Tatalaksana dan Titrasi

Insulin
RSUD Balangan
dr. Riswanto, SpPD

Diabetes 2003-2025 Epidemiology Projections
An
An increasing
increasing problem
problem worldwide
worldwide
World
2003 = 194 M
2025 = 333 M
NA ↑ 72%
EUR
23.0 M
36.2 M 48.4 M
58.6 M EMME
↑57.0% SEA
↑21% 19.2 M WP
39.4 M 39.3 M
↑105% 81.6 M 43.0 M
↑108% 75.8 M
↑79%
SACA
AFR
14.2 M
26.2 M 7.1M
15.0 M
↑85%
↑111%

M = million, AFR = Africa, NA = North America, EUR = Europe,
SACA = South and Central America,
EMME = Eastern Mediterranean and Middle East,
SEA = South-East Asia, WP = Western Pacific
Diabetes Atlas Committee. Diabetes Atlas 2nd Edition: IDF 2003. 2

Islet Cell of Pancreas

3

Science. 2005. PANCREATIC ISLET MORPHOLOGY β-Cells (insulin) α-Cells (glucagon) NORMAL PANCREAS Adapted from Rhodes CJ. 307:380–384 .

Levy MN. St. Mo: Mosby. Inc. 5 . and neural input Adapted from Berne RM. hormones. Louis.Roles of Insulin and Glucagon in Normal Glucose Homeostasis + – Insulin* Glucose Glucagon* (plasma concentration) (plasma concentration) (plasma concentration) – + *Insulin and glucagon secretion are also influenced by other nutrients. Physiology. 1998: 822–847. eds.

.

.

PANCREATIC ISLET MORPHOLOGY: STRUCTURAL DEFECTS ARE EVIDENT IN TYPE 2 DM Normal T2DM β-Cells Amyloid (insulin) plaque α-Cells (glucagon) • Disorganized and misshapen THE PANCREAS IN TYPE 2 • Marked reduction in β-cell number DIABETES • Amyloid deposit T2DM = type 2 diabetes mellitus Adapted from Rhodes CJ. 307:380–384 . Science. 2005.

Sekresi Insulin Kepekaan terhadap Insulin 50 % DM-2 50 % Pre-Diabetes 70 .100 % Gangguan Toleransi Glukosa 50 % 150 % Gangguan Metabolisme Glukosa 70 % 100 % Metabolisme Glukosa Normal 100 % Riwayat Alami Diabetes Mellitus tipe-2 .

.

3 Kuantil HbA1c Monnier L et al.3-10.5-9.4 8. Diabetes Care 2003 .4-8.3 7.2 9.Kontribusi kadar glukosa puasa dan glukosa prandial terhadap HbA1c Kontribusi kadar glukosa prandial Kontribusi terhadap HbA1c 30% 40% 45% 50% 70% 70% 60% 55% 50% 30% Kontribusi kadar glukosa puasa < 7.2 >10.

13:676−86. Diabetes Care 1990.Both fasting and postprandial hyperglycaemia contribute to overall hyperglycaemia 15 Postprandial hyperglycaemia Blood glucose (mmol/l) 10 Fasting hyperglycaemia Diabetes profile 5 Healthy profile 0 06:00 12:00 18:00 24:00 06:00 Time of day Riddle M. .

Well – validated Lifestyle core therapies + Lifestyle + Metformin Metformin At diagnosis : + + Basal insulin Intensive insulin Lifestyle + Lifestyle Metformin + Metformin + Sulfonilurea Step 1 Step 2 Step 3 Less – validated core therapies Lifestyle + Lifestyle Metformin + + Metformin Pioglitazon + (No hypogycemia. Pioglitazone Oedema/ CHF + Bone loss ) Sulfonilurea Lifestyle + Lifestyle Metformin + + Metformin GLP-1 agonist (No hypogycemia. + Weight loss Basal insulin Nausea /vomiting) Algorythm for Metabolic management Type -2 Diabetes .

Penatalaksanaan DM 1 2 3 4 .

Penemuan insulin .

Diabetes Devices Pipeline .past. Advisory present Board and Meeting future 18-19 March-2011 March 2009 Slide no 16 Historical steps in Novo Nordisk’s insulin development New Generation Insulin Analogs Basal Insulin Analogs Advancements Biphasic Insulin Analogs Rapid-acting Insulin Analogs 2000s Recombinant Human Animal Insulin Isolation Insulin of Insulin (Banting & Best) Preparations 1990s 1977 1922 Time .

.

.

.

( Program Insulin ) dosis =BBx0.5 60%rapid : 40% basal Menjelang Menjelang Menjelang Menjelang Makan Pagi Makan Siang Makan Malam Tidur Malam 20% 20% 20% 40% Rapid-Acting Rapid-Acting Rapid-Acting Extended Long acting Menekan Mengendalikan Hiperglikemi Post Prandial Glukosa darah Basal Memacu glikogenesis Menekan Hepatic Glucose Production .

