Achmad Rudijanto

Divisi Endokrin Metabolik Departemen Ilmu Penyakit Dalam Fakultas Kedokteran Universitas Brawijaya RSUD dr. Saiful Anwar Malang 2010

Diabetes is an increasing healthcare epidemic throughout the world

Global projections for the number of people with diabetes
(2079 age group), 20072025 (millions)

Africa Eastern Mediterranean and Middle East Europe North America South and Central America South-East Asia Western Pacific

28.3 40.5 +43%

53.2 64.1 +21%

24.5 44.5 +81% 10.4 18.7 +80%

67.0 99.4 +48% 46.5 80.3 +73% Riskesdas, 2008: Riskesdas, - Prevalence 5.7% - Pre DM 11.0%

16.2 32.7 +102%

IDF. Diabetes Atlas 3rd Edition 2006

Worldwide: 246 million people in 2007 380 million projected for 2025 55% increase

Prediabetes

Pasien terdiagnosis Pasien terdiagnosis DM DM

RISDKESDAS, 2007
Diagnosed DM = 1,5% Diagnosed DM = 1,5% Undiagnosed DM = 4,2% Undiagnosed DM = 4,2% Total DM = 5,7% Total DM = 5,7% GTG = 10,2 % GTG = 10,2 % Pasien DM belum Pasien DM belum terdiagnosis terdiagnosis

List of countries with the highest numbers of estimated List of countries with the highest numbers of estimated cases of diabetes for 2000 and 2030 cases of diabetes for 2000 and 2030
2000 People with Diabetes (millions)
31.7 20.8 17.7 8.4 6.8 5.2 4.6 4.6 4.3 3.2

2030 People with Diabetes (millions)

79.4 42.3 30.3 21.3 13.9 11.3 11.1 8.9 7.8 6.7

Ranking Country
1 2 3 4 5 6 7 8 9 10 India China U.S. Indonesia Japan Asian Russian Federation Brazil Italy Bangladesh

Country
India China U.S. Indonesia Pakistan Brazil Bangladesh Japan Philippines Egypt

Sarah Wild. Diabetes Care 27, 2004

Kriteria Diagnosis Hiperglikemi

TIPE 2 DIABETES PADA SAAT DIAGNOSIS

20% RETINOPATI 9% NEUROPATI Teriagnosed tipe2 2 diabetes ~ 23 juta Tak Terdiagnosis tipe 2 diabetes ~ 7 juta TH2030 8% NEFROPATI

UP TO 50% PENYAKIT JANTUNG / PEMB. DARAH

GTG ~ 70 juta

Wild S. Diabetes Care 29, 2006

KOMPLIKASI AKUT
HIPERGLKEMIA HIPOGLIKEMIA Kaki DM Gagal ginjal dll
Diabetic Ketoacidosis Hyperglycemic Hyperosmoler State

KOMPLIKASI KRONIK

PROBLEMA KAKI DIABETES

Setiap 30 detik, terdapat kehilangan satu kaki akibat diabetes diseluruh dunia. 70% amputasi kaki diseluruh dunia disebabkan oleh diabetes. Sebagian besar amputasi dimulai oleh adanya ulkus kaki. Berita baik: sekitar 85% amputasi akibat ulkus diabetes dapat dicegah.

Patomekanisme kaki diabetes

Kelainan pembuluh darah

Kerusakan syaraf

PROBLEMA KAKI DIABETES

Risk Factors for Ulceration

Local Issuues:
Peripheral neuropathy Peripheral neuropathy Structural foot deformity Structural foot deformity Trauma and improperly fitted shoes Trauma and improperly fitted shoes Callus Callus History of prior ulcer/amputation History of prior ulcer/amputation Prolonged elevated pressure Prolonged elevated pressure Limited joint mobility Limited joint mobility

General or Systemic Contributions:

Uncontrolled hyperglycemia Uncontrolled hyperglycemia Duration of diabetes Duration of diabetes Peripheral vascular disease Peripheral vascular disease Blindness or visual loss Blindness or visual loss Chronic renal disease Chronic renal disease Older age Older age

DIABETIC FOOT RISK STRATIFICATION AND TRIAGE

ACTIVE
Presence of active ulceration, spreading infection, critical Definition ischemia, gangrene or unexplained hot, red, swollen foot with or without the presence of pain
Rapid referral to and management by a member of a Multidisciplinary Foot ACTION Team. Agreed and tailored management/treatment plan according to patient needs. Provide written and verbal education with emergency contact number. Referral for specialist intervention when required Annual assessment by specialist podatrist. Agreed and tailored management / treatment plan by specialist podatrist according to patient needs. Provide written and verbal education with emergency contact numbers. Referral fro specialist intervention if/when requred

HIGH

Previous ulceration or amputation or more than one risk factor present e.g. loss of Definition sensation or sign of peripheral vascular disease with callus or deformity

