Currents Issues and Challenges in Chronic Disease Control

Agus Widiyatmoko

Pulmonary conditions are among the most prevalent types of chronic health problems
Number (in millions) of Americans reporting specific chronic conditions*
2,4
Stroke Cancers Diabetes Heart disease Mental disorders

10,6 13,7 19,1 30,3 36,8

Hypertension

49,2
Pulmonary conditions

10

20

30

40

50

60

70

Million
*This study evaluated the burden of seven of the most common chronic diseases/conditions (cancer, diabetes, heart disease, hypertension, mental disorders, pulmonary conditions, and stroke. Source: DeVol, R, Bedroussian, A, et al. An Unhealthy America: The Economic Burden of Chronic Disease. The Milken Institute. October 2007. Full report and methodology available at: www.chronicdiseaseimpact.com.

Mental health conditions, such as depression, dramatically increase disability* when paired with other chronic health conditions
Degree of disability due to select chronic diseases
25

Degree of disability due to select chronic diseases plus depression

25 20 15 10 23 20 17 19

Degree of disability

20 15 10 6 5 0
Diabetes Arthritis Angina Asthma

7
5 0
Diabetes Arthritis Angina Asthma

3,5

*Disability is the measure of difficulty completing important and ordinary life tasks and roles.
Source: WHO World Health Survey, Moussavi, et al, (2007) Lancet

Older adults are more likely to have chronic health conditions, but Americans of all ages are affected
Percent of U.S. population with chronic conditions

100% 80% 60% 40 40% 20% 0% 0-19 20-44

Ages

90 68 42 15 6 45-64 65+ 72
1 or more chronic conditions 2 or more chronic conditions

26

Source: Anderson, G. Chronic Conditions: Making the case for ongoing care. Johns Hopkins University. November 2007.

Cancer
Prevalence and Incidence of Cancer More than 18 million new cases of cancer have been diagnosed in the United States since 1990.
American Cancer Society 2004, Cancer Facts and Figures

Approximately 1.37 million new cancer cases were expected to be diagnosed in 2005.
American Cancer Society 2005, Cancer Facts and Figures

The National Cancer Institute estimated that in January 2001, there were approximately 9.8 million Americans with a history of cancer.
American Cancer Society 2005, Cancer Facts and Figures

American men have approximately a one-in-two lifetime risk of developing cancer. American women have approximately a one-in-three lifetime risk.
American Cancer Society 2005, Cancer Facts and Figures

Cancer
AgeA Major Risk Factor Age is the major risk factor for cancerabout 76% of all cancers are diagnosed in individuals age 55 and over.
American Cancer Society 2005, Cancer Facts and Figures

The incidence of colorectal cancer is more than 50 times higher in people ages 60-79 than in those under 40. 91% of new cases and 94% of deaths from colorectal cancer occur in individuals 50 and older.
American Cancer Society 2005, Colorectal Cancer Facts and Figures

A womans risk of breast cancer increases with ageabout 80% of breast cancer cases occur in women over age 50.
National Institute on Aging, Age Page: Cancer facts for people over 50

Age is the greatest risk factor for prostate cancer with more than 70% of all cases diagnosed in men age 65 and older.
Prostate Cancer Foundation

Cancer
The Burden of Cancer The Human Burden In 2002, cancer patients made 25.3 million office visits to their physicians.
Woodwell and Cherry 2004, National Ambulatory Medical Care Survey

In 2002, cancer patients made 2.1 million visits to hospital outpatient departments.
Hing and Middleton 2004, National Hospital Ambulatory Medical Care Survey

45% of middle-age men who have been diagnosed with cancer in the last year have recurring pain. 41% of middle-age women with a history of cancer experience recurring pain.
Pfizer 2005, The Burden of Cancer in American Adults

Cancer
The Burden of Cancer The Human Burden 1.3 million cancer patients were discharged from hospital inpatient stays in 2003. More than 650,000 of them were over 65.
DeFrances, Hall, and Podgornik 2005, National Hospital Discharge Survey

Less than 20% of 65-year-olds who have been diagnosed with cancer are free of comorbidities and physical limitations.
Joyce et al. 2005, The Lifetime Burden of Chronic Disease among the Elderly

43% of older men and 45% of older women with a history of cancer report some type of activity limitation.
Pfizer 2005, The Burden of Cancer in American Adults

Cancer
The Burden of Cancer The Economic Burden The National Institutes of Health estimated the overall cost of cancer in 2004 was $189.8 billion. This figure includes $69.4 billion in direct medical costs, $16.9 billion in indirect morbidity costs, and $103.5 billion in indirect mortality costs.
American Cancer Society 2005, Cancer Facts and Figures

Colorectal cancer treatment costs about $6.5 billion per year; breast cancer treatment costs nearly $7 billion per year; and cervical cancer treatment costs around $2 billion per year.
Brown, Lipscomb, and Snyder 2001, The Burden of Illness of Cancer

Direct annual spending for prostate cancer is $3.6 billion.

