Challenge in The Diabetes

Management to Improve Patient

Outcome
 DIABETES : Global Emergency
53%
WORLD

592
million
people living
with
diabetes
WORLD

387 Africa 93%

Middle East and North Africa 85%
million
South East Asia 64%

South and Central America 55%

10 Negara dengan Penduduk Diabetes Terbanyak

Jepang 7212050 Western Pacific 46%
Turki 7227450 Indonesia menjadi Negara Urutan
Jerman 7279350 Ke-5 dengan Penduduk Diabetes
Terbanyak di Dunia
Mesir 7593270
Europe 33%
Mexico 9018620
Indonesia 9116030 North America and Caribbean 30%
Brazil 11623320
USA 25779340 2014 2035
India 66846880 NAME OF PRESENTATION | 2
2
RRC 96288030 Sumber: Atlas IDF, Sixth edition, 2014
 Majority of T2DM patients in Asia Pacific fail to achieve
glycaemic control (HbA1c <7.0%)
Australia Thailand Singapore India Indonesia
(St Vincent’s1) (Diab Registry2) (Diabcare3) (DEDICOM4) (Diabcare5)


30.0% 30.2% 33.0% 37.8% 32.1%
37.
70.0% 69.8% 67.0% 62.2% 62.2 67.9%
8

China S. Korea Malaysia

(Diabcare7) (KNHANES8) (DiabCare9)
HbA1c at or
below target
39.7% 41.1% 43.5% 22.0% HbA1c above target

60.3% 58.9% 56.5% 78.0%

• HbA1c, glycated haemoglobin; T2DM, type 2 diabetes mellitus

Bryant W, et al. MJA. 2006;185:305–9. 2. Kosachunhanun N, et al. J Med Assoc Thai. 2006;89:S66–71. 3. Lee WRW, et al. Singapore Med J. 2001;42:501–7. 4.
Nagpal J & Bhartia A. Diabetes Care. 2006;29:2341–8. 5. Soewondo P, et al. Med J Indoes. 2010;19:235–44. 6. Tong PCY, et al. Diabetes Res Clin Pract.
2008;82:346–52. 7. Pan C, et al. Curr Med Res Opin. 2009;25:39–45. 8. Choi YJ, et al. Diabetes Care. 2009;32:2016–20. 9. Mafauzy M, et al. Med J Malaysia.
2011;66:175–81.
 Masalah DM di Indonesia
Tahun 2007 - 2013

Sumber : Riskesdas Sumber : Riskesdas

2007 2013
 Prevalensi Diabetes Melitus
Pada Penduduk Usia ≥ 15 Tahun Menurut Propinsi
di Indonesia Tahun 2013
4
3.7
3.6
3.5 3.4
3.3

3 3
3
2.8
2.7
2.5 2.5
2.5 2.3 2.3 2.3
2.2 2.2
2.1 2.1
2 2
2 1.9 1.9
1.8
1.6 1.6 1.6
1.5
1.5 1.3 1.3
1.2 1.2 1.2
1 1
1
0.8

0.5

(Sumber: Riskesdas, 2013)

In newly diagnosed patients, risk reductions are observed
for every 1% reduction in HbA1c

Relative risk reduction† 95% CI

Microvascular complications  37% 33 – 41
Any diabetes-related endpoint  21% 17 – 24
Diabetes-related death  21% 15 – 27
All-cause mortality  14% 9 – 19
Fatal and non-fatal MI  14% 8 – 21
†All P < 0.0001
Newly diagnosed T2DM at baseline; 7.5 – 12.5 years’ follow-up (median = 10.0 years)

• CI, confidence interval; HbA1c, glycated haemoglobin; MI, myocardial infarction; T2DM, type 2 diabetes mellitus

• 1. Stratton IM, et al. Brit Medicine J. 2000; 321:405–12. 2. Colagiuri, et al. National evidence based guideline for blood glucose control in type 2
diabetes. Diabetes Australia and the NHMRC,Canberra 2009.
 UKPDS ‘legacy effect’: reductions in relative risk
at 10-year post-study follow-up
0.91
Any diabetes-related endpoint 0.83 0.99 P = 0.04

0.83
Diabetes-related death 0.73 0.96 P = 0.01

Death from any cause 0.87

0.79 0.96 P = 0.007

Myocardial infarction 0.85

0.74 0.97 P = 0.01

Stroke 0.91
1.13 P = 0.39
0.73
0.82
Peripheral vascular disease 0.56 1.19 P = 0.29
0.76
Microvascular disease 0.64 0.89 P = 0.001

-
-

-
Data represent point estimate and 95% CI 0.1 0.5 1 5 10
Intensive better Conventional better
Intensive = Sulfonylurea or insulin in 5-year UKPDS.
Median HbA1c at end of UKPDS 7.9%
Conventional = diet only in 5-year UKPDS.
Median HbA1c at end of UKPDS 8.5%

Holman RR, et al. N Engl J Med. 2008;359:1577–89.

