Professional Documents
Culture Documents
Medical Care
Learning Objectives
Discuss the PERKENI Diabetes Mellitus
National Practice Guidelines/Standards of Care
Standards of Care:
PERKENI and ADA
PERKENI created Diabetes Mellitus National
Clinical Practice Guidelines (2011-revises)
PERKENI: Screening
Screening is conducted on those who have diabetes
risks, but do not show any symptoms
of DM.
and
Prevention/
Delay of T2DM
Family history of DM
Cardiovascular disorder
Overweight
Sedentary life style
Known IFG or IGT
Hypertension
Elevated triglyceride, low
HDL or both
History of Gestational DM
History of given birth
> 4000g
PCOS
Lifestyle Changes
Medical Nutritional
Therapy
Periodic Blood
Glucose & Risk
Factor Monitoring
Pharmacology
Therapy
Not yet
recommended
Hypertension
Dyslipidemia
Physical health
Body weight
control
Physical activity
Weight reduction
If overweight,
reduce body
weight by 5-10%
Physical exercise
for 30 minutes,
5 times/week, or
150 minutes/week
Diagnosis
Screening/Testing
for Diabetes in
Asymptomatic Patients
Diabetes Symptoms
126
FBG
<126
FBG
atau
126
100-125
<100
atau
RBG
>200
<200
RBS
>200
140-199
<140
>126
<126
atau
RBG
OGTT 2 hour BG
200
<200
>200
Diabetes Mellitus
140-199
IGT
<140
IFG
Education
Dietary Planning
Physical Exercise
Achieving Ideal Body Weight
Normal
PERKENI: Diagnostic
Criteria for Diabetes Mellitus
Classic symptoms of diabetes + random glucose plasma level
200 mg/dL. Random glucose plasma level is a test which access
glucose plasma level at a single time without concerning about last
meal schedule.
or
Classical symptoms of diabetes + fasting plasma glucose
126 mg/dL. Fasting means patients not getting intake calories
for minimum 8 hours.
or
2-h plasma glucose at glucose tolerance test 200 mg/dL.
Glucose tolerance test done by the WHO standard using 75g
anhydrous glucose which solvent in the 100 cc water
or
HbA1c 6.5%
PERKENI GUIDELINES 2011-revices
Uncertain DM
DM
Random
Venous
blood glucose plasma
level
Capillary blood
(mg/dL)
<100
100-199
200
<90
90-199
200
Fasting blood
glucose level
(mg/dL)
Venous
plasma
<100
100-125
126
Capillary blood
<90
90-99
100
Note:
For high-risk groups which show no abnormal results, the test should be done
every year. For those aged > 45 years without other risk factors, screening can
be done every 3 years.
HbA1c
Diabetes Care
Target of Treatment
BMI (kg/m2)
18.5 <23
18.5 <23
Blood Glucose
FPG (mg/dL)
<100
<100
<140
<140-180
<7.0
<7.0
<130/80
<130/80
<200
<200
Triglyceride (mg/dL)
<150
<150
>40 / >50
>40 / >50
<100
<70
A1C (%)
Blood Pressure
Lipid
Diabetes Self-Management
Team Care:
Physician
Nurse
Dietitian
Educator
Self-management skills
Preparing pills, insulin
Follow drug schedule
Side effect awareness