Pfizer 2005, The Burden of Cancer in American Adults

Cancer
The Burden of Cancer The Economic Burden The annual national cost of informal caregiving for cancer patients is an estimated $1 billion.
Hayman et al. 2001, Estimating the Cost of Informal Caregiving for Elderly Patients with Cancer

Every year, $38.4 billion of direct medical services is spent on cancerassociated care for community-dwelling adults.
Pfizer 2005, The Burden of Cancer in American Adults

Chronic Disease and Tobacco:

Effects of Cigarette Smoking on Chronic Disease

Effects of Smoking
Smoking harms nearly every organ of the body. Generally, smoking causes many diseases and reduces the overall health of smokers.

The adverse health effects from cigarette smoking account for an estimated 438,000 deaths, or nearly 1 of every 5 deaths, each year in the United States. More deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined.

Effects of Smoking
Diseases known to be caused by smoking, include: bladder, esophageal, laryngeal, lung, oral, and throat cancers, chronic lung diseases, coronary heart and cardiovascular diseases, as well as reproductive effects and sudden infant death syndrome. The list of diseases caused by smoking has been expanded to include abdominal aortic aneurysm, acute myeloid leukemia, cataract, cervical cancer, kidney cancer, pancreatic cancer, pneumonia, periodontitis, and stomach cancer.

Source: 2004 Surgeon Generals ReportThe Health Consequences of Smoking

Effects of Smoking: Cancer

Cancer is the second leading cause of death and was among the first diseases causally linked to smoking. Lung cancer is the leading cause of cancer death, and cigarette smoking causes most cases. Compared to nonsmokers, men who smoke are about 23 times more likely to develop lung cancer and women who smoke are about 13 times more likely. Smoking causes about 90% of lung cancer deaths in men and almost 80% in women. Cancer-causing agents (carcinogens) in tobacco smoke damage important genes that control the growth of cells, causing them to grow abnormally or to reproduce too rapidly.

Source: 2004 Surgeon Generals ReportThe Health Consequences of Smoking

Effects of Smoking: Cancer

Cigarette smoking is a major cause of esophageal cancer in the United States. Reductions in smoking and smokeless tobacco use could prevent many of the approximately 12,300 new cases and 12,100 deaths from esophageal cancer that occur annually. The combination of smoking and alcohol consumption causes most laryngeal cancer cases. In 2003, an estimated 57,400 new cases of bladder cancer were diagnosed and an estimated 12,500 died from the disease. For smoking-attributable cancers, the risk generally increases with the number of cigarettes smoked and the number of years of smoking, and generally decreases after quitting completely. Cigarette smoking increases the risk of developing mouth cancers. This risk also increases among people who smoke pipes and cigars. Reductions in the number of people who smoke cigarettes, pipes, cigars, and other tobacco products or use smokeless tobacco could prevent most of the estimated 30,200 new cases and 7,800 deaths from oral cavity and pharynx cancers annually in the United States.

Source: 2004 Surgeon Generals ReportThe Health Consequences of Smoking

Lung Cancer

Effects of Smoking: Coronary Heart Disease and Stroke

Coronary heart disease and stroke, the primary types of cardiovascular disease caused by smoking, are the first and third leading causes of death in the United States. More than 61 million Americans suffer from some form of cardiovascular disease, including high blood pressure, coronary heart disease, stroke, congestive heart failure, and other conditions. More than 2,600 Americans die every day because of cardiovascular diseases, about 1 death every 33 seconds. Toxins in the blood from smoking cigarettes contribute to the development of atherosclerosis. Atherosclerosis is a progressive hardening of the arteries caused by the deposit of fatty plaques and the scarring and thickening of the artery wall. Inflammation of the artery wall and the development of blood clots can obstruct blood flow and cause heart attacks or strokes.
Source: 2004 Surgeon Generals ReportThe Health Consequences of Smoking

Coronary Heart Disease

Effects of Smoking: Coronary Heart Disease and Stroke

Smoking-related coronary heart disease may contribute to congestive heart failure. An estimated 4.6 million Americans have congestive heart failure and 43,000 die from it every year. Strokes are the third leading cause of death in the United States. Cigarette smoking is a major cause of strokes. The U.S. incidence of stroke is estimated at 600,000 cases per year, and the one-year fatality rate is about 30%. The risk of stroke decreases steadily after smoking cessation. Former smokers have the same stroke risk as nonsmokers after 5 to 15 years.
Source: 2004 Surgeon Generals ReportThe Health Consequences of Smoking

