komplikasi deabetes mellitus
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komplikasi DM, dapat berupa stroke, penyakit jantung, dan penyakit pembuluh darah. - PowerPoint PPT PresentationTRANSCRIPT
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KOMPLIKASI DM
Tatag Primiawan
Bagian/SMF Penyakit DalamFK UGM/RS Dr Sardjito Yogyakarta
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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 PostpandrialHiperglycemi T-2 DM phase I
Beta Cell function 50 %
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Komplikasi Diabetes
Komplikasi akut
Komplikasi kronis mikroangiopathy
makroangiopathy
hipoglikemi
Keto-asidosis diabetik Koma hiperglikemi hiperosmoler non-ketotik
hiperglikemi
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Diabetic Retinopathy
Leading causeof blindnessin adults1,2
Diabetic Nephropathy
Leading cause of end-stage renal disease3,4
CardiovascularDisease
Stroke2- to 4-fold increase in cardiovascular mortality and stroke5
DiabeticNeuropathy
8/10 individuals with diabetes die from CV events6
1UK Prospective Diabetes Study Group. Diabetes Res 1990; 13:1–11. 2Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 3The Hypertension in Diabetes Study Group. J Hypertens 1993; 11:309–317. 4Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98. 5Kannel WB, et al. Am Heart J 1990; 120:672–676.
6Gray RP & Yudkin JS. Cardiovascular disease in diabetes mellitus. In Textbook of Diabetes 2nd Edition, 1997. Blackwell Sciences. 7King’s Fund. Counting the cost. The real impact of non-insulin dependent diabetes. London: British Diabetic Association, 1996. 8Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
Peripheral Arterial Disease
Microangiopathy Macroangiopathy
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Retinopathy
It’s recommended to perform a routine-retinal check up each year
Diabetic retinopathy – haemorhage – ablasio - blindness
Methods: Direct opthalmoscope Indirect opthalmoscope Retinal photography
Early referral
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Nephropathy Start : microalbuminuria - macroalbuminuria - ↓renal filtration rate - renal failure
Early detection of microalbuminuria is required, referring experienced physician
If GFR<30
consult to the nephrologists
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Coronary Heart DiseaseMore cautious especially to those who have historical CHD, family history.
Stress test and rest ECG
Consult to cardiologist
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Targets for treatment of Type 2 diabetes
< 7%< 7%
HbA1cHbA1c
< 7%< 7%
HbA1cHbA1c
< 7%< 7%
HbA1cHbA1c
< 7%< 7%
HbA1cHbA1c Blood pressure <130/80 mmHg
LDL cholesterol <100 mg/dL
HDL cholesterol >50 mg/dL F
>40mg/dL M
Triglycerides <150 mg/dL
STOP smoking!
30 minutes daily exercise
Diet advise
<6.0%?
<6.0%?
HbA1cHbA1c
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Peripheral Vascular Disease
Need for patient’s counseling
Need to examine:1. Deformation of foot and leg
2. Neuropathy
3. Decrease of foot’s blood flow
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Tekanan atau beban kaki berlebih
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Pemeriksaan kelainan syaraf
Mono filamenSemmes Weinstein 10 gramDeteksi adanya neuropati
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Deteksi dini Kelainan pembuluh darah kaki
1. Meraba denyut pembuluh darah pada
punggung kaki2. Pemeriksaan dengan alat
doppler
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Chronic complication’s treatment and management
Glycemic controlBlood pressure controlLipid controlOthers: healthy lifestyle and diet schedulingSome distinctive methods:
Retinopathy with photo coagulation Nephropathy with dialysis: hemodialysis or peritonial CHD with stent installment Peripheral vascular disease with metabolic and
infection control, foot rest Neuropathy symptomatis
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HYPOGLYCEMIA
• Hypoglycemia : blood glucose < 50 mg/dl
• Clinically, it is defined by Whipple triad :
1.Low plasma glucose level
2.Symptoms consistent with hypoglycemia
3.Resolution of symptoms with correction of plasma glucose
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Symptoms
Adrenergic symptoms (catecholamine mediated) : diaphoresis palpitations pallor tachycardia apprehension anxiety sensation of hunger headache weakness restlessness
Neuroglycopenic symptoms : reduced intellectual capacity irritability confusion abnormal behavior convulsion coma
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Management of hypoglycemia:• Mild hypoglycemia:
Oral glucose 15-20 g : 10-15 min then check blood glucose. If glucose level does not increase ≥18 mg/dl, give oral glucose again
• Severe hypoglycemia:Solution 50 ml of dextrose 50% given intravenously, check blood glucose in 20 min. If it is still hypoglycemia administrate once again
• Glucagon 1.0 mg s.c/i.m/i.v. Adverse effects include nausea, vomiting and headache. Contraindicated to sulfonylureas-induced hypoglycemia. Ineffective in patient who is anorectic, or with protracted hypoglycemia
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Ada pertanyaan ?
