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Early Detection and Standardized Diabetes

Management

Ratna Maila Dewi


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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
komplikasi
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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


HbA1c
period
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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


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Classical Diabetes Symptoms

Polyuria • Excessive Urination at night

Polyphagia • Excessive Hunger

Polydipsia • Excessive Thirst

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


exercise

Itchy Skin • affects legs, feet, and hands

Impotence • Physical and Physiological


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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

4
Inform Patient and
Initiate treatment
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Step 1: Risk Factors – PERKENI screening risk


factor guideline

Diabetes Associated
Unmodifiable Risk Modifiable Risk
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


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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


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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


TGT GDPT

Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2


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Cut-points: Diabetes, IGT and IFG

mg/dL
Fasting Plasma Glucose (FPG)

Diabetes

126

IFG (Impaired
Fasting Glucose

100
IGT (Impaired
Glucose Diabetes
NGT (Normal Tolerance)
Glucose
Tolerance)

140 200 mg/dL


2-hour Plasma
Glucose (PPG)
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Diagnosis of Type 2 Diabetes


KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

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


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

3. 2-hour post-OGTT ≥ 200 mg/dl.

Or
4. HbA1c ≥ 6,5% (NGSP)

Note:
• Classical symptom of diabetes (+), only need 1 abnormal BG
• No classical symptom of diabetes, need 2 x abnormal BG level in a different days
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Updated PERKENI Type 2 Diabetes Treatment


Algorithm

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 +
Intensification*
converted to HbA1c 3 OAD Combination
(ref: ADA 2010)

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


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Updated PERKENI Type 2 Diabetes Treatment Algorithm


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ADA/EASD Algorithm
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The Ominous Octet


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The Principles of OAD Combination Theory

• Two (or more) oral blood glucose-lowering


medicines that have different mechanisms of
action
• Two medications is better rather than increase
in initial medicine to maximum dosage
• Fewer side effects than mono-therapy at higher
doses
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Properties of available glucose-lowering agents


that may guide treatment choice in Type 2
Diabetes
Class Compounds(s) Cellular Primary Advantages Disadvantages
mechanism Physiological
action(s)
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
deficiency
Multiple
contraindications:
CKD, acidosis,
hypoxia,
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
schedule

Inzucci SE, et al. Diabetologia. 2012


Profil obat Anti hiperglikemia oral yang ada di
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Indonesia
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
insulin

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


alfa glukosidase glukosa Tinja lembek

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


insulin

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


insulin
Menhambat sekrsi glukagon

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


kembali glukosa di tubuli ISK
distal ginjal
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What is good glycemic control?

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


possible
• Minimise development and progression of microvascular
and macrovascular complications

ADA1 FPG HbA1c PPG


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

IDF2 FPG HbA1c PPG


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

PERKENI3 FPG HbA1c PPG


<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 .
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Insulin can be initiated at any time…

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


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

Inadequate
+ 1 OAD + 2 OAD + 3 OAD
Lifestyle

INITIATE INSULIN

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


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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
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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
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The benefits of good blood glucose control are


clear

Myocardial
Good control is infarction
≤ 7.0% HbA1c
-14%
HbA1c measures
the average
blood glucose Microvascular
level over the HbA1c complications
last three
-1% -37%
months

Deaths related
to diabetes

-21%
Source: UKPDS = United Kingdom Prospective Diabetes Study. Stratton IM
et al. BMJ. 2000;321(7258):405-412.
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Practical Monitoring Scheme

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009
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Practical Monitoring Scheme Cont…

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009
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Individualized Treatment based on several criteria


to control blood glucose

Inzucci SE, et al. Diabetologia. 2012


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Early Detection and Standardized Diabetes Management


Lecture

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
patients
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TERIMAKASIH
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