Stroke

Effects of Smoking: Respiratory Health

In 2001, chronic obstructive pulmonary disease (COPD) was the fourth leading cause of death in the United States, resulting in more than 118,000 deaths. More than 90% of these deaths were attributed to smoking. About 10 million people in the United States have been diagnosed with COPD, which includes chronic bronchitis and emphysema. COPD is consistently among the top 10 most common chronic health conditions. Smoking is related to chronic coughing and wheezing among adults. Smoking damages airways and alveoli of the lung, eventually leading to COPD. Smokers are more likely than nonsmokers to have upper and lower respiratory tract infections, perhaps because smoking suppresses immune function. In general, smokers lung function declines faster than that of nonsmokers.
Source: 2004 Surgeon Generals ReportThe Health Consequences of Smoking

COPD (Chronic Obstructive Pulmonary Disorder)

Statewide Impact

Tobacco-Related Mortality
Tobacco use is the leading preventable cause of death in the United States. Cigarette smoking causes an estimated 438,000 deaths, or about 1 of every 5 deaths, each year. This estimate includes approximately 38,000 deaths from secondhand smoke exposure. Cigarette smoking kills an estimated 259,500 men and 178,000 women in the United States each year.

Tobacco-Related Mortality
More deaths are caused each year by tobacco use than by all deaths from human immunodeficiency virus (HIV), illegal drug use, alcohol use, motor vehicle injuries, suicides, and murders combined.
On average, adults who smoke cigarettes die 14 years earlier than nonsmokers. Based on current cigarette smoking patterns, an estimated 25 million Americans who are alive today will die prematurely from smoking-related illnesses, including 5 million people younger than 18.6

Chronic Disease and Tobacco:

Health Effects of Cigarette Smoking and Chronic Disease
The pie chart represents the estimated annual number of smoking-attributable deaths in the United States during 1997 through 2001 by specific causes, as follows: Lung cancer: 123,800 deaths Other cancers: 34,700 deaths Chronic lung disease: 90,600 deaths Coronary heart disease: 86,800 deaths Stroke: 17,400 deaths Other diagnoses: 84,600 deaths

Source: CDC SAMMEC, MMWR 2005; Vol. 54, No. 25:6258.

Currents Issues
Hypertension Diabetes Mellitus

EPIDEMIOLOGI DAN PREVALENSI HIPERTENSI

Latar Belakang
Hipertensi adalah salah satu penyebab

kematian nomor satu, secara global. Komplikasi pembuluh darah yang disebabkan hipertensi dapat menyebabkan penyakit jantung koroner, infark miokard, stroke, dan gagal ginjal. Komplikasi pada organ tubuh menyebabkan angka kematian yang tinggi.

 Hipertensi dan komplikasinya

menyebabkan
penderita, keluarga dan negara harus

mengeluarkan lebih banyak biaya pengobatan dan perawatan, menurunkan kualitas hidup penderita.

Natural History of Hypertensive Disease

From endothelial dysfunction to target-organ damage

Endothelial dysfunction

Vascular dysfunction

Elevated BP

Target organ damage LVH

Hypertension, Aging, Smoking, Dyslipidemia

Renal dysfunction Stroke MI/CAD

Berbagai kondisi yang berhubungan dengan risiko serebrovaskuler

Mikroalbuminuria Hiperkoagulabilitas

DM tipe 2

Toleransi glukosa terganggu Resistensi insulin

Peningkatan risiko Peny. serebrovaskuler

Obesitas viseral

Hipertensi

Dislipidemia Hiperinsulinemia

Prevalensi Hipertensi
Prevalensi hipertensi meningkat sejalan

dengan perubahan gaya hidup seperti merokok, obesitas, inaktivatas fisik, dan stres psikososial. Hipertensi sudah menjadi masalah kesehatan masyarakat (public health problem) dan akan menjadi masalah yang lebih besar jika tidak ditanggulangi sejak dini.

Prevalensi di Dunia
Secara umum, prevalensi hipertensi pada usia

lebih dari 50 tahun berkisar antara 15%-20%. Prevalensi di

Vietnam pada tahun 2004 mencapai 34,5%, Thailand (1989) 17%, Malaysia (1996) 29,9%, Philippina (1993) 22%, dan

Singapura (2004) 24,9%.

Di Amerika, prevalensi tahun 2005 adalah 21,7%.

