Guideline of

Type 2
Diabetes
Management
in Indonesia
2019
Diabetes in Indonesia:
Epidemiology
 Epidemiology of Diabetes (IDF Atlas, 2019)

Number of people (20-79 years) with Top 10 countries or territories for number of adults
diabetes globally and by IDF Region (20–79 years) with diabetes in 2019, 2030 and 2045
Epidemiology of Diabetes (IDF Atlas, 2019)
Top 10 countries with diabetes (20-79 years) and their health
expenditure, 2019
 Diabetes in Indonesia: Prevalence
Basic Health Research, Ministry of Health, 2007, 2013, 2018

94.3 94.3 89.1

DM DM DM
5.7 6.9 10.9
Non-DM Non-DM Non-DM

26. 34. 13.

3 7 8
73 D-DM 65 D-DM 86
D-DM
.7 UD- .3 .2
UD- UD-
DM DM DM

2007 2013 2018

40 36.6
35 30.8
29.9
30 26.3
25 >2/3
>2/3
20 Undiagnosed
Undiagnosed
15 10.2
10 DM
DM
5 0
0
IFG IGT
2007 2013 2018
Diabetes in Indonesia: HbA1c achievement

DiabCare 1998: 1932 subjects

Mean HbA1c 8,1%

IDMPS 2006-2007: 674 subjects

Mean HbA1c 8,27%;
HbA1c <7% : 34%

DiabCare 2008: 1832 subjects

Mean HbA1c 8,16%
HbA1c <7% : 32%

Indonesian HbA1c is the highest compared with other

DiabCare 2012: 1967 subjects participant countries in DISCOVER study, even after
initiating second line of therapy (mean+SD = 9.2+2%)1,
Mean HbA1c 8,3% almost 70% patient >8%).2
HbA1c <7% : 30.8%
1. Soeatmadji DW et al. 2nd ICE on IMERI, 7 November 2017, Jakarta, Indonesia
2. Ji L et al. 53rd EASD, 11–15 September 2017, Lisbon, Portugal.
 Current Practice in the Management of
DM2 in Indonesia: IDMPS Study
The HbAlc average was 8.27% and only 37.4% had reached the HbAIc target of <7%.

Target Achievement (HbA1c < 7%)

90.0
80.0 76.2
70.0 65.9
61.2 62.6
60.0
50.0
38.8 37.4
40.0 34.1
30.0 23.8
20.0
10.0
0.0
LSM OAD Insulin Total

yes no #REF!
Soewondo P. J Indon Med Assoc. 2011 IDMPS study: The International Diabetes Management Practices Study
 Discover Study:
Higher number of complications in Indonesia compared to
neighboring countries

HbA1c among Neighboring Countries Micro and macrovascular complications

26.9 28.3
Indonesia

Malaysia
16.3 16.5
India
9.7

3.2
7.0 7.5 8.0 8.5 9.0 9.5 Indonesia Malaysia India
Mean adjusted HbA1c (%) Micro (%) Macro (%)

Ji L et al. 53rd EASD, 11–15 September 2017, Lisbon, Portugal.

Kosiborod M et al., Caediovas Diabetol 2018. https://doi.org/10.1186/s12933-018-0787-8
 Current challenges of diabetes in
Indonesia
• Absolute number of patients with prediabetes and diabetes are
high
• The prevalence of undiagnosed diabetes is high
• Earlier beta cell dysfunction
• Many patients with diabetes have not adequately achieved glucose
targets
• Most patients with diabetes have not been sufficiently aggressive
in controlling risk factors
• Many patients with diabetes have poor adherence
to therapy
• Complications related diabetes are high
• Budget is relatively low, and its spending/cost almost come from
complications
Diabetes: Pathogenesis,
Classification, and Diagnosis
 Pathogenesis of T2DM

Schwartz SS et al. Diabetes Care 2016;39:179–186

 Pathogenesis of T2DM
Beta cells centric construct: Egregious eleven
The beta cell is a FINAL COMMON DENOMINATOR of beta cell
damage

Schwartz SS et al. Diabetes Care 2016;39:179–186

 Pathogenesis of T2DM
Beta cells centric construct: Egregious eleven
Treated treatments for mediating pathway of hyperglycemia

