Overview of Diabetes Issues in Indonesia:

From theory to the real world

Achmad Rudijanto

Endocrinology and Metabolic Division of Internal Medicine Department

Faculty of Medicine Brawijaya University – Saiful Anwar General Hospital
M a l a n g - Indonesia
 Presentation title Date 2

Outlines

• The burden of Diabetes as a progressive disease

• National Health Survey (RISKESDAS) results
• Problem of diabetes management in Indonesia
• Team care approach and PROLANIS
• Summary
Estimated number of people with diabetes worldwide and per
region in 2015 and 2040 (20-79 years)
Diabetes In Indonesia.........

Top 10 Countries/Territories of number

Of people with diabetes (20-79 years), 2014 2035 Prediction

China 96,2

India 66,8

USA 25,7

Brazil 11,6

Indonesia 9,1 6%/year 5

Mexico 9

7 Egypt 7,5

German 7,2

Turkey 7,2

Japan 7,2

2030-2035

Prevalence: 5,55% (adult pop.) Prevalence: 5,55% (adult pop.)

Reference:
International Diabetes Federation. IDF Diabetes Atlas, 6th edition: 2013
2-3 x
International Diabetes Federation. IDF Diabetes Atlas, 6th edition: 2014 Update
http://www.idf.org/diabetesatlas IDF : 14.1 mill in 2035
WHO: > 21.0 mill in 2030
 Trend of DM Prevalence in Each Province 2007-2013

National Health Survey,

• Compare to National Health Survey 2007 the Indonesian Health Survey 2013 showed that the
prevalence of diabetes increases nearly twice, within 5 years
• The prevalence of diabetes in Indonesia was 5.7% in 2007
Top ten countries/territories for the number of the people with
impaired glucose tolerance (PRE-DIABETES) (20-79 y.o), 2015 and
2024

IDF Atlas 7th edition, 2015

Prominent risk factors of diabetes in Indonesia

60% 56.50%
47.30%
50% 44.40%
40%

30%
23% 23%
20% 16.70%
10%

0%
Obesity Central obesity Hypertension Physical inactivity High risk diet (less Smoking habit
fruits and
vegetables)

• Obesity, hypertension, and smoking habit are the most prominent risk factors for diabetes in
Indonesia
• The priority of promotion and prevention program are mandatory addressing for:
• decrease blood pressure
• reduce weight
• stop smoking.
National Health Survey 2007
24417 subjects from 33 provinces in Indonesia.
Proportion and Estimation number of DM, IFG and IGT in
peoples with age >15 y.o. in Indonesia (2013)

Proportion (%) Estimated

number
DM 6.9 12.191.564
IFG 36.6 64.668.297
IGT 29.9 52.830.111

Note:
• Estimated Indonesian population age >15 y.o was 176.689.336
• The absolute number of diabetic patients: 12 million; IFG: 64
million and IGT: 52 million

Indonesian National Health Survey, 2013

Almost 1 in 5 of Indonesians with diabetes are below
40 years
the majority are between 40-59 years

000 people

• Mostly of diabetic patient is in productive period of age (20-59 yo) with quite
longer for life expectancy
• Health cost will be increasing due to the indirect cost that must be pay (loss of
office hour and transportation)
Source: International Diabetes Federation. IDF Diabetes Atlas, 6th edn. Brussels,
Belgium: International Diabetes Federation, 2013. http://www.idf.org/diabetesatlas
Only less than 30% of Indonesians with diabetes
are already diagnosed

26.3% diagnosed

• Only less than 30% already diagnozed

• Mostly in the productive of ages
• It can be predicted that mostly patients
73.7% undiagnosed
will come to the health centers with
complication and need high cost
intensive care

Indonesia Health Survey, 2007

 11

Indonesian Health Survey 2007 and 2013

Riskesdas 2007 Riskesdas 2013

Target of treatment
• Good control defined as BMI, blood glucose, HbA1c, lipid profile,
and blood pressure achieved the targets
Target of treatments
Parameter Target
BMI (kg/m2) 18,5 - < 23*

Systolic blood pressure (mmHg) < 140 (B)

Diastolic blood pressure (mmHg) <90 (B)

Preprandial blood glucose (mg/dl) 80-130**

2 h PP blood glucose (mg/dl) <180**

HbA1c (%) < 7 (or individualy) (B)

