You are on page 1of 31

Early Detection and Standardized Diabetes


Ratna Maila Dewi

Slide 2

Deteksi Dini dan Tatalaksana Diabetes Melitus

Tipe 2

Main Learning Points

• Memahami proses dari skrining hingga diagnosis terkait

pedoman nasional

• Memahami pentingnya tatalaksana dan intensifikasi

pengobatan diabetes melalui pemantauan glukosa
darah dan HbA1c

• Memahami alasan dan kebutuhan untuk tindak lanjut

rutin dan mencapai target individu untuk menghindari
Slide 3

Beberapa Definisi sebelum kita memulai ....

Common Definitions

Abbreviation Definition

NGT Normal Glucose Tolerance (Gula Darah Normal)

FPG Fasting Plasma Glucose (Gula Darah Puasa)

PPG Post-Prandial Plasma Glucose (Gula Darah Post Prandial)

IGT Impaired Glucose Tolerance (Toleransi Glukosa Terganggu)

IFG Impaired Fasting Glucose (Gula Darah Puasa Terganggu)

Average amount of glucose in the bloodstreams over a 3-month

Slide 3

Classification of Diabetes

• Type 1 diabetes
• Absolute insulin deficiency due to the destruction of
pancreatic beta-cells
• Type 2 diabetes
• Type 2 is characterized by insulin resistance with relative
insulin deficiency to a predominately secretary defect
with insulin resistance
• Other specific types
• Gestational diabetes
• Glucose intolerance first detected in pregnancy that often
resolves after the birth of the baby

Diabetes Care 1997; 20: 1183-1197

Slide 4

Classical Diabetes Symptoms

Polyuria • Excessive Urination at night

Polyphagia • Excessive Hunger

Polydipsia • Excessive Thirst

Unexplained weight
• Weight Loss even if food in-
take is normal
Slide 5

Other Diabetes Symptoms

Blurred Vision • Damaging blood vessels in the eyes

Numbness and/or • Numbness and tingling in hands, legs

Tingling and feet

Fatigue • Frequent fatigue regardless of


Itchy Skin • affects legs, feet, and hands

Impotence • Physical and Physiological

Slide 6

4 Simple Steps from Screening to Diagnosis

1 2 3
Screen patients with Conduct 1st Blood Test Conduct 2nd Blood Test
diabetes risk factors (if required) and
establish Diagnosis

Inform Patient and
Initiate treatment
Slide 7

Step 1: Risk Factors – PERKENI screening risk

factor guideline

Diabetes Associated
Unmodifiable Risk Modifiable Risk

• Race and Ethnic • Overweight (BMI >23) • Polycystic Ovary

• Family History of • Hypertension > Syndrome (PCOS) or
Diabetes 140/90 mmHg another clinical
• History of Gestational • Dyslipidemia (HDL < condition related to
Diabetes 35 mg/dl and/or insulin resistance
• History of delivery a triglycerides >250 • Metabolic Syndrome
baby more than mg/dl (IGT, IFG, History of
4.000g • Unhealthy Diet Coronary Artery
• History of low birth • Limited Physical Disease , stroke
weight <2.500g Activity and/or PAD)

Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

Slide 8

Step 2: Conduct 1st Blood Test

Clinical Test
(+) Classic (-) Classical
Symptoms Symptoms

FBG ≥126 <126 FBG ≥126 100-125 <100

or or
RBG ≥200 <200 RBG ≥200 140-199 <140

Repeat FBG or RBG

2 Hour Post loading

Plasma Glucose

Diabetes Mellitus IGT IFG Normal

Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

Slide 9

Step 3: Conduct 2nd Blood Test (if required) and

Establish Diagnosis

Clinical Test
(+) Classic (-) Classical
Symptoms Symptoms

FBG ≥126 <126 FBG ≥126 100-125 <100

or or
RBG ≥200 <200 RBG ≥200 140-199 <140

Repeat FBG or RBG

≥126 <126 2 Hour Post loading

Plasma Glucose
≥200 <200

PPG ≥200 140-199 <140

Diabetes Mellitus IGT IFG Normal


Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

Slide 11

Cut-points: Diabetes, IGT and IFG

Fasting Plasma Glucose (FPG)



IFG (Impaired
Fasting Glucose

IGT (Impaired
Glucose Diabetes
NGT (Normal Tolerance)

140 200 mg/dL

2-hour Plasma
Glucose (PPG)
Slide 12

Diagnosis of Type 2 Diabetes

KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

1. Classical symptoms of Diabetes (+) & Random plasma

glucose concentration ≥ 200 mg/dl
2. Classical symptoms of Diabetes (+) & Fasting Plasma
Glucose ≥ 126 mg/dl.

3. 2-hour post-OGTT ≥ 200 mg/dl.

4. HbA1c ≥ 6,5% (NGSP)

• Classical symptom of diabetes (+), only need 1 abnormal BG
• No classical symptom of diabetes, need 2 x abnormal BG level in a different days
Slide 13

Updated PERKENI Type 2 Diabetes Treatment


Diabetes STEP 1 STEP 2 STEP 3

Healthy life style Healthy life style

Mono therapy Healthy life style
Note: + Healthy life style
1. Therapy failed if 2 OAD Combination +
target of HbA1c <
7% is not achieved Alternative option, if : Combination 2 OAD
within 2-3 months
• No insulin is available +
for each step
• The patient is objecting insulin Basal insulin
2. In case of no HbA1c
test, the use of blood • Blood glucose is still not optimally
glucose level is also controlled
permitted. Average
blood glucose level Healthy life style
for a few BG test in Insulin
one day can be +
converted to HbA1c 3 OAD Combination
(ref: ADA 2010)