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Insulin • Terbuat dari ekstrak pankreas babi atau sapi• Sekarang sudah dapat dibuat dari bakteri E. coli
yang ditanami gen insulin (human/ recombimant) banyak beredar di Indonesia
• Jarang timbul hipersensitif (human)• Pankreas orang dewasa menghasilkan 40-50
unit/hari.• Kadar insulin waktu puasa 10 µUnit/ml (0,4
ng/ml atau 69 pmol/L)
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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 Grave’s• Dengan tumor ganas• Dengan pemberian kortikosteroid
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Adapted from DeFronzo RA. Med Clin N Am 2004; 88:787–835.
Prevention Treatment–10 10+ YearsDiagnosis
Macrovascular complications
Microvascular complications
0
IFG/IGT Type 2 diabetes
Blood glucose
b-cell function
Insulin resistance
Type 2 diabetes is a progressive disease
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Klasifikasi Human Insulin
Kelas Mulai efek Puncak Lama Aksi pendekActrapid, Humulin R
15-30 mnt 2-4jam 6-8jam
Campuran (premixed)Mixtard 30/70, Humulin 30/70
60 mnt 1-8jam 14-15 jam
Aksi sedangHumulin NInsulatard (NPH)
2-4jam 1-8jam 14-15 jam
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Short acting
NPH insulin suspension – intermediate acting
ZN insulin suspension – intermediate acting
Sudah tidak diproduksi
Premix insulin 30/70 - biphasic
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Insulin Analog (Generasi Baru)
• Modifikasi dengan mengubah, mengganti atau menambah asam amino ke dalam struktur Insulin
• Lispro, Aspart, Gluycine: absorbsi cepat dan durasi kerja lebih singkat dibanding reguler insulin
• Glargin dan Detemir: absorbsi lambat dan durasi kerja lebih panjang
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Insulin Generasi Baru
26Rosskamp RH et al, Diabetes Care 22 (Suppl. 2) 1999; B109-B113
Rantai ARantai B
Asparagine pada A-21 human insulin diganti dengan glycine
Sesudah B-30, 2 arginine ditambahkan pada B-31 dan B-32
• Insulin glargine (HOE 901)• Analog human insulin kerja panjang (24 jam) • Diproduksi dengan teknologi
rDNA
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What are the reasons for the shortcomings of insulin?
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Subcutaneoustissue
Mol/l
Diffusion
Capillary membrane
10-3 10-4 10-5 10-8
Adapted from Brange J et al. Diabetes Care 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 baru
Kelas Mulai efek Puncak Lama Aksi cepat (analog)Lyspro (Humalog)Aspart (Novo Rapid)Gluysine (Apidra)
5-15 mnt 2 jam 4-6jam
Campuran (premixed)Humalog 25/75Novomix 30/70
5-15mnt 2-4jam 12-14 jam
Aksi PanjangLantusLevemir TANPA Puncak 24 jam
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Insulin Profiles – Schematic (duration)
0 2 4 8 10 12 14 16 18 20 22 24
Pla
sma In
sulin
Levels
Hours
NPH (12–16 hr)
Regular (6–8 hr)
Glargine (~24 hr)
Aspart, Lispro, Gluisyne (4–5 hr)
Ultralente (~16–20 hr )
Levemir
6
(~24 hr)
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Cara Menyimpan Insulin• Harus disimpan dalam lemari es (suhu 2-8 derajat
Celcius), vial yang sudah terbuka Novo-Nordisk (9 bln)
• Insulin dalam kamar penyejuk (15-20o C) selama 1 bulan, bila suhu >30o C insulin hilang kekuatannya
• Penfil Reguler – suhu kamar 30 hari Penfil 70/30 atau NPH- suhu kamar 7 hari• Bila insulin dingin diputar-putar di telapak tangan
atau ditaruh dalam suhu kamar dahulu• Karena perbedaan suhu insulin jangan diletakkan di
mobil atau bagasi pesawat• Insulin beku atau menggumpal, berubah warna,
jernih jadi keruh jangan dipakai
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Tehnik Penyuntikan Insulin
• Tutup vial diusap dengan alkohol 70%, untuk melarutkan tidak dikocok tetapi digulingkan
• Setelah masuk pada alat suntik, periksa gelembung udara, ketuk buang gelembung
• Suntikan pada subkutan setelah desinfektan, tegak lurus (pen), sudut 45 derajat bila dengan spuit agar tidak kena muskuler
• Bila insulin campuran sendiri (bukan premixed), ambil dulu insulin reguler, kemudian insulin menengah agar tidak tercemar yang keruh
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Cara mengurangi rasa sakit
