Reduction in some secondary CV endpoints demonstrated in PROactive study
Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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Glucagon-like Peptide 1 Agonist(exenatide)
How it works Stimulates insulin secretion
Expected HbA1creduction
0.51%
Adverse events GI side effects (nausea, vomiting, diarrhea)
Weight effects Weight loss of ~ 23 kg over 6 months (may be result of GI effects)
CV effects None mentioned in ADA recommendations
Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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Dipeptidyl Peptidase IV InhibitorsHow they work Inhibit degradation of endogenous
GLP-1
Expected HbA1creduction
~0.8%
Adverse events MinimalWeight effects Neutral
CV effects Unknown
Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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Amylin Agonists (pramlintide)How it works Synthetic amylin analogue that inhibits
glucagon production in a glucose-dependant fashion
Expected HbA1creduction
0.50.7%
Adverse events GI effects (nausea)
Weight effects Weight loss ~ 11.5 kg over 6 months (may be due to GI effects)
CV effects None mentioned in ADA recommendations
Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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InsulinHow it works Direct compensation for lack of
insulin sensitivityExpected HbA1creduction
1.52.5%
Adverse events Hypoglycemia
Weight effects Weight gain of ~ 24 kgCV effects Beneficial effect on TG and HDL
Weight gain may have an adverse effect on CV risks
Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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Indikasi terapi Insulin: DM tipe 1 DM tipe 2 yang tidak terkontrol diet, olah raga,
OHO. DM gestasional Gangguan faal hati & ginjal yang berat. Dengan infeksi akut (selulitis, gangren), TBC
berat, penyakit kritis (stroke/AMI) Dengan KAD/HHS Dengan fraktur atau pembedahan mayor Kurus (BB rendah), terkait malnutrisi (DMTM) Dengan penyakit Graves Dengan tumor ganas Dengan pemberian kortikosteroid
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Years From Diagnosis
T2 DMphase I
T2 DMphase II
Stages of Type 2 Diabetes
Lebovitz, 2000
T2 DM phase III
-12 -10 -6 -2 0 2 6 10 14
100
75
50
25
0
Beta CellFunction
(%)IGT Postpandrial
Hiperglycemi T-2 DM phase IBeta Cell function
50 %
25
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Summary: Expected HbA1c ReductionIntervention Expected in HbA1cInsulin 1.5 to 2.5%Metformin 1.5%Sulfonylureas 1.5%Glinides 1 to 1.5%a
TZDs 0.5 to 1.4%-Glucosidase inhibitors 0.5 to 0.8%GLP-1 agonist 0.5 to 1.0%Pramlintide 0.5 to 1.0%DPP-IV inhibitors ~0.8%
a Repaglinide is more effective than nateglinide Adapted from Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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Factors that May Affect ComplianceWeight Gain
GI Side Effects
2-3x Daily Dosing
Insulin intermediate/long XInsulin short/rapid X XMetformin X XSulfonylurea XGlinides X XTZDs X-Glucosidase inhibitors X XGLP-1 agonist X XPramlintide X XDPP-IV inhibitors
Adapted from Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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Which second-line therapy?HbA1C Pros Cons
SU 1.5 Large clinical database, inexpensive Weight gain and hypoglycaemia
TZD 0.51.4 No hypoglycaemia, some benefits on lipids
Oedema, heart failure, weight gain, expensive
Insulin 1.53+ Large clinical database, most effective Hypoglycaemia, weight gain, need for SMBG
AGI 0.50.8 No hypoglycaemia, weight neutral GI side-effects, expensiveGLP-1 analogue 0.51.0 No hypoglycaemia, weight loss GI side-effects, expensive, injectedMeglitinide 1.01.5 Fewer hypos than sulfonylurea TID dosing, expensive
SU: sulfonylurea; TZD: thiazolidinedione; AGI: -glucosidase inhibitor SMBG: self monitoring of blood glucose
ADA/EASD. Diabetes Care 2006; 29: 1963-1972, Diabetologia 2006; 49: 1711-21
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Years From Diagnosis
T2 DMphase I
T2 DMphase II
Stages of Type 2 Diabetes
Lebovitz, 2000
T2 DM phase III
-12 -10 -6 -2 0 2 6 10 14
100
75
50
25
0
Beta CellFunction
(%)IGT Postpandrial
Hiperglycemi T-2 DM phase IBeta Cell function
50 %
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Effectiveness of Type 2 Diabetes Therapy
Diet & Exercise 1%
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Klasifikasi InsulinKelas Mulai efek Puncak Lama Aksi pendekActrapid, Humulin R
15-30 mnt 2-4jam 6-8jamCampuran (premixed)Humulin 30/70,Mixtard 30/70
60 mnt 1-8jam 14-15 jamAksi sedangHumulin N, Insulatard
2-4jam 1-8jam 14-15 jam
Aksi panjangLantus , Levemir
Tanpa Puncak 24 jam
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What are the reasons for the shortcomings of insulin?