Prevalensi di Yogyakarta
Dari data penelitian di Kecamatan Mlati

Kabupaten Sleman didapatkan angka prevalensi hipertensi (berdasar kriteria JNC VII) sebesar 26,2% (Sjabani, Wijayanti, dan Prasanto, 2006) dan 11,4% pada studi dengan stratification random sampling 9 dari 45 dusun (Sjabani dan Bawazier, 2007)

Hypertension management issues

Measurement Investigation Non-pharmacological treatment Thresholds for drug treatment Targets for drug treatment Drug choices trial update Other treatments Follow-up

BHS classification of blood pressure levels

Systolic blood pressure (mmHg) Diastolic blood pressure

Category

Optimal blood pressure Normal blood pressure High-normal blood pressure Grade 1 Hypertension (mild) Grade 2 Hypertension (moderate) Grade 3 Hypertension (severe) Isolated Systolic Hypertension (Grade 1) Isolated Systolic Hypertension (Grade 2)

<120 <130 130-139 140-159 160-179 >180 140-159 >160

<80 (mmHg) <85 85-89 90-99 100-109 >110 <90 <90

Potential indications for the use of ambulatory blood pressure monitoring

Unusual variability

Possible white coat hypertension

Informing equivocal treatment decisions Evaluation of nocturnal hypertension

Evaluation of drug-resistant hypertension

Determining the efficacy of drug treatment over 24 hours Diagnoses and treatment of hypertension in pregnancy Evaluation of symptomatic hypotension

Routine investigations

Urine strip test for protein and blood Serum creatinine and electrolytes Blood glucose - ideally fasted Blood lipid profile (at least total and high density lipoprotein (HDL) cholesterol) ideally fasted for consideration of triglycerides Electrocardiogram

Lifestyle measures
Maintain normal weight for adults (body mass index 20-25 kg/m2) Reduce salt intake to <100 mmol/day (<6g NaCl or <2.4 g Na+/day) Limit alcohol consumption to 3 units/day for men and 2 units/day for women

Engage in regular aerobic physical exercise (brisk walking rather than weight lifting) for 30 minutes per day, ideally on most of days of the week but at least on three days of the week
Consume at least five portions/day of fresh fruit and vegetables Reduce the intake of total and saturated fat

Suggested target blood pressures during antihypertensive treatment. Systolic and diastolic blood pressures should both be attained, e.g. <140/85 mmHg means less than 140 mmHg for systolic blood pressure and less than 85 mmHg for diastolic blood pressure
Clinic BP (mmHg)
No diabetes Optimal treated BP pressure <140/85 Diabetes <130/80

Audit Standard

<150/90

<140/80

Audit standard reflects the minimum recommended levels of blood pressure control.

Despite best practice, the Audit Standard will not be achievable in all treated hypertensives.
For ambulatory (mean daytime) or home blood pressure monitoring - reducing these targets by ~10/5 is recommended.

Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs
Class of drug Alphablockers Compelling indications Benign prostatic hypertrophy Chronic renal disease, Type II diabetic nephropathy, proteinuric renal disease LV dysfunction post MI, intolerance of other antihypertensive drugs, proteinuric renal disease, chronic renal disease, heart failure Possible indications Compelling contraindications Urinary incontinence Pregnancy, renovascular disease

Caution Postural hypotension, heart failure Renal impairment PVD

ACEHeart failure, inhibitors LV dysfunction, post MI or established CVD, Type I diabetic nephropathy, 2o stroke prevention ARBs ACE inhibitorintolerance, Type II diabetic nephropathy, hypertension with LVH, heart failure in ACEintolerant patients, post MI

Renal impairment PVD

Pregnancy, renovascular disease

Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs
Class of drug Beta-blockers Compelling indications MI, Angina Possible indications Heart failure Caution Heart failure, PVD, Diabetes (except with CHD) Combination with betablockade Compelling contraindications Asthma/COPD, Heart block

CCBs (dihydropyridine) CCBs (rate limiting)

Elderly, ISH Angina

Angina Elderly

Heart block Heart failure Gout

Thiazide/thiazide- Elderly like diuretics ISH Heart failure 2 o stroke prevention

Other medications for hypertensive patients

Primary prevention
(1) Aspirin: use 75mg daily if patient is aged 50 years with blood pressure controlled to <150/90 mm Hg and either; target organ damage, diabetes mellitus, or 10 year risk of cardiovascular disease of 20% (measured by using the new Joint British Societies cardiovascular disease risk chart)
(2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years, with a 10 year risk of cardiovascular disease of 20% (measured by using the new Joint British Societies cardiovascular disease risk chart) and with total cholesterol concentration 3.5mmol/l (3) Vitaminsno benefit shown, do not prescribe

Other medications for hypertensive patients

Secondary prevention (including patients with type 2 diabetes)

