Faculty of Medicine University of Indonesia- Cipto Mangunkusumo National Referral Hospital Jakarta, Indonesia New PERKENI Guideline for Prevention and Management of Type 2 Diabetes and Its Supporting Evidence Outline of Presentation ! Epidemiology diabetes in Indonesia ! History of PERKENI Guidelines ! Results of DiabCare study ! Screening and diagnosis criteria ! Diabetes management and new drugs ! Algorithm of treatment ! Blood glucose monitoring ! Conclusion Prevalence of IGT and DM In Indonesia Known DM Undiagnosed DM Total DM IGT 1,5 % 4,2 % 5,7 % 10,2 % Indonesian National Health Survey, 2007 N = 24.400 > 15 years Provinces Prevalence of DM and TGT With Higher Than The Average of National Figure Indonesian National Health Survey, 2007 Konsensus Pengelolaan Dan Pencegahan Diabetes Melitus Tipe 2 Di Indonesia 2010 Perkumpulan Endokrinologi Indonesia What should be a guidelines ! Consensus ! Evidence based ! Reasonable ! Feasible ! Attainable ! and achievable by the patients. Who is the target of the national guidelines ! Primary care doctors ! Others health personnel History ! The Indonesian Endocrine Society (PERKENI) Guideline for Prevention and Management of Type 2 Diabetes had been written since 1993. ! Revised 4
times ! The latest update will be published at the end of 2010. Variable Data Age (Years)* (n=1719) 58.939.57 Gender** (n=1803) Male/ Female 793 (43.3) / 1010 (55.16) Age at Onset (Years)* (n=1686) 49.686.8 Duration of Diabetes (Years)* (n=1704) 8.615.97 Type of Diabetes** Type 1 Type 2 Others 17 (0.9) 1785 (97.5) 2 (0.1) BMI (Kg/m 2 ) 14 * (n=1646) <23 / !23 (%) 25.23.6 28.7 / 71.3 Duration of Treatment (Years)* (n=1817) 8.57.0 Duration of OADs (Years)* (n=1727) 8.46.8 Duration of Insulin (Years)** (n=1176) 2.83.0 Smoking (Yes)** (n=1831) 178 (9.7) Patient Demographic and Characteristics DiabCare Indonesia 2008 * Data expressed as Mean SD; ** Data expressed as n (%); Percentage are calculated out of total cohort (n=1832) except for BMI. Diabetes management variable Data, n (%) Type of Management Diet Insulin monotherapy Insulin and OAD combination OAD monotherapy Herbal None - 317 (17.3) 356 (19.4) 1133 (61.9) 5 (0.3) 20 (1.1) Type of OAD Therapy Biguanides Sulphonylureas Meglitinides Alpha Glucosidase inhibitors Thiazolidinediones Other OADs Traditional Herbal medicines Double drug fixed dose combination Triple drug fixed dose combination 1085(59.3) 1036(56.6) 8(0.4) 461(25.2) 51(2.8) 48 (2.6) 5(0.3) 88 (4.8) 5 (0.3) Diabetes Management - The DiabCare Indonesia 2008 Diabetes management variable Data, n (%) Insulin therapy (N=666) Insulin analogues Human Insulin 164 (25) 497 (74.7) Units/day, (meanSD) Once daily Twice daily More than twice daily 37.818.2 126 (18.9) 371 (55.7) 167 (25.1) Mode of insulin administration Pen Syringe Pump 631(94.7) 18(2.7) 19 (2.9) Insulin Treatment - The DiabCare Indonesia 2008 Glycemic Control In The Study Population Fasting Postprandial A1c 143.6 mg% 207.7 mg% 8.1 % DiabCare Indonesia 2008 A1c and FPG stratified according to different guidelines DiabCare Indonesia 2008 Parameter 2003 2008 Age (Yrs) 58.79.3 58.99.5 Duration of diabetes (Yrs) 9.26.6 9.27.2 Sex (M/F) % 42.9/57.1 44/56 Type 2 DM (%) 98.2 97.4 Mean BMI (kg/m2) 24.13.5 25.13.6 Mean A1c (%) 7.92.0 8.11.6 Mean FPG (mmol/l) 8.43.4 7.92.4 Mean PPG (mmol/l) 11.63.9 11.53.6 HDL-cholesterol (mmol/l) 1.30.4 1.30.8 Triglycerides (mmol/l) 2.01.1 1.70.6 Comparison of 2003 and 2008 DiabCare study List of Centre DiabCare Indonesia 2008 ! Cipto Mangunkusumo Central Hospital, Jakarta ! Fatmawati Hospital, Jakarta ! Husada Hospital, Jakarta ! Hasan Sadikin Hospital, Bandung ! Kariadi