LDL cholesterol (mg/dl) <100 (<70 with high CVD risk) (B)

HDL cholesterol (mg/dl) Man : >40; Woman : >50 (C)

Trigliserida (mg/dl) <150 (C)

Type-2 DM Consensus - PERKENI, 2015

T2DM: Progressive loss of insulin
secretion with increasing insulin resistance1

Impaired Undiagnosed Known

glucose tolerance diabetes diabetes

Insulin resistance

Insulin secretion
Postprandial glucose

Fasting glucose

Microvascular complications
Macrovascular complications

1. Adapted from: Ramlo-Halsted BA, Edelman SV. Clincial Diabetes 2000;18(2): http://journal.diabetes.org/clinicaldiabetes/v18n22000/pg80.htm
The problems and stage of Type-2
Diabetes in relationship to β–cell function

β-cell reserve

β-cell
function
1-2%
1 – 2 per
year
every year
β-cell function continues to decline regardless
of intervention in T2DM

Progressive Loss of β-cell Function Sulfonylurea (n=511)

100 Occurs prior to Diagnosis Diet (n=110)
Metformin (n=159)

80
β-cell Function (%)*

60

40

20

0
–5 –4 –3 –2 –1 0 1 2 3 4 5 6
Years since Diagnosis
T2DM=type 2 diabetes mellitus.
*β-cell function measured by homeostasis model assessment (HOMA).
Adapted from UKPDS Group. Diabetes 1995;44:1249–58
 ADA 2015: recommendations for antihyperglycaemics
Monotherapy Metformin
Efficacy (↓HbA1c) High
Hypoglycaemia Low risk
Weight Neutral/loss
Side effects GI/lactic acidosis
Cost Low
If A1C target not achieved after 3 months of monotherapy, proceed to 2-drug combinatiion (order not meant to denote any
specific preference-choice dependend on a variety of patient and desease specific factors)

Metformin + Metformin + Metformin + Metformin + Metformin + Metformin +

Option to Dual Therapy SU DPP-4i SGLT2 GLP-1RA Insuin Basal
TZD Highest
rapidly Efficacy (↓HbA1c) High High Intermediate High High
Hypoglycaemia Moderate risk Low risk Moderate risk Low risk High risk
progress to Low risk
Gain
Weight Gain Gain Neutral Gain Loss
MDI in cases Hypoglycaemia Oedema, HF, Fx Rare Hypoglycaemia GI Hypoglycaemia
Side effects
of severe Cost Low High High Low High Variable
hyperglycae If A1C target not achieved after 3 months of dual therapy, proceed to 3-drug combinatiion (order not meant to denote any specific
preference-choice dependend on a variety of patient and desease specific factors)
mia (HbA1c
Metformin + Metformin + Metformin + Metformin + Metformin + Metformin +
≥10.0– Triple Therapy
12.0%) SU + TZD + DPP-4i + SGLT2
SU
GLP-1RA + Insulin Basal +
TZD
TZD SU SU SU

OR DPP-4i OR DPP-4i OR TZD OR TZD OR TZD OR DPP-4i

OR
OR SGLT2 OR SGLT2 OR SGLT2 OR DPP-4i OR Insulin OR SGLT2
OR GLP-1RA OR GLP-1RA OR OR Insulin OR GLP-1RA
Insulin
OR Insulin OR Insulin
If A1C target not achieved after 3 months of triple therapy and patient (1) on oral combination move to injection; (2) on GLP-1 RA add
basal insulin ; 0r (3) on optimally titrated basal insulin add GLP-1RA or mealtime insulin in refractory patients consider adding TZD or
SGLT2
Metformin +
Combination
injectable therapy Basal Insulin + Mealtime insulin or GLP-1RA

American Diabetes Association. Diabetes Care 2015

Type-2 DM Management Consensus in Indonesia

Healthy lifestyle

HbA1C <7.5% HbA1C >7.5% HbA1C >9.0%

Symptoms (-) Symptoms (+)

OHA Monotherapy* Two combination of OHAs 2 OHAs combination

Insulin ± OHA
Three combination of OHAs 3 OHAs combination
- Metformin - GLP1 agonist
Metformin atau obat lini pertema yang
- GLP1 agonist - DPP4 inhibitors
- GLP1 agonist