Diabetes Pipeline Advisory Board Meeting 18-19 March 2009 Jika GDP yang tinggi mulai basal insulin jika GDP dan 2j PP yang tinggi mulai dengan premix atau tambahkan basal dengan OAD atau mulai basal bolus .

Diabetes Pipeline Advisory Board Meeting 18-19 March 2009 Titrasi basal bolus insulin GDP basal titrasi • <70mg/dl kurangi 2 unit • Basal insulin • 70-130mg/dl maintanace dose • 130-180 mg/dl naikkan 2u tiap 3hari • >180mg/dl naikkan 4u tiap 3 hari • Cek HbA1C /3bln GD 2j PP titrasi • Fast acting Mulai 4u /hari naikkan 2u sampai target tercapai tiap 3hari OAD stop begitu start insulin rapid .

Diabetes Pipeline Advisory Board Meeting 18-19 March 2009 Titrasi premix insulin GD sblm mkn pagi titrasi premix <72 mg/dl kurangi 4u Premix 72-126mg/dl tetap Insulin 126-144mg/dl naikkan 2u >144mg/dl naikkan 4u Monitor GDP dan Gd2 j PP selama titrasi .

efficacy. Diabetes Pipeline Advisory Board Meeting 18-19 March 2009 Analogue Insulin: ANALOG INSULIN for better physiologic. safety and flexibility NovoRapid – Rapid Acting Analog NovoMix – Premix Analog Levemir – Long Acting Analog .

Diabetes Pipeline Advisory Board Meeting 18-19 March 2009 ---. Insulin endogen Levemir ---. NovoRapid NovoMix Breakfast Lunch Dinner Bed time .

.

Limitation of Reguler & Premix HI Period of unwanted hyperglycemia Normal insulin secretion at mealtime Change in serum insulin Human insulin Period of unwanted hypoglycemia Baseline time inflexibility injection level Time (h) SC injection .

Injection Site Rotation .

Pen Injection Technique Injection Techniques .

Trigliserida < 150 150 – 199  200 8.5–22. Kriteria Pengendalian DM Baik Sedang Buruk 1. Glukosa darah 2 jam 80 – 144 145 – 179  180 3. IMT (kg/m2) 18.5 6. Kolesterol LDL (mg/dl) < 100 100 – 129  130 6. Kolesterol HDL (mg/dl) > 45 7.5 – 8 >8 4. Glukosa darah Puasa 80 – 109 110 – 125  126 2.9 23 – 25  25 9. A1C (%) < 6. Kolesterol total (mg/dl) < 200 200 – 239  240 5. Tekanan darah (mmHg) < 130/80 130-140/80-90 >140/90 .

AACE.2) (6.5 <6.0† 6.8)**1 (<10.29(suppl 1):S43–8. 5. et al. 2005. Global Guideline for Type 2 Diabetes.0)** (7. 4. Diabetes Care 2006.8)** (<8.0)** (<10.pdf.5)2 (5.5 AACE=American Association of Clinical Endocrinologists.idf.0† FBG.5 <7. http://www. 2. 3. Diabetologia 2006. mg/dl <140 <180 140 <145 <180 (mmol/l) (<7.49:1711–21.8(suppl 1):40–82. Endocr Pract 2002. Brussels: International Diabetes Federation. Diabetes Care 2006. †ADA and ADA/EASD guidelines recommend HbA1c levels as close to normal (<6%) as possible without significant hypoglycaemia 1.0) (3.0)** *DCCT referenced assays: normal range 4–6%. Nathan DM. IDF. IDF=International Diabetes Federation 1.07. mg/dl <100 90130 110 <110 70−130 (mmol/l) (<5.org/webdata/docs/IDF %20GGT2D.29(suppl 1):S4–S42.0) (<6. ADA=American Diabetes Association.2) PPBG.Guidelines provide HbA1c. ADA. independent FBG and PPBG targets Healthy ADA1 AACE3 IDF4 ADA/ EASD5 HbA1c* (%) <6.01 <7. EASD=European Association for the Study of Diabetes.9−7. . **1–2 hours postprandial. ADA.

Type 2 Diabetes Mellitus Complications MICROVASCULAR MACROVASCULAR Retinopathy. glaucoma or Cerebrovascular cataracts disease Cardiomyopathy Coronary heart Nephropathy disease Peripheral Neuropathy vascular disease Erectile dysfunction .

baal.Kaki Diabetes Neuropati Vaskular Manifestasi Neuropati Diabetik Infeksi Sangat bervariasi Kesemutan. kebas. hilang rasa sering tidak terhiraukan MERUPAKAN RISIKO TERJADINYA ULKUS. KARENA SENSASI NYERI TIDAK ADA Nyeri (Painful Neuropathy) .