Schwartz SS et al. Diabetes Care 2016;39:179–186

 Classification of diabetes
Diabetes can be classified into the following general categories
• Type 1 diabetes (due to autoimmune b-cell destruction, usually leading
to absolute insulin deficiency)
• Type 2 diabetes (due to a progressive loss of adequate b-cell insulin
secretion frequently on the background of insulin resistance)
• Gestational diabetes mellitus (diabetes diagnosed in the second or
third trimester of pregnancy that was not clearly overt diabetes prior to
gestation)
• Specific types of diabetes due to other causes, e.g., monogenic
diabetes syndromes (such as neonatal diabetes and maturity-onset
diabetes of the young), diseases of the exocrine pancreas (such as cystic
fibrosis and pancreatitis), and drug- or chemical-induced diabetes (such
as with glucocorticoid use, in the treatment of HIV/AIDS, or after organ
transplantation)

Perkeni 2019; ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31

 Criteria for the diagnosis of diabetes

PG >126 mg/dL (7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.*
OR
2-h PG >200 mg/dL (11.1 mmol/L) during OGTT. The test should be performed as
described by the WHO, using a glucose load containing the equivalent of 75 g
anhydrous glucose dissolved in water.*
OR
A1C >6.5% (48 mmol/mol). The test should be performed in a laboratory using a
method that is NGSP certified and standardized to the DCCT assay.*
OR
In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random
plasma glucose >200 mg/dL (11.1 mmol/L).

DCCT, Diabetes Control and Complications Trial; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; WHO, World Health
Organization; 2-h PG, 2-h plasma glucose. *In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test
results from the same sample or in two separate test samples.

Perkeni 2019; ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31

 Criteria for the diagnosis of prediabetes

FPG 100 mg/dL (5.6 mmol/L) to 125 mg/dL (6.9 mmol/L) (IFG)
OR
2-h PG during 75-g OGTT 140 mg/dL (7.8 mmol/L) to 199 mg/dL (11.0
mmol/L) (IGT)
OR
A1C 5.7–6.4% (39–47 mmol/mol)

FPG, fasting plasma glucose; IFG, impaired fasting glucose; IGT, impaired glucose
tolerance; OGTT, oral glucose tolerance test; 2-h PG, 2-h plasma glucose. *For all
three tests, risk is continuous, extending below the lower limit of the range and
becoming disproportionately greater at the higher end of the range.

Perkeni 2019; ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31

 Criteria for testing for diabetes or
prediabetes in asymptomatic adults
1. Testing should be considered in overweight or obese (BMI >25 kg/m 2 or >23 kg/m2 in
Asian
Americans) adults who have one or more of the following risk factors:
• First-degree relative with diabetes
• High-risk race/ethnicity (e.g., African American, Latino, Native American, Asian
American, Pacific Islander)
• History of CVD
• Hypertension (>140/90 mmHg or on therapy for hypertension)
• HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride level >250 mg/dL
(2.82 mmol/L)
• Women with polycystic ovary syndrome
• Physical inactivity
• Other clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis
nigricans)
2. Patients with prediabetes (A1C >5.7% [39 mmol/mol], IGT, or IFG) should be tested yearly.
3. Women who were diagnosed with GDM should have lifelong testing at least every 3 years.
4. For all other patients, testing should begin at age 45 years.
5. If results are normal, testing should be repeated at a minimum of 3-year intervals, with
consideration of more frequent testing depending on initial results and risk status.