Foot care
Daily foot care & appropriate shoes
Medical checkup
Exercise
Monitoring:
Self-Monitoring
of Blood Glucose (SMBG)
SMBG: one tool to assess therapy in diabetic patients that is
recommended especially in:
n (%)*
Type of Management
Diet only
OAD Insulin monotherapy
Insulin monotherapy
Insulin and OAD combination
1133 (61.88)
317 (17.31) 35
356 (19.44)
Herbal
5 (0.27)
None
20 (1.09)
*n = 1785
n (%)*
1085 (59.26)
Sulphonylureas
1036 (56.58)
Meglinitides
Alpha glucosidase inhibitors
8 (0.44)
461 (25.18)
TZDs
51 (2.79)
Other OADs
48 (2.62)
5 (0.27)
88 (4.81)
Phase - I
Lifestyle
Modification
Phase - III
Lifestyle
Modification
+
OAD
Monotherapy
Phase - II
Alternative:
Insulin not available
Patient preference
Glucose control not
optimal
Lifestyle
Modification
+
Lifestyle
Modification
2 OADs
Combination
Lifestyle
Modification
2 OADs
Combination
+
Basal Insulin
+
Notes:
Fail: not achieving A1c target < 7% after 2-3 months of treatment
(A1c = average blood glucose conversion, ADA 2010)
3 OADs
Combination
Intensive Insulin
7 8%
Lifestyle
Modification
Lifestyle
Modification
8 - 9%
Lifestyle
Modification
Monotherapy
2 OADs
Combination
Met, SU, AGI,
Glinid, TZD,
DPP-IV
Notes:
Fail: not achieving A1c target < 7%
after 2-3 months of treatment
(A1c = average blood glucose conversion, ADA 2010)
> 9%
Lifestyle
Modification
+
3 OADs
Combination
Met, SU, AGI,
Glinid, TZD,
DPP-IV
9 - 10%
> 10%
Lifestyle
Modification
+
2 OADs
Combination
Met, SU, AGI,
Glinid, TZD,
DPP-IV
Lifestyle
Modification
Basal Insulin
+
Intensive
Insulin
Microva
sc
CVD
Mortality
Initial Trial
Factors
Psychosocial
considerations
Adequate
Resources or support
systems
inadequate
Low
Risk of hypoglycemia
High
Short
Duration of type-2 DM
long
Long
Life expectancy
Short
None
Microvascular disease
Advances
None
Cardiovascular disease
Established
None
Coexisting conditions
DPP-4 I
GLP1 RA
TZD
AGI
COL
SVL
BCR
OR
HYPOs
Neutral
Neutral
Neutral
Neutral
Neutral
Neutral
SU/glini
de
INSULIN
Moderate
to severe
Moderate
to severe
Neutral
SGLT2
PRAML
Neutral
Neutral
Mild
Weight
Slight loss
Neutral
Loss
Gain
Neutral
Neutral
Neutral
Gain
Gain
Loss
Loss
Renal / GU
Contra
indicated
grd 3B,4,5
Neutral ?
Exenaitide
contra
indicate in
clr crt<30%
May
worsen
fluid
retention
Neutral
Neutral
Neutral
More
hypoglyce
mia
More hypo
risk & fluid
retention
Infection
Neutral
GI Sx
Moderate
Neutral
Moderate
Neutral
Moderate
Mild
Moderate
Neutral
Neutral
Neutral
Moderate
CHF
Neutral
Neutral
Neutral
Moderate
Neutral
Neutral
Neutral
Neutral
Neutral
Neutral
Neutral
CVD
Benefit
Neutral
Neutral
Neutral
Neutral
Neutral
Benefit
Neutral
Neutral
Neutral
BONE
Neutral
Neutral
neutral
Moderate
bone loss
Neutral
Neutral
Neutral
Neutral
Neutral
Bone
loss?