Metformin or first line oHA

- DPP4 inhibitors - Tiazolidindion
- DPP4 inhibitors
- Alfa glucosidase - SGLT2
- Tiazolidindion
inhibitors inhibitors**

2 other OHAs
- SGLT2
lain

- SGLT2 ** - Basal Insulin

inhibitors**
inhibitor Insulin intensification
- SU / Glinid
- Basal Insulin
- Tiazolidindion
- Cholesevelam**
- SU / Glinid
- Sulfonilurea
- Bromocriptin QR
- Cholesevelam**
- Glinide
- Alfa glucosidase
- Bromocriptin QR Note::
If HbA1c not achieved inhibitor
<7% within 3 - Alfa glucosidase
If HbA1c not achieved * Drug choosing based on: safety, patients profile,
months, add second target within 3 months, add inhibitor availability, and cost
drug (two the third drug (three If HbA1c not achieved target ** Cholesevelam not yet available Indonesia and
combination) combination) within 3 months, follow by Bromokriptin QR usually used for hypophyisis tumor
insulin initiation or threatment
intensification

PERKENI, 2015
Management pattern: Oral/non-insulin injectable therapy
100% Oral/non-insulin
Injectable therapy regimen 2
90%

80% 77,8%
Proportion of patients
receiving oral/non-insulin
70%
injectable therapy 1
58,5%
60%

50%

No 40%
15.8%
30%
23,5%

20%

10% 7,7%
Yes
1,6% 1,2% 0,8% 0,4% 1,0%
84.2%
0%

Metformin and Sulphonylureas were the most commonly used OADs among treated patients.
1 n = 1967; 2 n = 1656
DiabCare Indonesia, 2012
DiabCare Indonesia 2012
Status of diabetes care: Proportion of patients having HbA1c less than 7% at
study entry

Average HbA1c HbA1c categories**

9% 8.33%
8,33 (2,20)%*
35%
8% PERKENI Guideline 30.8%
<7% 30%
7%

6% 25%
20.7% 21.4%
5%
20%
4%
15% 13.1% 12.4%
3%
10%
2%

1% 5%

0% 0%
<7% 7 to <8% 8 to <9% 9 to <10% ≥10%
HbA1c
*Mean (SD)
**67,6% patients were not achieving PERKENI target, missing data 1,7%
 Presentation title Date 20

DiabCare Indonesia 2008

Glycaemic Control According to Duration of Diabetes

HbA1c (%) FPG and PPG

 Summaries of type-2 DM algorithm

Diet + exercise+ body weight control

Monotherapy

Two OHA combination  + Basal Insulin  Basal plus

 Basal bolus
Three OHA combination  + Basal Insulin  Premix
 Insulin remains the most efficacious glucose
lowering agent
Decrease in HbA1c: Potency of monotherapy
HbA1c %

CHOOSING INSULIN EARLIER

FOR BETTER EFFICACY

Nathan et al., Diabetes Care 2009;32:193-203.

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 and as soon as possible

Inadequate
+ 1 OAD + 2 OAD + 3 OAD
Lifestyle
• A1C > 9.5%
• FPG > 250 mg/dL
• RBG > 300 mg/dL

INITIATE INSULIN

ADA, 2015
Skyler, 2005
DiabCare Indonesia 2012
Management pattern: Insulin Treatment

Proportion of patients Injection type (2) Insulin regimen (2)

receiving insulin
Therapy (1) Missing
0.6%
Premix
OD Premix
Vial/Syrin 2.0%
ge 4.15 TID
7.8% Basal
OAD
18.3%
Yes
Premix
34.7% BOD
30.6%
Using Pen Basal-
No Device Bolus
65.3% 95.9% 32.4%
Others
8.3%

1 n = 1967
2 n = 683
Rates of any hypoglycemia in Type-1 and Type-2 Diabetes

Indonesian cohort of IO-HAT study – NADI 2016

DiabCare Indonesia 2012
Management pattern: Insulin Treatment

Average number of Average Total daily insulin

injections/day 1 dose (IU)
3 40 37,9 (24,1) *
2,6 (1,1) *
35
2.5
30
2
25
1.5 20
15
1
10
0.5
5
0 0

1n = 680
2n = 676
* Mean (SD)
Only 30.8% achived the target of treatment

Achieved A1C <7%

Many factors may influenced to the

30.8%
achievement:
69.2% • Compliance of patients
• Less aggressive therapy
Unachieved A1C <7% • Late insulin used
• Others:
• Availability of team care