(1) Aspirin: use for all patients unless contraindicated

(2) Statin: use sufficient doses to reach targets if patient is aged up to at least 80 years with a total cholesterol concentration 3.5 mmol/l (3) Vitamins no benefit shown, do not prescribe

Lipid targets

Targets for lipid lowering Ideal TC<4.0mmol/l or LDL <2.0mmol/l or 25% in TC or 30% in LDL-C whichever is the greater TC <5.0mmol/l or LDL <3.0mmol/l or 25% in TC or 30% in LDL-C whichever is the greater

Audit

Current Issues

Clinical Development CYT006-AngQb

The randomized, double-blind and placebo-controlled

study was designed to evaluate the safety, tolerability and exploratory efficacy of the vaccine candidate. The phase I part of the study included 16 normotensive subjects and the phase IIa part 72 hypertensive participants with mild to moderate hypertension. In the phase I study part, the 16 participants received one injection of the vaccine (100 g) or placebo. In the phase IIa study part, two dose levels of the vaccine (100 g and 300 g) were compared to placebo. The 72 hypertensive participants received 3 injections of the vaccine or placebo at weeks 0, 4 and 12. Exploratory efficacy of the vaccine was assessed in individual subjects by 24-hour ambulatory blood pressure monitoring at baseline and post-treatment (i.e. 2 weeks after the last injection).

Achtung, Achtung
What comes to you of good is verily from Allah; and what comes to you of ill is from your own self (your actions)
[Al Quran s. an-Nisa (4): 79]

50

? Type 2 Diabetes mellitus (T2DM)

T2DM: The Growing Epidemic

Progressive metabolic disease Increased prevalence globally Potential causes
Aging population Lifestyle changes Limited physical activity Obesity High caloric intake

51

Indonesia 4th world-rank

Prevalence of T2DM
Estimation of DM patients in 2020
Worldwide: 306 mio (Mc Carthy/Zimmet, 1993) Indonesia: 21.3 mio (Konsensus, 2006)

52

Estimation of T2DM in ASEAN

1995: 8.5 mio 2000: 12.3 mio 2010: 19.4 mio

The diabetes epidemic: facts

DM 246 million people worldwide (380 million by 2025) Each year 7 million people develop diabetes. Each year, 3.8 million deaths Every 10 seconds a person dies Every 10 seconds two people develop diabetes.
RISKESDAS 2008: Prevalensi 5,7% INDONESIA 2000 5.6 million people with DM 2020 8.2 million people with DM

Th 2000 DM di Indonesia 8,426,000

World 5th largest prevalence !! (International Diabetes Federation)

IDF , Diabetes ATLAS 2006

IGT is driving the worldwide diabetes pandemic

50 45 40 35 30 25 20 15 10 5 0 20-44

% of population

IGT Undiagnosed type 2 diabetes Diagnosed type 2 diabetes

45-54

55-64

65

Age (years)

Harris. Consultant. 1997;37 Suppl:S9

United Nations Resolution 61/225:

20 December 2006

This landmark Resolution recognizes diabetes as a chronic, debilitating and costly disease associated with major complications that pose severe risks for families, countries and the entire world. It designates 14 November, World Diabetes Day For the first time, a non-infectious disease has been seen as posing as serious a global health threat as infectious epidemics such as HIV/AIDS.

56

Prevalence
Indonesia: 1.1 2.3% 7.3 ~ 12.7%
Jakarta

(urban): 1.7% (1982) 5.7%

(1993) Makassar (urban): 1.5% (1981) 2.9% (1998) Manado: 6.1% (1995) Depok: 12.7% (2000) Singaraja: 7. 3% (2003) Yogyakarta (urban, semiurban, rural): 1.5% (1986)

Pemeriksaan Laboratorium Gula Darah (GD)

mg/dL Normal <100 <100 Prediabetes 100-199 100-125

Diabetes > 200 > 126 > 200

GDs GDp GDpp

<100

100-199

HbA1C (%) 6-7 7-8 8-9 9 - 10 > 10

GD rata-rata 135 - 170 170 - 205 205 - 240 240 - 275 > 275

57

Jenis-Jenis Diabetes
Diabetes tipe 2
Kasus diabetes yang sering ditemui Sering tanpa gejala Silent Killer
Kerusakan pankreas Membutuhkan suntikan insulin terjadi pada masa bayi/kanak2 / remaja Diabetes hanya pada saat kehamilan Setelah melahirkan GD kembali normal Kemungkinan beberapa tahun kemudian menetap menjadi Diabetes tipe 2 Karena kelainan genetik Infeksi Obat-obatan dll

Diabetes tipe 1

Diabetes pada kehamilan (gestasional)