Hospital, Semarang ! Sardjito Hospital, Yogyakarta ! Moewardi Hospital, Solo ! Diabetes Clinic, Darmo Hospital, Surabaya ! Private Clinic, Surabaya Sanglah Hospital, Bali Wahidin Sudirohusodo Hospital, Makassar Kandou Hospital, Manado Moh. Husein Hospital, Palembang Adam Malik Hospital, Medan M Jamil Hospital, Padang Abdul Wahab Syahranie Hospital, Samarinda Ulin Hospital, Banjarmasin Saiful Anwar Hospital, Malang Conclusions ! Poor glycaemic control in majority of patients is a concern. ! There is a need for a large proportion of patients to be adjusted to more intensive pharmacotherapy ! and a multi-disciplinary approach for management should be adopted ! The study findings should be communicated to policymakers and physicians to help them provide proper healthcare and its facilities in Indonesia. Konsensus Pengelolaan Dan Pencegahan Diabetes Melitus Tipe 2 Di Indonesia 2010 Perkumpulan Endokrinologi Indonesia Overview ! Epidemiology diabetes in Indonesia ! History of PERKENI Guidelines ! Results of DiabCare study ! Screening and diagnosis criteria ! Diabetes management and new drugs ! Algorithm of treatment ! Blood glucose monitoring ! Conclusion Criteria for testing for diabetes in asymptomatic adult individuals 1. Testing should be considered in all adults who are overweight (BMI > 25 kg/m2*) and have additional risk factors: ! physical inactivity ! first-degree relative with diabetes ! members of a high-risk ethnic population (e.g., African American, Latino, Native ! American, Asian American, Pacific Islander) ! women who delivered a baby weighing > 9 lb or were diagnosed with GDM ! hypertension (> 140/90 mmHg or on therapy for hypertension) ! HDL cholesterol level < 35 mg/dl and/or a triglyceride level > 250 mg/dl ! women with polycystic ovary syndrome ! A1C > 5.7%, IGT, or IFG on previous testing ! other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans) ! history of CVD 2. In the absence of the above criteria, testing diabetes should begin at age 45 years 3. If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk status. *At-risk BMI may be lower in some ethnic groups. Standards of Medical Care in Diabetes2010 ADA Categories of Increased Risk for Diabetes Testing Value Fasting Plasma Glucose (FPG) 100 125 mg/dl : IFG 2-h PG in the 75-g OGTT 140-199 mg/dl : IGT A1C 5.76.4% Standards of Medical Care in Diabetes2010 ADA Criteria for the diagnosis of diabetes (ADA) 1) A1C >6.5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.* OR 2) FPG >126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.* OR 3) Two-hour plasma glucose > 200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.* OR 4) In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose > 200 mg/dl (11.1 mmol/l). *In the absence of unequivocal hyperglycemia, criteria 13 should be confirmed by repeat testing. Standards of Medical Care in Diabetes2010 ADA Recommendation of the International Expert Committee For Diagnosis Diabetes ! A1C assay is an accurate, precise measure of chronic glycemic levels and correlates well with the risk of diabetes complications. ! A1C assay has several advantages over laboratory measures of glucose. ! Diabetes should be diagnosed when A1C is 6.5%. Diagnosis should be confirmed with a repeat A1C test. Confirmation is not required in symptomatic subjects with plasma glucose levels 200 mg/dl. ! If A1C testing is not possible, previously recommended diagnostic methods (e.g., FPG or 2HPG, with confirmation) are acceptable. ! A1C testing is indicated in children in whom diabetes is suspected but the classic symptoms and a casual plasma glucose 200 mg/dl are not found. Diabetes Care 