*Intensive Insulin: use of basal insulin together with insulin prandial

Slide 14

Updated PERKENI Type 2 Diabetes Treatment Algorithm

Slide 15

ADA/EASD Algorithm
Slide 16

The Ominous Octet

Slide 18

The Principles of OAD Combination Theory

• Two (or more) oral blood glucose-lowering

medicines that have different mechanisms of
• Two medications is better rather than increase
in initial medicine to maximum dosage
• Fewer side effects than mono-therapy at higher
Slide 19

Properties of available glucose-lowering agents

that may guide treatment choice in Type 2
Class Compounds(s) Cellular Primary Advantages Disadvantages
mechanism Physiological
Biguanides Metformin Activates Hepatic Glucose Extensive Gastrointestinal side
AMP-kinase Production  Experience effects
No weight gain Lactic acidosis risk
No hypoglycaemia (rare)
Likely CVD Events  Vitamin B12
CKD, acidosis,
dehydration etc.
Sulfonylureas Glibenclamide / Closes KATP Insulin secretion  Extensive Hypoglycemia
glyburide channels on experience Weight gain
Glipizide beta cell Microvascular Risk  Blunts myocardial
Gliclazide plasme (UKPDS) ischaemic
Glimepiride membranes preconditioning ?
Low durability
Meglitinides Repaglinide Closes KATP Insulin secretion  Postprandial Hypoglycemia
Nateglinide channels on glucose excursions  Weight gain
beta cell Dosing flexibility Blunts myocardial
plasme ischaemic
membranes preconditioning ?
Frequent dosing

Inzucci SE, et al. Diabetologia. 2012

Profil obat Anti hiperglikemia oral yang ada di
Slide 20

Gol.Obat Cara Kerja Utama ESO Utama Penurunan HbA1c

Sulfonilurea Meningkatkan sekresi BB Naik 1–2%

Insulin Hipoglikemia

Glinid 0,5 – 1,5 %

Metformin Menekan produksi glukosa Dispepsia 1,0 – 2,0 %

hati Diare
Menambah sensitivitas thd Asidosis Lakta

Penghambat Menghambat absorbsi Flatulen 0,5 – 0,8 %

alfa glukosidase glukosa Tinja lembek

Tiazolidindion Menambah sensitifitas thd Edema 0,5 – 1,4 %


DPP-iv inhib Meningkatkan sekresi Sebah- muntah 0,5 – 0,8 %

Menhambat sekrsi glukagon

SGLT-2 inhib Menghambat penyerapan Dehidarsi, 0,8 – 1,0%

kembali glukosa di tubuli ISK
distal ginjal
Slide 22

What is good glycemic control?

• Overall aim to achieve glucose levels as close to normal as

• Minimise development and progression of microvascular
and macrovascular complications


<130 mg/dL < 7.0% <180 mg/dL


<110 mg/dl < 6.5% <145 mg/dL


<100 mg/dl < 7% <140 mg/dl

1. American Diabetes Association Diabetes Care 2009;32 (Suppl 1):S1-S97

2. IDF Clinical Guidelines Task Force. International Diabetes Federation 2005. 3. PERKENI 2011 Konsensus .
Slide 23

Insulin can be initiated at any time…

• Traditionally, insulin has been reserved as the last line of

• …However, considering the benefits of normal glycemic
status, Insulin can be initiated earlier.

+ 1 OAD + 2 OAD + 3 OAD


Adapted from Nathan DM, et al. Diabetes Care 2009; 31:193-203

Slide 24

Insulin Indications

Absolut Indication
Type 1 Diabetes
Relative Indication
Patients who fail to reach target with OAD optimal dosage
(3-6 months)
Type 2 DM Outpatient with:
Pregnancy not controlled with diet
Infected Diabetes Feet
High Blood Glucose Fluctuations
Repeated History of Ketoacidosis
History of Pankreotomi
Besides the above, there are a number of conditions
where insulin is required, e.g. chronic liver, kidney
function interruption and high dosage steroid therapy
Slide 24

HbA1c correlation with blood glucose level

HbA1c Kadar Gula Darah

Mg/dl Mmol/L
6 128 7,0
6,5 140 7,8
7 154 8,6
7,5 169 9,4
8 183 10,1
8,5 197 10,9
9 212 11,8
9,5 226 126
10 240 134

Hubungan antara A1C dan eAG dijelaskan dengan rumus 28,7 X A1C - 46,7 = eAG
Slide 26

The benefits of good blood glucose control are


Good control is infarction
≤ 7.0% HbA1c
HbA1c measures
the average
blood glucose Microvascular
level over the HbA1c complications
last three
-1% -37%

Deaths related
to diabetes

Source: UKPDS = United Kingdom Prospective Diabetes Study. Stratton IM
et al. BMJ. 2000;321(7258):405-412.
Slide 26

Practical Monitoring Scheme

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009
Slide 27

Practical Monitoring Scheme Cont…

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009
Slide 28

Individualized Treatment based on several criteria

to control blood glucose

Inzucci SE, et al. Diabetologia. 2012

Slide 29

Early Detection and Standardized Diabetes Management


Summary Main Learning Points

• Diabetes is a progressive disease that • Understand the importance of treating

must be treated in order to avoid long- diabetes and reaching individual targets
term complications to avoid complications
• Good glycemic control according to • Understand the process from
PERKENI is: screening to diagnosis and the
• HbA1c <7% associated national guidelines
• FPG: <100 mg/dl • Understand the reason and need for
routine follow-up and intensify
• PPG: <140 mg/dl treatment on diabetes via blood
• Patient treatment need to be glucose- and HbA1c monitoring
individualized according to the
characteristics of each particular
Slide 30

Slide 31
Slide 32