ACTION

MODERATE

One risk factor present e.g. loss of sensation or signs of Definition peripheral vascular disease without callus or deformity

ACTION

Annual assessment by podatrist. Agreed and tailored management/ treatment plan by podatrist according to patient needs. Provide written and verbal education with emergency contact members

LOW

No risk factors present e.g. no loss of sensation, no sign Definition of peripheral vascular disease and no other risk factors

ACTION

Annual screening by a suitably trained Health Care Professional Agreed self management plan. Provide written and verbal education with emergency contact numbers. Appropriate access to podatrist when required

These risk categories relate to the use of the SCI-DC foot risk startification tool

PENCEGAHAN PRIMER
Tujuan Utama: mengidentifikasi risikp terjadinya ulkus kaki Skor Risiko
3

Karakteristik
Ada neropati Terjadu ulkus sebelumnya Ada penyakit pembuluh darah tepi Ada neropati Tanpa adanya ulkus sebelumnya Ada deformitas Ada neropati Tanpa adany ulkus sebelumnya Tanpa deformitas Tanpa neropati Tanpa adanya ulkus sebelumnay Tanpa deformitas

RISIKO AMPUTASI

Apakah kita telah benar dalam mengklasifikasi risiko terjadinya ulkus kaki diabetes?

Apa manfaat pencegahan?

Keuntungan untuk masa mendatang:
Penurunan terjadinya ulkus kaki sampai 50-70% Penurunan nagka kejadian amputasi Penurunan biaya kesehatan dan sosial Perbaikan kualitas hidup terkait derajat kesehatan

Pencegahan Primer Kaki Diabetic : dimulai dengan pengobatan DM

Menejemen Diabetes

Kontrol glukosa:
Diet/life style Latihan Obat oral/insulin

Penyakit penyerta:
Dislipidemia Hipertentsi Obesita CHD Problem Nutrisi

Komplikasi penyerta:
Retinopati CVD Nefropati Neuropati Infeksi Komplikasi yg lain

Harrison, 2005

diabetes mellitus treatment

1. Diet 3. BW control 4. Drugs / Insulin

2. Excersice 5. Routine control

Bersama terasa ringan

Pemeriksaan kaki secara berkala

Gunakan alas kaki yang benar

Pemeriksaan pembuluh darah dan syaraf

Ankle-Brachial Index (ABI)

- Noncompressible - Normal - Bordeline (equivocal) - Mild-to-moderate peripherral arterial disease - Severe peripheral arterial disease

Right ABI

Higher right ankle pressure Higher arm pressure

Leftt ABI

Higher left ankle pressure Higher arm pressure

Doppler Ultrasonography

Pencegahan Primer

PENCEGAHAN PRIMER
Tujuan Utama: mengidentifikasi risiko terjadinya ulkus kaki Skor Risiko
3

Karakteristik
Ada neropati Terjadu ulkus sebelumnya Ada penyakit pembuluh darah tepi Ada neropati Tanpa adanya ulkus sebelumnya Ada deformitas Ada neropati Tanpa adany ulkus sebelumnya Tanpa deformitas Tanpa neropati Tanpa adanya ulkus sebelumnya Tanpa deformitas

RISIKO AMPUTASI

PENCEGAHAN PRIMER
Tujuan Utama: mengidentifikasi risiko terjadinya ulkus kaki Skor Risiko
3

Karakteristik
Ada neropati Terjadu ulkus sebelumnya Ada penyakit pembuluh darah tepi Ada neropati Tanpa adanya ulkus sebelumnya Ada deformitas Ada neropati Tanpa adany ulkus sebelumnya Tanpa deformitas Tanpa neropati Tanpa adanya ulkus sebelumnya Tanpa deformitas

RISIKO AMPUTASI

Bila telah terjadi ulkus, apa yang harus dilakukan?

Pencegahan sekunder: Pemeriksaan harian sekunder:

Sol sepatu

Angka kejadian ulang ulkus kaki diabetes

DIABETES DAY

World Diabetes Day 14 November

Indonesian Diabetes Day 12 July

Shift in care approach

Provider oriented

patients provider provider provider provider

Patient oriented

provider

Patients as provider for himself

Menghadapi hal baru Menyangkal kenyataan Timbul marah Tidak siaptidak tahu apa yang harus dilakukan Merasa tidak aman Takut kehilangan Merasa tidak berguna Putus asa

Did we prepare?

Empowering

Ringkasan
Prevalensi diabetes semakin tinggi Sering disertai komplikasi a.l kaki diabetes Kaki diabetes penyebab utama amputasi Dimulai dengan timbulnya ulkus 85% amputasi dapat dicegah Perhatian dan perawatan harian merupakan kunci utama pencegahan

esia IA do n A D In S A k u P ER k u i sa A ub Ak