2009 ; 32 : 1327-1334 Advantages of Proposal to Use HbA1c for Diabetes Diagnosis Standardized and aligned to the DCCT/ UKPDS; measurement of glucose is less well standardized Better index of overall glycemic exposure and risk for long-term complications HbA1c level is not affected by short-term lifestyle changes Substantially less biologic variability Substantially less preanalytic instability No need for fasting or timed samples Relatively unaffected by acute (e.g., stress or illness related) perturbations in glucose levels Currently used to guide management and adjust therapy Convenient for patients i.e. no fasting or other test preparation required Accurate, precise measure of chronic glycaemic levels Lower between- and within-subject coefficients of variation and reduced possibility of pre-analytic errors compared with glucose Correlates with risk of diabetes defining complications (retinopathy) Familiar test parameter i.e. already used to guide therapeutic decisions Diabetes Care 2009; 32(7): 1327-1334 Disadvantages of Proposal to Use HbA1c for Diabetes Diagnosis Relationship between HbA1c and glucose, whilst good, is not perfect Whilst existing glucose based diagnostic criteria remain valid, the current proposal does not advocate a confirmatory check of glucose at any stage Point of care instruments currently considered inadequate for diagnostic purposes Methods suffer from multiple interferences that clinicians may not be aware of The proposed cut-off of 6.5% is predictive of retinopathy but is it the most appropriate outcome on which to choose a diagnostic target? Not appropriate for diagnosis of gestational diabetes Upper limit of normal HbA1c (6.0%) leaves a diagnostic hiatus between 6.1 and 6.5%, in addition to a discrepancy between the typical treatment target of <7% and the diagnostic level Racial disparities in HbA1c may exist that are independent of blood glucose Diabetes Care 2009; 32(7): 1327-1334 Proposed Criteria for Screening and Diagnosis of Diabetes J Clin Endocrinol Metab 2008 ; 93: 24472453 Diagnostic criteria for diabetes mellitus 1. Classic symptoms of diabetes + random glucose plasma level ! 200 mg/dL . Random glucose plasma level is a test which access glucose plasma level at a single time without concerning about last meal schedule. or 2. Classic symptoms of diabetes + Fasting plasma glucose ! 126 mg/dL. Fasting means patients not getting intake calories for minimum 8 hours. or 3. 2-h plasma glucose at glucose tolerance test ! 200 mg/ dL. Glucose tolerance test done by the WHO standard using 75 g anhydrous glucose which solvent in the 100 cc water. PERKENI Guideline 2010 Kadar glukosa darah sewaktu dan puasa sebagai patokan penyaring dan diagnosis DM (mg/dL) Bukan DM Belum pasti DM DM Kadar glukosa darah sewaktu Plasma vena <100 100 -199 >200 Darah kapiler < 90 90-199 >200 Kadar glukosa darah puasa Plasma vena <100 100-125 >126 Darah kapiler < 90 90-99 >100 Catatan : Untuk kelompok risiko tinggi yang tidak menujukkan kelainan hasil dilakukan ulangan tiap tahun. Bagi mereka yang berusia >45 tahun tanpa faktor risiko lain, pemeriksaan penyaring dapat dilakukan setiap 3 tahun. PERKENI GUIDELINES 2010 PERKENI GUIDELINES 2010 Overview ! Epidemiology diabetes in Indonesia ! History of PERKENI Guidelines ! Results of DiabCare study ! Screening and diagnosis criteria ! Diabetes management and new drugs ! Algorithm of treatment ! Blood glucose monitoring ! Conclusion Treatment Algorithm for Type 2 Diabetes in Indonesia The Indonesian Society of Endocrinology, 2006 ! Principles in selecting antihyperglycemic interventions: ! Effectiveness in lowering glucose ! Extraglycemic effects that may reduce long- term complications ! Safety profiles ! Tolerability ! Ease of use ! Expense Nathan DM, et al. Diabetes Care 2009;32 193-203. L I S T O F O A D 2006 33 Expected HbA 1c reduction according to intervention Intervention Expected ! in HbA 1c (%) Lifestyle interventions 1 to 2% Metformin 1 to 2% Sulfonylureas 1 to 2% Insulin 1.5 to 3.5% Glinides 1