Diabetes tipe lain

58

Faktor Resiko Diabetes Dapat dimodifikasi

Penyakit jantung/stroke kurang gerak/malas Pola makan tidak sehat

Hipertensi (140/90 mmHg)

Prediabetes GDsPrediabetes : 100-199

makan berlebihan Dislipidemia (HDL 35 mg/dL dan atau trigliserida 250 mg/dL)

GDp:100-125 GDpp:100-199
59

Kegemukan (IMT > 23 kg/m2)

Faktor Resiko Diabetes Tidak dapat dimodifikasi

Usia > 45 tahun

Riwayat keluarga diabetes

Riwayat pernah Diabetes gestational

riwayat melahirkan bayi > 4 Kg

Mereka yang mempunyai faktor resiko dianjurkan melakukan permeriksaan gula darah untuk tujuan skrining/penyaring.
60

Komplikasi Diabetes
Akut
(Muncul Tiba-tiba)

Kronik
(muncul perlahan-lahan, dalam hitungan tahun)
Stroke Retinopati dan Katarak Serangan Jantung (infark) Gagal Ginjal Neuropati (kesemutan,baal)

Penyakit Pembuluh Darah Tepi (luka di kaki, ulkus) 61

Bagaimana Bersahabat dengan diabetes ??

prediabetes / non diabetes

Diabetes

Diabetes

Komplikasi diabetes
71

Should we attempt to prevent diabetes?

important health problem the early development is understood a test to detect the predisease (OGTT) safe, effective, and reliable method(s) to prevent or at least delay the disease

PRIMARY PREVENTION
Therapy: safe, effective, and reliable

In the Finnish study

1 year number needed to treat (NNT): 22 5 year NTT: 5

In the DPP
Lifestyle 3 years NNT: 7 Metformin 3 years NTT: 7

None of the interventions were associated with any major harmful effects

PRIMARY PREVENTION
Recommendations to prevent or delay diabetes

Individuals at high risk Screening & Intervention strategy Follow-up counseling Monitoring for the development of diabetes Treatment for other CVD risks Drug therapy should not be routinely & must be cost-effectiveness.

SECONDARY PREVENTION
Knowledge from UKPDS and DECODE
UKPDS1
Total load (HbA1c)
Hyperglycaemia Postprandial peaks

DECODE2

Microangiopathy
Chronic glucose toxicity Tissue damage Diabetes complication
DECODE: Diabetes Epidemiology: Collaborative Analysis of Diagnostic Criteria in Europe, HbA1c: haemoglobin A1c, UKPDS: UK Prospective Diabetes Study

Macroangiopathy
Acute glucose toxicity

1. Stratton IM, et al. BMJ 2000;321:40512. 2. DECODE. Diabetes Care 2003;26:68896.

Pengendalian gula darah

Diabetes
Komplikasi

Mengendalikan gula darah terkontrol baik : 1. Pengaturan Makan 2. Kegiatan Jasmani 3. Memakan obat-obat yang dianjurkan dokter
77

1. Pengaturan Makan
Pengaturan Pola makan Diabetes Pola makan orang sehat normal

3J
78

Pengaturan Makan

Jenis Jumlah
Karbohidrat 60 - 70 % Protein 10 - 15 % Lemak 20 - 25 %

Sumber zat tenaga Sumber zat pembangun Sumber zat pengatur

Jadwal Makan
Makan pagi Makan siang Selingan 10.00 12.00-13.00 Makan malam Selingan Selingan* 16.00 19.00 21.00
79

07.00-08.00

Makanan yang harus

dibatasi/dihindari

Makanan yang mengandung banyak kolesterol (kuning telur, otak, jeroan, daging berlemak, keju, kerang) Makanan yang mengandung lemak jenuh (gorengan, minyak kelapa, santan kental) Makanan yang mengadung gula murni (sirup, permen,kue manis, coklat manis, dsb)

Gula < 5% kebutuhan kalori sehari Garam < 1 sendok teh (6-7 g) sehari.

85

Pengaturan Makan

Makanan Khusus
Produk bubuk : kandungan gizi
makanan lengkap untuk penyandang DM
Diperlukan dalam keadaan tertentu: Saat tidak nafsu makan/sakit Sibuk/tidak sempat makan Bekal dalam perjalanan

Pemanis alternatif
tujuan meningkatkan kualitas rasa produk makanan rendah kalori & untuk penyandang Diabetes
aman digunakan asal tidak melibihi batas aman (Accepted Daily Intake)
86

2. Kegiatan Jasmani

90

Kegiatan Jasmani
Kurangi Aktifitas
Hindari aktifitas sedenter

menonton televisi, menggunakan internet, main game komputer Jalan cepat Golf Berenang Bersepeda Berkebun Berjalan kaki ke pasar (tidak menggunakan mobil) Menggunakan tangga (tidak menggunakan lift) Menemui rekan kerja (tidak hanya melalui telepon ) Berjalan-jalan Membereskan rumah

Persering Aktifitas
Mengikuti olahraga rekreasi dan beraktifitas fisik tinggi pada waktu liburan

Aktifitas Harian
Kebiasaan bergaya hidup sehat

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Kegiatan Jasmani

Manfaat Latihan jasmani

bagi Diabetes tipe 2 1. Kadar glukosa darah 2. 3. 4.