• Saat menyuntik, insulin pada suhu kamar• Alat suntik tidak ada gelembung udara• Sebelum menyuntik, tunggu alkohol
mengering• Otot tidak dalam keadaan menegang• Tusukkan kulit dengan cepat• Alat suntik jangan berubah arah pada saat
menyuntik atau dicabut• Jangan gunakan jarum suntik yang tumpul
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Tempat Penyuntikan
Ideal untuk insulin aksi pendek atau campuran pagi hari:• Perut dibawah pusarIdeal untuk insulin aksi menengah, aksi panjang atau
campuran malam hari:• Lengan atas bagian luar • Glutea • Paha atas bagian luarSebaiknya berpindah tempat untuk
mencegah insulin lipodistrofi atau jaringan sikatrik yang luas
Regio satu berpindah ke regio lain sekitar 2 minggu 33
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Tehnik dan Lokasi Suntikan
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Absorpsi insulin dipengaruhi:
• Jenis insulin (premixed, aksi panjang, aksi pendek, aksi cepat, dll)
• Cara pemberian (s.c., i.m. atau i.v.)• Lokasi (regio, ada lipoatrofi/lipohipertrofi)• Temperatur• Olah raga/latihan• Pijat• Obat vasoaktif
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Degradasi/ekskresi Insulin
• Hati 60-80%• Ginjal 10-20%Akumulasi jumlah insulin dapat terjadai
pada penurunan fungsi ekskresi hati dan ginjal dosis dikurangi
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Efek samping
• Hipoglikemia• Hipokalemia• Reaksi alergi/urtikaria (jarang pada insulin
dengan kemurnian tinggi & Human insulin• Edema perifer karena retensi natrium
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Riddle MC. Diabetes Care 1990;13:676–686.
300
200
100
0
Pla
sma
glu
cose
(m
g/d
l)
6 am 12 pm 6 pm 12 pm 6 am
Time of day
MealtimeglucosespikesFastinghyperglycemia
Normal
RELATIF CONTRIBUTION OF FPG AND PPG TO 24 HOURS BLOOD GLUCOSE CONTROL
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Dosis Insulin
• Dimulai dosis 0,3-1,5 unit/Kg BB atau 10 unit insulin basal perhari Bedtime (NPH. Glargine, Detemir)
• Dosis Insulin jangka menengah 75-80% jumlah insulin jangka pendek perhari, dapat diberikan 2 dosis pagi dan malam (dosis malam<pagi nocturnal cicardian)
• Insulin Premix analog dapat diberikan 3x/hari
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Cara Pemberian Insulin (SK)
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BARRIERS TO INSULIN THERAPY
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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 42
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OptiPen® Pro 1: alat suntik Lantus cartridge
OptiPen Pro 1 : No. Reg. : DEPKES RI AKL. 2090230093943
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NovoPen®
44
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Humapen®
45
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LABUHA
LAKUKAN
BUKAN
HANYA
ANGAN ANGAN
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BACAN
BATASI MAKAN MINUM MANIS
AKTIF OLAHRAGA GERAK BADAN
CEGAH ROKOK
AWASI TEKANAN DARAH
NO ALKOHOL, NO CHOLESTEROL
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terima kasih
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Ada pertanyaan ?
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Algorithm I.v. Insulin Infusion Therapy
BG (mg/dL) Insulin infusion dose (u/hr) Algr1 Algr2 Algr3 Algr4
< 60 = Hypoglycemia (need dextrose Tx) 60-70 0 0 0 0 70-109 0,2 0,5 1 1,5 110-119 0,5 1 2 3 120-149 1 1,5 3 5 150-179 1,5 2 4 7 180-209 2 3 5 9 210-239 2 4 6 12 240-269 3 5 8 16 270-299 3 6 10 20 300-329 4 7 12 24 330-359 4 8 14 28 >360 6 12 16 28
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Metabolic Ketoacidosis (Ketoasidosis metabolik)
Hyperglycemic Hyperosmoler State (Kondisi hiperglikemik hiperosmoler)
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Asam laktat ↑
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KRITERIA DIAGNOSIS
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1 jam I
dextran L
icu, CVP
NaCl 0,9% 500 cc + RI 50 U, 20 tts
jam II
konsentrasi maksimal
25 mEq KCl dlam 500 cc
pH<7,2 + shock
pCO2 ↓ ?
NaCl 0,45%
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