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clinic in Tanzania
A. Terjadi autoimun
B. Kurangnya jumlah insulin dalam tubuh
C. Tubuh tidak merespon insulin (resistensi insulin)
D. Semua benar
Definisi Diabetes
Diabetes melitus adalah suatu kelompok penyakit metabolik
duanya.
Penyebab Diabetes
1. Kekurangan Jumlah insulin
Sulphonylureas
Pancreas Glinides
Impaired beta-cell DPP-4 inhibitors
dysfunction GLP-1 RA Kidney
Insulin Glucose
reabsorption
liver
Fat and Muscle
Increased hepatic
glucose output Glucosa Level Insulin
resistance &reduced
glucose uptake
Metformin Metformin
Pioglitazone Pioglitazone
DPP-4 inhibitors (Insulin)
GLP-1 RA
Insulin Gut
Diminished Incretin effect
DPP-4 inhibitors
GLP-1 RA
Qualitative illustration of the spectrum of factors associated with different forms of DM,
including the variable age at onset, lack of obesity, metabolic syndrome, genetic associations,
different forms of immune changes, C-peptide secretion, and the need for insulin therapy.
1. Ramlo-Halsted BA, et al. Prim Care. 1999;26(4):771-789. 2. Piya MK, et al. Br J Clin Pharmacol. 2010;70(5):631-634. 3. DeFronzo RA. Med Clin N Am. 2004;88(4):787-835.
4. Stratton IM, et al. BMJ. 2000;321:405-412.
Classification of Diabetes
A. Type 1 diabetes
-cell destruction
B. Type 2 diabetes
Progressive insulin secretory defect
C. Gestational Diabetes Mellitus (GDM)
D. Other specific types of diabetes
Monogenic diabetes syndromes
Diseases of the exocrine pancreas, e.g., cystic
fibrosis
Drug- or chemical-induced diabetes
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Question
Tahun 2015, menurut data IDF, Indonesia menduduki peringkat ke -
...... Sebagai negara dengan populasi diabetes tertinggi
A. 7
B. 8
C. 9
D. 10
Pada tahun 2015, Indonesia menjadi peringkat #7
populasi diabetes tertinggi di dunia
Orang dengan
diabetes
meningkatkan
risiko
7 berkembangnya
berbagai masalah
7 kesehatan yang
serius
Source: International Diabetes Federation. IDF Diabetes Atlas., 6th edition update 2015
.http://www.idf.org/diabetesatlas
Diabetes Rule of Halves di Indonesia
>50%
9.1
10.0 Penderita tidak sadar
memiliki diabetes
10,0
<1%
Mencapai target terapi
7 dari 8
4,6 4,4 Pasien yang
membutuhkan insulin,
0,7 tidak mendapatkannya
14.1 juta
Adalah jumlah pasien
prediabetes, IGT (20-
79)
Source: International Diabetes Federation. IDF Diabetes Atlas, Update 2014
Question
Di bawah ini adalah gejala hiperglikemia/diabetes yakni:
A. Sering berkeringat
B. Ada luka sukar sembuh
C. Mudah emosi
D. Tidak nafsu makan
Gejala Diabetes
Prediabetes*
FPG 100125 mg/dL
(5.66.9 mmol/L): IFG
OR
A1C 5.76.4%
* For all three tests, risk is continuous, extending below the lower limit of
a range and becoming disproportionately greater at higher ends of the
range.
www.diabetes.org/are-you-at-risk
American Diabetes Association Standards of Medical Care in Diabetes.
Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Two-Step Strategy
www.BetterDiabetesCare.nih.gov
Mean Glucose
Mean Plasma Glucose* Fasting Premeal Postmeal Bedtime
A1C <7.0%*
(<53 mmol/mol)
Preprandial capillary 80130 mg/dL*
plasma glucose (4.47.2 mmol/L)
Peak postprandial capillary plasma <180 mg/dL*
glucose (<10.0 mmol/L)
A. Metformin
B. Glibenclamide
C. Glimepiride
D. Acarbose
Add another class of agent best suited to the individual (agents listed in alphabetical order):
Class Relative Hypo- Weight Effect in Cardiovascular Other therapeutic considerations Cost
A1C Lowering glycemia Outcome Trial
Incretin agents:
DPP-4 Inhibitors Rare Neutral to Neutral (alo, saxa, sita) Caution with saxagliptin in heart failure $$$
GLP-1R agonists to Rare Neutral (lixi) GI side-effects $$$$
Insulin secretagogue:
Meglitinide Yes Less hypoglycemia in context of missed meals but $$
usually requires TID to QID dosing
Sulfonylurea Yes Gliclazide and glimepiride associated with less $
hypoglycemia than glyburide
SGLT2 inhibitors to Rare Superiority Genital infections, UTI, hypotension, dose-related $$$
(empa in T2DM patients with changes in LDL-C, caution with renal dysfunction
clinical CVD) and loop diuretics, dapagliflozin not to be used if
bladder cancer, rare diabetic ketoacidosis (may
occur with no hyperglycemia)
Pasien J.L.,
Pasien J.L.,
15 February,
15 December, 1922
1923
Question
Insulin basal/kerja panjang contohnya:
A. NovoRapid
B. NovoMix
C. Levemir
D. Actrapid
Question
Insulin prandial/bolus/kerja cepat contohnya:
A. NovoRapid
B. NovoMix
C. Levemir
D. Insulatard
Perkembangan Insulin
New Generation
Insulin Analogs
Basal
Insulin Analogs
Advancements
Biphasic
Insulin Analogs
Rapid-acting
Insulin Analogs
2000s
Recombinant
Human
Animal Insulin
Isolation
Insulin
of Insulin
(Banting & Best) Preparations 1990s
1977
1922
Time
Jenis Insulin (berdasarkan durasi kerja)
Levemir
---- NovoRapid
NovoMix
0.0
-0.5
HbA1c%
-1.0
-1.5
-2.0
-2.5
SU/GLIN
Metformin
TZD
Pramlintide
Exenatide
GLP-1
Insulin
DPPIV inh
AGIs
FPG <70 mg/dL (3.8 mmol/L) decrease dose FPG <80 mg/dL (4.4 mmol/L)
3 units
-2.2*
1. Soewondo, et al.,2013, Clinical experience with insulin detemir: results from the Indonesian cohort of the
international A1chieve study, Diabetes Research and Clinical Practice 100, suppl. S1 (2013) S47S53
Levemir memiliki risiko hipoglikemia yang rendah
Levemir menurunkan risiko hipoglikemia nokturnal sampai
dengan 65% lebih rendah dibandingkan NPH
-29%
-44%
Insulin Detemir
-53%
Insulin NPH
Relative Risk
Phillis-Tsimikas. Clin Ther 2006;28(10):156981; Riddle et al 2003. Diabetes Care; 26 (11): 3080-6;
Penambahan berat badan lebih rendah
Pemberian Levemir satu kali sehari berasosiasi dengan penambahan berat badan yang secara signifikan
lebih rendah dibandingkan dengan insulin glargine1,2
2,3
2,0 2,0
1,6 56%
Less
1,0 1,0
0,7
0,0 0,0
NPH Levemir Glargine
Insulin glargine Levemir
1. Rosenstock, et al.,2008, A randomised, 52-week, treat-to-target trial comparing insulin detemir with insulin glargine when administered as add-on to
glucose-lowering drugs in insulin-naive people with type 2 diabetes, Diabetologia (2008) 51:408416
2. Philis-Tsimikas,et al.,2006, Comparison of Once-Daily Insulin Detemir with NPH Insulin Added to a Regimen of Oral Antidiabetic Drugs in Poorly
Controlled Type 2 Diabetes, Clinical Theurapetic/Volume 20, Number 10, 2006
Pilihan untuk intensifikasi patient centre
Contoh:
Dosis Levemir terakhir 20 U, pasien di intensifikasi menggunakan
NovoMix.
Maka, NovoMix diberikan 2x, masing-masing 10 U di sebelum makan pagi
dan 10 U sebelum makan malam. Levemir dihentikan. SU dihentikan.
Metformin dilanjutkan.