Kegemukan

Lipid (lemak) darah ResikoTekanan darah tinggi

5. Resiko penyakit jantung koroner

6. Kualitas hidup & kemampuan kerja
92

Perencanaan olahraga bagi penyandang Diabetes

1.Konsultasi dengan dokter atau edukator (pra latihan) 2. Persiapan latihan jasmani

3. Pengawasan selama latihan dengan memonitor: a. Denyut nadi b. Keluhan seperti: pusing, gemetaran, lemas, sesak, dll
4. Gunakan sepatu olahraga yang sesuai :

93

Bahaya/risiko olahraga pada penyandang Diabetes

1. Memperburuk kadar glukosa darah 2. Hipoglikemia akibat olahraga 3. Gangguan pada kaki

4. Komplikasi jantung & pembuluh darah

5. Cedera otot dan tulang
94

3. Obat-obatan oral & Insulin

95

Intervensi obat-obat untuk mengurangi Komplikasi akibat diabetes

Setiap penurunan 1% HBA1C

Mengurangi kejadian*

Kematian karena diabetes Serangan jantung

1%

Komplikasi mikrovaskular (mata, ginjal, saraf)

Penyakit pembuluh darah tepi (Luka di kaki)
*p<0.0001
96 UKPDS 35 BMJ 2000;321:405-412

Obat-obat Oral dan Insulin

Obat-obat oral (makan)

Metformin

Glimepiride

Acarbose (Glucobay)

Repaglinide

Rosiglitazone
97

Obat-obat Oral dan Insulin

Obat-obat oral (makan)

Obat -obat oral diperlukan bila

sasaran gula darah belum tercapai dengan pengaturan makan & latihan jasmani.
Penyandang Diabetes yang

harus selalu minum obat agar kadar glukosa darahnya terkendali. Untuk
penyandang Diabetes seperti ini, tentu sepanjang hidupnya harus selalu memerlukan obat.

Pemakaian Obat Oral jangka panjang dapat mengendalikan

kadar glukosa darah sehingga bermanfaat mencegah komplikasi Diabetes termasuk kerusakan ginjal. 98

Obat-obat Oral dan Insulin

Insulin
Cara pemberian insulin dapat dilakukan dengan menggunakan: Semprit dan jarum

Pen insulin

Pompa insulin

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Indikasi penggunaan insulin

Obat-obat Oral dan Insulin

Keadaan lain yang memerlukan terapi insulin adalah: 1. Penurunan berat badan yang cepat 2. Hiperglikemia berat disertai ketosis 3. Ketoasidosis diabetik 4. Hiperglikemia hiperosmolar non ketotik 5. Hiperglikemia dengan asidosis laktat 6. Stres berat (infeksi sistemik, operasi besar, stroke, serangan jantung) 7. Kehamilan dengan DM (DM gestasional) yang tidak terkendali dengan perencanaan makan. 8. Gangguan fungsi ginjal atau hati yang berat 9. Adanya kontraindikasi dan atau alergi terhadap OHO

103

Terapi Diabetes
KONSERVATIF ( LAMA)

Obat-obat Oral dan Insulin

+
+
3

2
1
104

Cara konservatif : Bertindak Setelah Gagal

Merubah Gaya Hidup Minum Obat satu Menaikan Dosis Obat Kombinasi Minum Obat Minum Obat Obat + Single Insulin + Multiple Insulin

HbA1c
(%)
10 9 8 7 6

KerusakanPancreas /Komplikasi

Kemajuan pasien Diabetes

Regrets and

New Solution Intensive Insulin Therapy

Kita Telah Gagal

Memelihara / Dalam waktu lama memperbaiki Hyperglycemia fungsi Beta-cell

Kita telah mengabaikan

Mengurangi kwalitas hidup

Blindness, Amputation, Neuropathic Pain

Death
Heart Attack Stroke

Pengobatan dng Intensive Insulin

Insulin Dengan Obat Oral banyak Pasien gagal mencapai normoglycemia.