Perkeni 2019; ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31

Guideline the Management of
Diabetes in Indonesia
 Management of Diabetes in Indonesia: Aims

• Short-termly: relief complains, increase quality of

life, and prevent acute complications
• Long-termly: prevent, regress and inhibit
progressivity of chronic macro- and micro-
angiopathy
• Final aims: lower morbidity and mortality

Perkeni, 2019
 Management of Diabetes in Indonesia

Education and support

Medical nutrition therapy (MNT)

Physical activity

Smoking cessation

Medications

Perkeni, 2019; ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31

 Medical Nutrition Therapy
Basal calories need: 25-30 kcal/ideal BW
Ideal BW: 90% (height in cm -100) x 1kg

• Carbohydrate 45-60%
• Protein 10-20%
• Fat 20 – 25%
• saturated fat <7%
• Polyunsaturated fat <10%
• Sufficient vitamin & minerals
• Na : <2300 mg/day

Perkeni 2019, ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31

 Physical activity
• Children and adolescents with type 1 or type 2 diabetes or
prediabetes should engage in 60 min/day or more of moderate- or
vigorous-intensity aerobic activity, with vigorous muscle-
strengthening and bone-strengthening activities at least 3 days/
week. C
• Most adults with type 1 C and type 2 B diabetes should engage in
150 min or more of moderate- to vigorous-intensity aerobic
activity per week, spread over at least 3 days/week, with no more
than 2 consecutive days without activity. Shorter durations
(minimum 75 min/week) of vigorous- intensity or interval training
may be sufficient for younger and more physically fit individuals.
• Adults with type1 C and type 2 B diabetes should engage in 2–3
sessions/week of resistance exercise on non-consecutive days.
• All adults, and particularly those with type 2 diabetes, should
decrease the amount of time spent in daily sedentary behavior. B
Prolonged sitting should be interrupted every 30 min for blood
glucose benefits. C
• Flexibility training and balance training are recommended 2–3
times/week for older adults with diabetes. Yoga and tai chi may be
included based on individual preferences to increase flexibility,
muscular strength, and balance. C
Perkeni 2019, ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31
 Physical activity
• Children and adolescents with type 1 or type 2 diabetes or
prediabetes should engage in 60 min/day or more of moderate- or
vigorous-intensity aerobic activity, with vigorous muscle-
strengthening and bone-strengthening activities at least 3 days/
week. C
• Most adults with type 1 C and type 2 B diabetes should engage in
150 min or more of moderate- to vigorous-intensity aerobic
activity per week, spread over at least 3 days/week, with no more
• Aerobic,
than 2 consecutive days without activity. Shorter durations
(minimum 75 min/week) of vigorous- intensity or interval training
• 150 minutes/weeks,
may be sufficient for younger and more physically fit individuals.
• Adults with type1 C and type 2 B diabetes should engage in 2–3
• >3 days/week
sessions/week of resistance exercise on non-consecutive days.
• All adults, and particularly those with type 2 diabetes, should
decrease the amount of time spent in daily sedentary behavior. B
Prolonged sitting should be interrupted every 30 min for blood
glucose benefits. C
• Flexibility training and balance training are recommended 2–3
times/week for older adults with diabetes. Yoga and tai chi may be
included based on individual preferences to increase flexibility,
muscular strength, and balance. C
Perkeni 2019, ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31
 Antihyperglycemics tackle fasting and
postprandial plasma glucose through different
mechanisms of action
Glucose storage
and production
Metformin
Sulfonylureas
Meglitinides Insulin
secretion Glucose
storage and use
Insulins

Delayed gastric Islet β-cell

Amylin mimetics emptying
BLOOD Glucose uptake
GLUCOSE and FFA release Thiazolidinediones
GLP-1
receptor agonists
Glucagon
Glucose SGLT-2 inhibitors
secretion
DPP-4 inhibitors reabsorption
Islet α-cell

Incretin Neurotransmitter
-glucosidase inhibitor release release
Dopamine agonists
Bile acid sequestrants

• Bailey CJ, et al. Clin Pharmacol Therapeutics 2015;98:170–84

DeFronzo RA, et al. Diabetes 2009;58:773–95
 Algorithm of type 2 diabetes management
in Indonesia (Perkeni, 2019)
GOAL THERAPY : HbA1c <7% (Individualised)

HEALTHY
HEALTHY LIFESTYLE
LIFESTYLE MODIFICATION
MODIFICATION
Entry
Entry HbA1c
HbA1c Entry
Entry HbA1c
HbA1c Entry
Entry HbA1c
HbA1c
<7.5%
<7.5% >7.5%-9%
>7.5%-9% >9%
>9%