 Multiple, Complex Pathophysiological
Abnormalities in T2DM
pancreatic
incretin insulin
effect secretion
pancreatic
glucagon
_ secretion
gut
carbohydrate
?
delivery & HYPERGLYCEMIA
absorption

+ peripheral
hepatic renal glucose
glucose glucose uptake
production excretion
Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
 Multiple, Complex Pathophysiological
Abnormalities in T2DM
GLP-1R Insulin
agonists pancreatic
Glinides S U s insulin
incretin
effect secretion
DPP-4 Amylin pancreatic
inhibitors mimetics glucagon
_ secretion DA
agonists
gut
AGIs
carbohydrate
?
delivery & HYPERGLYCEMIA
absorption
Metformin TZDs
_
Bile acid
sequestrants

+ peripheral
hepatic SGLT2i renal glucose
glucose glucose uptake
production excretion
Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
Patient-Centered Approach
“...providing care that is respectful of and responsive to
individual patient preferences, needs, and values – ensuring
that patient values guide all clinical decisions.”
• Gauge patient’s preferred level of involvement.

• Explore, where possible, therapeutic choices. Consider using

decision aids.

• Shared Decision Making – a collaborative process between

patient and clinician, using best available evidence and taking into
account the patient’s preferences and values

• Final decisions regarding lifestyle choices ultimately lie with the

patient.

Diabetes Care 2012;35:1364–1379; Diabetologia 2012;55:1577–1596

Figure 1. Modula on of the
intensiveness of glucose Approach to the management
lowering therapy in T2DM of hyperglycemia
more HbA1c less
stringent 7% stringent
PATIENT / DISEASE FEATURES
Risks potentially associated
with hypoglycemia and low high
other drug adverse effects

Disease duration
newly diagnosed long-standing

Usually not
Life expectancy modifiable
long short

Important comorbidities
absent few / mild severe

Established vascular
complications absent few / mild severe

Patient attitude and

expected treatment efforts highly motivated, adherent, less motivated, non-adherent, Potentially
excellent self-care capacities poor self-care capacities modifiable

Resources and support

Readily available limited
system
Diabetes Care 2015;38:140-149; Diabetologia 2015;10.1077/s00125-014-3460-0
Common barriers to achieving glycaemic control

Healthcare system Physicians Patients

Organizational Lack of awareness,
Lack of awareness and
constraints; difficulty familiarity and
understanding
coordinating care agreement

Low motivation and/or Poor compliance;

Lack of reimbursement
Inadequate staffing and
specialist support
outcome expectancy reluctance to take
life-long medication
Lack of confidence in
managing diabetes that
Lack of adherence to
requires multiple lifestyle modifications
medications

Increased legal liability Insufficient time and/or Fear of side effects,

resources such as weight gain and
hypoglycaemia
Difficulty in coordinating Inability to reconcile
care guidelines with patient
Limited access to care
preferences

• Adapted from: Defronzo, RA. Diabetes. 2009;58: 773–95; Erhardt L, et al. Vascular Disease Prevention.
2004; 1:167174.
 ADA-EASD Position Statement Update:
Management of Hyperglycemia in T2DM, 2015
3. ANTI-HYPERGLYCEMIC THERAPY
•Glycemic targets
- HbA1c < 7.0% (mean PG 150-160 mg/dl [8.3-8.9 mmol/l])
- Pre-prandial PG <130 mg/dl (7.2 mmol/l)
- Post-prandial PG <180 mg/dl (10.0 mmol/l)
- Individualization is key:
 Tighter targets (6.0 - 6.5%) - younger, healthier
 Looser targets (7.5 - 8.0%+) - older, comorbidities,
hypoglycemia prone, etc.
- Avoidance of hypoglycemia
PG = plasma glucose
Diabetes Care 2012;35:1364–1379; Diabetologia 2012;55:1577–1596
PILAR PENATALAKSANAAN DM TIPE 2

1. edukasi

Pilar
4. Intervensi penata- 2. Terapi gizi
Farmakologis laksanaan medik

3. Latihan
Jasmani

Konsensus Pengelolaan dan Pencegahan DM Tipe 2 di Indonesia, 2011

 Set area descriptor | Sub level 1 15
Author | 00 Month Year
 Principles in Selecting
Antihyperglycemic Interventions

Efficacy in lowering glucose

Extraglycemic effect

Safety profiles
Tolerability

Ease of use
Cost

Nathan Diabetes Care 2009

 Algoritma Pengelolaan DM Tipe-2 di Indonesia,
KONSENSUS PERKENI 2015
HEALHTY LIFESTYLE

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

SIGNS (-) SIGNS (+)

Monotherapy* 2 OHO combination* with different 2 Combination

mechanism Insulin ± OHO
- Metformin 3 OHO combination 3 Combination
- GLP1 agonist
Metformin atau obat lini pertema yang lain

- Agonis GLP1
- DPP4-I - GLP1 agonist
- DPP4-I
- TZD - DPP4-I
- AGI

Metformin atau obat lini pertema yang lain

- SGLT2-I ** - TZD
- SGLT2-I ** - Insulin basal - SGLT2-I **
- TZD - SU / Glinide - Basal insulin
- Sulfonylurea - Colesevelam** - SU / Glinide