Pengobatan dng Insulin adalah Cara pengobatan yang paling Effective utk menurunkan Kadar Gula Darah

Proactive Jangan Menunggu sampai

Mengalami hyperglycemia Atau komplikasi

Segera Bertindak
Capailah normoglycemia HbA1c < 6.5% Pakailah Cara terbaik

Secepat Mungkin

Setelah pengobatan Oral

Se Dini anda mulai dengan Yg lama Secara bertahapPengobatan intensive Tidak berhasil Fungsi beta cell masih bisa Dipertahankan dan Anda dapat Fungsi beta-cell Hidup sehat tanpa minum Obat
Tidak dapat dikembalikan.

Obat-obat Oral dan Insulin

Kriteria Pengendalian DM
Baik Gula darah puasa (mg/dL) Gula darah 2 jam (mg/dL) 80 - 99 80 -144 Sedang 100 - 125 145 - 179 Buruk 126 180

A1c (%)
Kolesterol total (mg/dL) Kolesterol LDL (mg/dL) Kolesterol HDL (mg/dL)

< 6,5
< 200 < 100 > 40 (Pria) > 50 (wanita) < 150 18,5 - <23 130/80

6,5 - 8
200 - 239 100 - 129

>8
240 130

Trigliserida (mg/dL) IMT (kg/m2) Tekanan darah (mmHg)

150 - 199 23 - 25 > 130-140/ > 80-90

200 >25 > 140/90

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Upaya Mempertahankan Target Terapi pada DM Tipe-2 (Perkeni, 2006)

A1C (%) Saat Ini GDP (mg/dL) saat ini Terapi Saat Ini Tindak Selanjutnya Terapi diiteruskan (2-3 bulan)
Diawasi dan dilakukan penyesuaian Rx untuk mencapai target Diawasi dan dilakukan penyesuaian Rx untuk mencapai target

6-6.5

110

T E R U S K A N P E R U B A H A N G A Y A H I D U P

Terapi tunggal atau terapi kombinasi Terapi Tunggal Meglitinide, SU, AGI Metformin, TZD Insulin analog pre-mixed Insulin analog kerja cepat atau insulin basal Terapi Kombinasi Meglitinide, SU, AGI Metformin, TZD Insulin analog pre-mixed Insulin analog kerja cepat atau insulin basal Terapi tunggal atau terapi kombinasi

Terapi diteruskan bila tercapai target terapi Penyesuaian terapi bila diperlukan untuk mencapai target GDP dan 2 jam PP Dimulai terapi kombinasi Metformin + SU atau Meglitinide Metformin, + TZD atau AGI TZD + SU Increatin mimetic + metformin dan/atau SU Basal atau insulin analog pre-mixed Kombinasi lain Terapi kombinasi maksimal Terapi insulin maksimal Bila GDP meningkat tambahkan insulin basal Bila GDPP meningkat tambahkan bolus Bila GDP dan GDPP meningkat, tambahkan terapi basal-bolus atau insulin analog premixed Dimulai terapi insulin (Basal-Bolus) Insulin kerja panjang ditambah kerja cepat Insulin analog pre-mixed

6.5-8.5

200

Diawasi dan dilakukan penyesuaian Rx untuk mencapai target

> 8.5

> 300

Diawasi dan dilakukan penyesuaian Rx untuk mencapai target

Insulin analog kerja cepat dapat ditambahkan pada setiap bentuk terapi pada setiap saat untuk menurunkan GDPP Insulin basal ditujukan untuk menurunkan GDP

Target terapi A1C GDP GDPP < 6.5% < 110 mg/dL < 140 mg/dL

Misconceptions in Indonesia

Insulin menyebabkan ketergantungan Insulin untuk DM yang berat; Insulin merusak ginjal Insulin dapat mematikan Terapi Undur-undur Jalan tanpa alas kaki menyehatkan

Strategi agar setara dengan orang normal

1) 2) 3) 4) 5) Menemukan pasien DM sedini mungkin Pemantauan metabolik teratur Optimalisasi & Intensifikasi pengobatan Memulai terapi Insulin tepat waktu Treat to target untuk semua kelainan metabolik

In 2007, the world will spend an estimated 215-375 billion USD to care for diabetes and its complications (WDF) Pranoto, 2009

TANTANGAN DI INDONESIA
Fasilitas pelayanan DM di Pelayanan Primer Pelayanan di RS sebagai pusat rujukan Misconception pasien DM Peningkatan jumlah DM Biaya pengobatan DM yang tinggi Meningkatkan kemampuan tenaga Medis

THANK YOU

Joslin 75-Year Medalists Spencer Wallace

Joslin 50-Year Medalists C. Lynn Wickwire (left) and Sandy Asherman

Joslin 75-Year Medalists Robert L. Bates

Selalulah tersenyum dan bahagia

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