MONOTHERAPY
MONOTHERAPY SYMPTOMS
SYMPTOMS
DUAL
DUAL THERAPY
THERAPY
Metformin ((combination NO YES
combination of
of 22 drugs
drugs
GLP-1 RA with
with different
different
mechanism)
mechanism)
If
If not
not at
DUAL
DUAL INSULIN
DPP-4i at INSULIN
goal
goal in
in 3
3 GLP-1 RA TRIPLE
TRIPLE THERAPY
THERAPY THERAPY
THERAPY ±±
months,
drug

months, ((combination
combination of
of 33 drugs
drugs with
linedrug

AG-i proceed with Other

Other
proceed DPP-4i different OR
to
to DUAL
DUAL different mechanism)
mechanism) Agents
Agents
firstline

SGLT-2i THERAP
THERAP If
If not
not at
at
Y TZD goal in
in 3 GLP-1 RA TRIPLE
TRIPLE
drug

Y
otherfirst

goal 3
linedrug

TZD months,
months, THERAPY
THERAPY
SGLT-2i proceed
proceed toto DPP-4i
orother

TRIPLE
firstline

TRIPLE If
If not
not at
SU/GN at
drugs
linedrugs

THERAPY
THERAPY
Basal goal
goal in
in 3
3
TZD
otherfirst

(combinatio
Metforminor

(combinatio months,
Insulin n
n of
of 3
3 months,
Metformin

proceed
drugs) ADD OR INTENSIFY
orother

proceed
Secondline

drugs) SGLT-2i to
SU/GN to ADD
ADD
OR INSULIN
Second

OR
Basal Insulin
Metforminor

INTENSIF
INTENSIF
AG-i
Metformin

Y
Y Insulin
Insulin
SU/GN Therapy
Therapy

AG-i
 Summary of glycemic recommendations for
many nonpregnant adults with diabetes

A1C < 7.0% (53 mmol/mol)*

Pre prandial capillary plasma 80–130 mg/dL* (4.4–7.2
glucose mmol/L)
Peak postprandial capillary
plasma glucose† <180 mg/dL* (10.0 mmol/L)
*More or less stringent glycemic goals may be appropriate for individual patients.
Goals should be individualized based on duration of diabetes, age/life expectancy,
comorbid conditions, known CVD or advanced microvascular complications,
hypoglycemia unawareness, and individual patient considerations. †Postprandial
glucose may be targeted if A1C goals are not met despite reaching preprandial
glucose goals. Postprandial glucose measurements should be made 1–2 h after the
beginning of the meal, generally peak levels in patients with diabetes.

Perkeni 2019; ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31

 Estimated average glucose (eAG)
A1C (%) mg/dL* mmol/L
5 97 (76–120) 5.4 (4.2–6.7)
6 126 (100–152) 7.0 (5.5–8.5)
7 154 (123–185) 8.6 (6.8–10.3)
8 183 (147–217) 10.2 (8.1–12.1)
9 212 (170–249) 11.8 (9.4–13.9)
10 240 (193–282) 13.4 (10.7–15.7)
11 269 (217–314) 14.9 (12.0–17.5)
12 298 (240–347) 16.5 (13.3–19.3)

Data in parentheses are 95% CI. A calculator for converting A1C results into eAG, in either mg/dL or
mmol/L, is available at professional.diabetes.org/eAG. *These estimates are based on ADAG data of ;2,700
glucose measurements over 3 months per A1C measurement in 507 adults with type 1, type 2, or no
diabetes. The correlation between A1C and average glucose was 0.92 (6,7). Adapted from Nathan et al.

Perkeni 2019; ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31

 Mean glucose levels for specified HbA1c
levels
HbA1c Mean Mean Mean Mean Mean
(%) plasma fasting premeal postmeal bedtime
glucose glucose glucose glucose glucose
(mg/dL) (mg/dL) (mg/dL) (mg/dL) (mg/dL)
6 126
5.5–6.49 122 118 144 136
6.5–6.99 142 139 164 153
7 154
7.0–7.49 152 152 176 177
7.5–7.99 167 155 189 175
8 183
8.0–8.5 178 179 206 222
9 212
10 240
11 269
12 298

Perkeni, 2019; ADA 2019