2 Obat lini kedua

- Glinide - Bromocriptine QR Insulin intensification
- Colesevelam**
When HbA1c not reach - AGI - Bromocriptine QR
target <7% within 3 - AGI
months, add second drug (2 Note :
OHO combination When HbA1c not reach
target <7% within 3 When HbA1c not reach * Choose the drugs based on advantages,
months, add third drug (3 disadvantages and availability of drugs
target <7% within 3
(tabel-II)
OHO combination months, initiate insulin ** Colesevelam not available yet in
therapy or insulin Indonesia; Bromocriptin QR usually used for
intenficitation hypophysis Tu therapy

PERKENI, 2015
 Challenges in Achieving Glycemic Goals
in Diabetes
• Less aggressive treat-to-target approach by some
clinicians1
• Suboptimal use of available therapies1
• Inability of any single agent’s MOA to address all core
defects of type 2 diabetes2
• Potential for increased side effects with use of
multiple agents3
• Suboptimal adherence to lifestyle measures1
• Underuse of medications as a result of
– Cost4
– Complexity of therapy5

1. Blonde L. Clin Cornerstone. 2005;7(suppl 3):S6–S17.

2. Van Gaal LF et al. Diabetologia. 2003;46(suppl 1):M44–M50.
3. McDonald HP et al. JAMA. 2002;288:2868–2879.
4. Piette JD et al. Diabetes Care. 2004;27:384–391.
5. Donnan PT et al. Diabet Med. 2002;19:279–284.
 Therapeutic inertia: failure to intensify therapy
despite unmet treatment goals
Patients with diabetes often experience long periods of poor blood glucose
control prior to a change in medication
Physician factors Patient factors Healthcare system factors
Failure to set clinical targets Deny having the disease No clinical guidelines available
Failure to initiate treatment Believe that the disease is not No disease registry
serious (morbidity database)
Failure to titrate treatment until Low health literacy No visit planning
goal is achieved
Failure to identify and treat Too many medications No active outreach
comorbidities
Insufficient time Medication side effects No decision support
Reactive rather than proactive care Poor communication between No team approach to care
approach patient and physician
Do not trust the doctor Poor communication between
physician and staff
Depression, substance abuse Cost of medication

O’Connor PJ, et al. Agency for Healthcare Research and Quality 2005. Available at:
www.ahrq.gov/downloads/pub/advances/vol2/OConnor.pdf (accessed June 2012).
Conservative vs. proactive management of diabetes
Diet OAD
OAD + multiple
OAD daily insulin
10 monotherapy OAD + basal
monotherapy OAD injections
insulin
uptitration
combination
Conventional 9

HbA1c (%)
management
(traditional stepwise 8
approach)

6
Diet
10 OAD
monotherapy

9 OAD + multiple
HbA1c (%)

Proactive OAD OADs OAD + basal daily insulin

combinations uptitration insulin injections
management 8
(early combination
approach)
7

6
Duration of diabetes

• HbA1c, glycated haemoglobin; OAD, oral anti-diabetic

| 20 agent.

• 1. Del Prato S, et al. Int J Clin Pract. 2005;59;1345–55. 2. Campbell IW, et al. Br J Cardiol. 2000;7:625–31.
 Practical approaches to reducing clinical inertia

Monitoring and
Financial incentives providing feedback on
quality of care

Visit resolution
Reducing
Cognitive interventions
and accountability clinical
targeting specific
tools inertia decision pathologies

Patient initiative
Clinical decision More frequent clinic
visits Physician initiative
support
Healthcare system
initiative

| 21
• O’Connor PJ, et al. Agency for Healthcare Research and Quality 2005. Available at: www.ahrq.gov/downloads/pub/advances/vol2/OConnor.pdf (accessed June 2012).
 The diabetes multidisciplinary team
The multidisciplinary team may
include, but is not limited to:
• General practitioners
• Endocrinologists
• Diabetes nurse educators Diabetes
multidisciplinary
• Cardiologists team

• Nephrologists
• Dietitians
• Mental health professionals1
• Pharmacists
• Ophthalmologist/Optometrist
• Podiatrists

The person with diabetes and his/her family are central

to the diabetes healthcare team2
| 22
American Diabetes Association. Diabetes Care. 2009;32(Suppl.1):S13–-61. 2. Armour TA, et al. Diabet Med.
2005;22:1295–305.
 Summary
• In Indonesia there is an increasing prevalence of T2DM which
poses a huge burden in the region
• Glycaemic control is critical to reduce risk for diabetes-related
outcomes
• Barriers to optimal glycaemic control such as therapeutic
inertia, and the lack of self-management, patient compliance
and treatment concordance
– Recognition of these barriers is important and addressing them
will improve patient outcomes
– The multidisciplinary team plays an important role in managing
T2DM patients and providing comprehensive diabetes
education

| 23
Thank you