to 1.5% 1 Thiazolidinediones 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 0.5 to 0.8% 1. Repaglinide is more effective than nateglinide Adapted from Nathan DM, et al. Diabetes Care 2009;32:193-203. Comparative Effectiveness and Safety of Oral Medications for Type 2 Diabetes Mellitus Compared with newer agents, metformin and second-generation sulfonylureas share 3 additional advantages: ! lower cost, ! longer use in practice, ! more intensive in long-term trials with clinically relevant end points. Ann Intern Med. 2007;147:386-399. 35 Inhibition of DPP-4 Increases Active GLP-1 GLP-1 inactive (>80% of pool) Active GLP-1 Meal DPP-4 Intestinal GLP-1 release GLP-1 t ! =12 min DPP-4=dipeptidyl peptidase-4; GLP-1=glucagon-like peptide-1 Adapted from Rothenberg P, et al. Diabetes. 2000; 49(suppl 1): A39. Abstract 160-OR. Adapted from Deacon CF, et al. Diabetes. 1995; 44: 1126-1131. Vildagliptin Effective across Hyperglycemia Spectrum BL HbA1c "8% n= 1569 543 490 362 174 BL=baseline; HbA1c-hemoglobin A1c; vilda=vildagliptin *P <0.001 from BL. HbA1c change from baseline to Week 24 (end point) pooled monotherapy intention-to-treat / primary intention-to-treat population. Data on file, Novartis Pharmaceuticals. Vilda 50 mg twice daily BL= 8.7 7.6 8.5 9.5 10.6 C h a n g e
f r o m
B L
i n
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8< HbA1c "9% 9< HbA1c "10% HbA1c >10% * * * * Overall * ! Evidence generated from a comprehensive clinical program of >20,200 patients a
! A potent, highly selective, and reversible DPP-4 inhibitor ! Robust efficacy ! sustained efficacy over 2 years ! efficacy comparable with TZD and acarbose in monotherapy (at 24 weeks) ! efficacy demonstrated in IGT population ! Excellent tolerability ! low risk for hypoglycemia ! superior GI tolerability versus metformin ! no weight gain overall ! weight loss relative to TZD ! incidence of edema similar to placebo ! overall incidence of AEs comparable with placebo ! No drug-drug interaction with commonly prescribed agents Vildagliptin: Summary for Monotherapy AE=adverse event; DPP-4=dipeptidyl peptidase-4; GI=gastrointestinal; TZD=thiazolidinedione a 20,200 represents the overall patient numbers included in studies for monotherapy and combination therapy. DPP-IV Inhibitor for Glycemic Control AACE/ACE algorithm DPP-IV inhibitors can be given at any level of A1C, as a monotherapy, dual therapy, or triple therapy. Endocr Pract. 2009;15(6):540-59 PERKENI guideline 2010 DPP-IV inhibitor was included in one of the oral medications for diabetes. These drugs consumed together with or before meals and can be given as monotherapy or dual therapy combined with modification lifestyle. Exenatide (Exendin-4) 39amino acid peptide incretin mimetic that exhibits glucoregulatory activities similar to the mammalian incretin hormone GLP-1 - Well tolerated - Reduce A1C with no weight gain - No increased incidence of hypoglycemia in T2DM - Causes a relatively high frequency of gastrointestinal disturbances (transitory) Diabetes Care 28:1092-100, 2005 DIAGNOSIS TAHAP-1 (Mono-Terapi) TAHAP-2 (Kombinasi 2 obat) TAHAP-3 (Insulin intensif) DIABETES GSH + Metformin Atau salah satu dari: SU, AGI, Glinid, TZD, DPP-IV inh GSH + Metformin Ditambah salah satu dari: SU, AGI, Glinid, TZD, DPP-IV inh Kombinasi 3 obat GSH + Metformin Ditambah dua diantara: SU, AGI, Glinid, TZD, DPP-IV inh Insulin intensif Basal plus atau Basal bolus Mencapai target HbA1C <7% TERUSKAN Catatan: - GSH: gaya hidup sehat, SU: sulfonilurea, AGI: alfa glukosidase inhibitor, TZD: tiazolidindion, DPP-IV inh: dipeptidil peptidase inhibitor - Kombinasi 3 obat hanya diberikan bila penyandang DM (diabetisi) menolak insulin - Untuk terapi insulin " lihat konsensus insulin PB PERKENI 2-3 bulan gagal 2-3 bulan gagal 2-3 bulan gagal HbA1C 8-9% >9% 9-10% >10% <7% Catatan: 7-8% GHS GHS (Gaya Hidup Sehat): Penurunan berat badan Mengatur diit Latihan jasmani teratur GHS + Monoterapi Met, SU, AGI, Glinid, TZD, DPP- IV GHS + Kombinasi 2 obat Met + SU, AGI, Glinid, TZD, DPP- IV GHS GHS + + Kombinasi 3 macam obat Kombinasi 2 macam obat Met + SU, AGI, Glinid, TZD, DPP- IV Met + SU, AGI, Glinid, TZD, DPP- IV + Basal Insulin GHS + Insulin Intensif 1. Dinyatakan gagal apabila dengan terapi 2-3 bulan tidak mencapai target HbA1C <8% 2. Bila tidak ada pemeriksaan HbA1C dapat dilakukan pemeriksaan rata-rata glukosa darah sehari dan dikonversikan ke HbA1C menurut kriteria ADA 2010 Algoritma pengelolaan DM tipe 2 tanpa disertai dekompensasi alternatif terutama untuk internist Belum dianjurkan Diabetes Prevention Overview ! Epidemiology diabetes in Indonesia ! History of PERKENI Guidelines ! Results of DiabCare study ! Screening and diagnosis criteria ! Diabetes management and new drugs ! Algorithm of treatment ! Blood glucose monitoring ! Conclusion Self Monitoring of Blood Glucose ! To evaluate individual response to therapy and assess whether glyceamic targets are being achieved. ! Useful in preventing hypoglycemia and adjusting medications (particularly prandial insulin doses), medical nutrition therapy, and physical activity. Standards of Medical Care in Diabetes-2010. Self Monitoring of Blood Glucose ! Patients starting basal insulin therapy at bedtime or initiating premixed insulin therapy before dinner should monitor the morning fasting blood glucose levels daily. ! Patients with T1DM and pregnant women taking insulin " SMBG is recommended three or more times daily ! The optimal frequency and timing of SMBG for patients with type 2 diabetes on noninsulin therapy is unclear Standards of Medical Care in Diabetes-2010. Self Monitoring of Blood Glucose (SMBG) Tools to assess treatment in diabetic patients that is recommended especially in: 1. Patients that will undergo insulin therapy 2. Patients receiving insulin therapy 3. Patients with A1C level did not reach the target 4. Women planned for pregnancy / pregnant women with hyperglycemia, 5. Patients with recurrent hypoglycemia. PERKENI Guidelines 2010 Target of Treatment Risk CVD (-) Risk CVD (+) IMT (kg/m 2 ) 18,5 - < 23 Glukosa darah - Puasa (mg/dL) < 100 - 2 jam PP (mg/dL) < 140 A1C (%) < 7,0 < 7,0 Tekanan Darah < 130/80 < 130/80 Profil Lipid Total kolesterol (mg/dL) Trigliserid (mg/dL) HDL kolesterol (mg/dL) LDL kolesterol (mg/dL) < 100 < 70 PERKENI Guidelines 2010 In conclusion ! In the forthcoming national guideline on the Prevention and Management of Type 2 DM, PERKENI already update several critical issues such as the screening and diagnostic criteria, target of treatment, algorithm of management, and blood glucose monitoring. ! We also aware that to improve quality of diabetes care in Indonesia, the written guidelines should be followed by the activities of capacity building for all health personnel and the facilities improvement of health care for diabetes mellitus ! A multi-disciplinary approach for management should be adopted