Subcutaneoustissue
Mol/l
Diffusion
Capillarymembrane
103 104 105 108
AdaptedfromBrangeJetal.DiabetesCare 1990;13:923
Dissociation in subcutaneous tissue
That has to dissolve in SC fluids and dissociate into monomers..
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Klasifikasi Insulin yang baruKelas Mulai efek Puncak Lama Aksi cepat (analog)Lyspro (Humalog)Aspart (Novo Rapid)Apiora
5-15 mnt 2 jam 4-6jam
Campuran (premixed)Humalog Mix 25/75Novomix 30/70
5-15mnt 2-4jam 12-14 jam
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LOKASI PENYUNTIKKAN
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Insulin Regimen Evolution
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Pemakaian semprit dan jarum memungkinkan Anda untuk mengatur dosis dan membuat formulasi campuran insulin. Keterbatasannya adalah membutuhkan ketrampilan yang cukup untuk menarik dosis insulin dengan tepat.
Cara menyuntik insulin
Insulin > Cara pemberian insulin > Semprit dan jarum
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Dahulu:Agar tidak salah dosis,kemasan insulin40U/ml atau 100U/mldisesuaikan denganskala pada spuit,bisa 40 atau 100
Sekarang: ?Tidak tersedia lagi
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NovoPen
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Sistem NovoLet
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INSULIN ANALOG: 1.NovoRapid2.NovoMix3.Levemir
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Summary: Expected HbA1c ReductionIntervention Expected in HbA1cInsulin 1.5 to 2.5%Metformin 1.5%Sulfonylureas 1.5%Glinides 1 to 1.5%a
TZDs 0.5 to 1.4%-Glucosidase inhibitors 0.5 to 0.8%GLP-1 agonist 0.5 to 1.0%Pramlintide 0.5 to 1.0%DPP-IV inhibitors ~0.8%
a Repaglinide is more effective than nateglinide Adapted from Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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Factors that May Affect ComplianceWeight Gain
GI Side Effects
2-3x Daily Dosing
Insulin intermediate/long XInsulin short/rapid X XMetformin X XSulfonylurea XGlinides X XTZDs X-Glucosidase inhibitors X XGLP-1 agonist X XPramlintide X XDPP-IV inhibitors
Adapted from Nathan DM et al. Diabetes Care 2006;29(8):1963-72.
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ADA/EASD consensus algorithm
At diagnosis:Lifestyle + Metformin
Lifestyle + Metformin+ Basal insulin
Lifestyle + Metformin+ Sulfonylurea
Lifestyle + Metformin+ Intensive insulin
Tier 1:well-validated therapies
STEP 1 STEP 2 STEP 3
Call to action if HbA1c is 7%
Tier 2:Less well validated therapies
Lifestyle + Metformin+ PioglitazoneNo hypoglycaemiaOedema/CHFBone loss
Lifestyle + Metformin+ Pioglitazone+ Sulfonylurea
Lifestyle + metformin+ Basal insulin
Lifestyle + metformin+ GLP-1 agonistNo hypoglycaemiaWeight lossNausea/vomiting
Nathan DM, et al. Diabetes Care 2009;32 193-203.
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DM tipe 1
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1980
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1980 2009
CV: dr. R Bowo Pramono SpPD KEMD DIAGNOSIS & MANAJEMEN DM TIPE 2Slide Number 3Slide Number 4Slide Number 5Correlation between HbA1c level and mean plasma glucosa levels on multiple testing over 2-3 monthsHasil dari UKPDS: Kontrol yang baik pada DM T2 mampu menurunkan resiko komplikasiPRINSIP PENGOBATAN DIET JADWAL MAKAN DIABETESPRINSIP OLAHRAGA PADA DIABETESSlide Number 11Treatment options for type 2 diabetesMetforminSulfonylureasINCREASED INSULIN SECRETIONGlinidesDipeptidyl Peptidase IV Inhibitors-Glucosidase InhibitorsThiazolidinedionesGlucagon-like Peptide 1 Agonist (exenatide)Dipeptidyl Peptidase IV InhibitorsAmylin Agonists (pramlintide)InsulinIndikasi terapi Insulin:Slide Number 25Summary: Expected HbA1c ReductionFactors that May Affect ComplianceWhich second-line therapy?Slide Number 29Effectiveness of Type 2 Diabetes TherapyKlasifikasi InsulinWhat are the reasons for the shortcomings of insulin?Klasifikasi Insulin yang baruLOKASI PENYUNTIKKANInsulin Regimen EvolutionSlide Number 36Slide Number 37Slide Number 38NovoPen Sistem NovoLetSlide Number 41Slide Number 42Slide Number 43Slide Number 44Slide Number 45Summary: Expected HbA1c ReductionFactors that May Affect ComplianceADA/EASD consensus algorithmSlide Number 49Slide Number 50Slide Number 51