Diabcare Indonesia 2012

Hyperglycaemia affects both macro- and
microvascular disease

Hyperglycaemia

Macrovasculature Microvasculature

Accelerated
Microangiopathy
atherosclerosis

Hypoxia
Neovascularisation
Ischaemia

Orasanu & Plutzky. J Am Coll Cardiol 2009;53:S35–42

DiabCare Indonesia 2008
Diabetes Complications
80%

70%

60%

50%

40%

30%

20%

10%

0%
Neuropathy Cataract Angina Pectoris Non Prol. Diab. Stroke Healed ulcer Serum
Retinopathy Creatinine > 2
mg/dL

16.9% of all complications were severe late complications

Complication profile: Diabetes Complications

100%

90%

80%

70%
59,1%
60%

50%

40%
32,4%
29,1%
30%
22,8%
20% 14,5% 12,4%
10%

0%
Any recorded Any recorded renal Any recorded eye Any recorded foot Peripheral neuropathy Erectile dysfunction
cardiovascular complications complications complications
complications

n = 1967
Peripheral neuropathy, erectile dysfunction, eye complications, and cardiovascular complications
were most common.
DiabCare Indonesia, 2012
Ontario’s Chronic Disease Prevention and Management Framework
Ontario’s Framework Ministry of Health and Long-Term Care, 2007

Team
Care
PROLANIS

• PROLANIS is a proactive integrated system involving

health care center, National health insurance (BPJS) and
client (patient)
• The objectives of PROLANIS: to achieve good QOL for
each patient members through good implementation of
standard of care of the disease to prevent complications
• It’s implemented to maintain health status of the
chronic diseases patients, to achieve optimal QOL by
cost effective heath cost
PROLANIS
• PROLANIS program give an opportunity to the patient
with chronic diseases get a appropriate treatment of
their disease in health care center

 PROLANIS activities:
 Medical consultation
 Education,
 Promotion
 Home Visit,  Prevention
 Reminder,  Early detection
 Prompt treatment
 Club activity
 Medical checkup and monitoring
Early and prompt treatment prevent DM complications

Collaboration of many

Healthy Risk Early Early &

lifestyle identification Detection & Appropriate
promotion & Manage Therapy Treatment

Diabetes tipe-2
sectors

Type 2
diabetes

Micro-
Undiagnosed vascular
diabetes disease
IGT
Normal

Macro-
vascular
Up to 10 years disease

NHANES: National Health and Nutrition Examination Survey

www.cdc.gov/nchs/products/elec_prods/subject/nhanesii.htm
Janka HU. Fortschr Med 1992;110:637–41
Diabetes & Metabolic Diseases Control
Healthy people People with risk Diabetic population

Health integrated risk factors DM and Complications

promotion management management

- Healthy enviroment - Early detection of risk - DM Management - Prevention & Rehabilitation

KTR, Sarana OR, etc
- Healthy lifestyle
Healthy Diet, smoking (-),
Exercise
- Early detection
- Medical counseling
- Referral system
factor - Emergency of Complication
- Hypertension - Out patients - Medical Rehabilitation
- Dyslipidemia/Obesity - Hospitalized patients - Home Care, survivor
- Smoking - Comorbid stroke & neuro-restoration
- Diagnosis and prompt - Complications - Diabetes foot care
treatment - Rehabilitation - Exercise
- PATUH/PANDU P.T.M - Monitoring
- Referral system - Referral system - Referral system

- POSBINDU of NCD - NCD serve of care - Primary, Secondary and - FASYANDAS / PHC
- POSBINDU NCD
- Community - FASYANDAS / PHC Tertiary health center
- Community

RF Surveillance – PHC / community – SP2TP Survey / NCD Registry - SIRS

Sumber: Dit Pengendalian Penyakit Tidak Menular, Kementerian Kesehatan

Summary

• The prevalence of DM in Indonesia has been increasing

• Less than 1/3 of patients already diagnosed and less than 1/3
achieved HbA1c <7%
• High incidence of any hypoglycemic events may influenced to
intensification of treatment and limit further HbA1c reduction
• Well organize promotion and prevention programs are needed to
reduce prevalence and number of patients
• PROLANIS system give an opportunity to reach better outcome of
treatment as well as promotion and prevention activities
 Presentation title Date 38

Thank You