Neutral
Likelihood of adverse
events
Treatment Approach
Other drugs than metformin can be used as initial treatment in some cases
Type-2 Diabetic Patients
insulin
Comorbid
Recurrent HYPOs
Overweight / Obese
Cardiovascular Diseases
Liver diseases
Target of treatment
FBG : 95 mg/dl
2hrPP : 120 mg/dl
Assessment of Common
Comorbid Complications
Dyslipidemia
Dyslipidemia increases cardiovascular risk
Check lipid profile in first visit newly diabetic patient
and repeat at least every 1 year
Target of treatment:
LDL:
Without CVD < 100 mg/dl
With
CVD < 70 mg/dl
HDL:
Men > 40 mg/dl; women > 50 mg/dl
TG:
<150 mg/dl
Therapy:
Non pharmacology
Pharmacology: statin, fibrate, niacin
Hypertension
Initiation therapy when BP: >130/80 mmHg
Target of treatment: 130/80 mmHg
Therapy:
Non pharmacology
Reduce BW
Exercise
Stop smoking and alcohol
Reduce salt intake
Pharmacology:
ACE-I
ARB
CCB
Low dose diuretic
Alpha-receptor blocker
Nephropathy
Assess urine albumin excretion annually
Persistence micro-albuminuria (30-299 mg/24 hrs)
indicated DN
Recommendations: Hypoglycemia
Glucose (15 20g) preferred treatment for conscious
individual with hypoglycemia
Summary
Thank You
40
41
Generic
name
Glibenclamid
Glipizid
Gliklazid
Sulfonylurea
Glikuidon
Glimepirid
Glinide
Repaglinid
Nateglinid
Thiazolidinedione
Gluckosidase
alpha inhibitor
Pioglitazone
Acarbose
Metformin
Biguanide
Trade name
mg/tab
Duration of
action (hrs)
Freq/day
Daonil
2.5 5
2.5 15
12 24
12
Minidiab
5 10
5 20
10 16
12
Glucotrol-XL
5 10
5 20
12 16**
80
80 320
10 20
12
30 60
30 120
24
30
30 120
68
23
Amaryl
1-2-3-4
0.5 6
24
Gluvas
1-2-3-4
16
24
Amadiab
1-2-3-4
16
24
Metrix
1-2-3-4
16
24
1.5 6
Starlix
120
360
Actos
15 30
15 45
24
Deculin
15 30
15 45
24
Pionix
15 30
15 45
18 24
Glucobay
50 100
100 300
Eclid
50 100
100 300
500 850
250 3000
68
13
500
500 3000
68
23
24
Diamicron
Diamicron-MR
Glurenorm
Dexanorm
Glucophage
Glumin
Glucophage XR
500 750
Taking
time
Before
meal
Not depend
on meal
First spoon
With/after
DPP-IV
inhibitors
Generic
name
Trade name
mg/tab
Duration of
action (hrs)
Freq/day
50
50 100
12 24
12
Januvia
25 100
24
Onglyza
24
Max dose of
glibenclamid 20 mg/day
12 24
12
Vildagliptin
Galvus
Sitagliptin
Saxagliptin
Taking
time
Not depend
on meal
250/1.25
Metformin +
Glibenclamid
Glucovance
500/2.5
500/5
Glimepirid +
Metformin
Fixed
combintaion
Amaryl-Met FDC
Pioglitazone +
Metformin
Pionix M
Sitagliptin +
Metformin
Janumet
1/250
2/500
2/500
4/1000
15/500
30/850
50/500
50/1000
Max dose of
pioglitazone 45 mg/day
With / after
meal
18 24
50/500
Vildagliptin +
Metformin
Galvusmet
50/850
50/1000
Max dose of
vildagliptin 100 mg/hari
12 24
Insulin in Indonesia
Insulin
Onset of action
Peak of action
Duration of action
30-60 minute
30-90 minute
3-5 hrs
Vial, pen/cartridge
5-15 minute
30-90 minute
3-5 hrs
Pen/cartridge
5-15 minute
30-90 minute
3-5 hrs
Pen
5-15 minute
30-90 minute
3-5 hrs
Pen, Vial
2-4 hrs
4-10 hrs
10-16 hrs
Vial, Pen/cartridge
2-4 hrs
No Peak
20-24 hrs
Pen
2-4 hrs
No Peak
16-24 hrs
Pen
30-60 minute
Dual
10-16 hrs
Pen/cartridge
10-20 minute
Dual
15-18 hrs
Pen
Insulin Campuran
Mechanism
Advantages DisadvantageCost
s
Biguanide
s
Activates AMPkinase
Hepatic glucose
production
Extensive
experience
No hypoglycemia
Weight neutral
? CVD
Gastrointestinal
Lactic acidosis
B-12 deficiency
CKD
Low
SUs /
Meglitinid
es
Closes K-ATPchannels
Insulin secretion
Extensive
experience
Microvasc. risk
Hypoglycemia
Weight gain
Low durability
? Ischemic
preconditioning
Low
TZDs
PPAR- activator
insulin
sensitivity
High
DPP-4
inhibitors
Inhibits DPP-4
Increases GLP-1,
GIP
No hypoglycemia
Well tolerated
Weight gain
Edema / heart
failure
Bone fractures
? MI (rosi)
Modest
A1c
? Bladder
ca (pio)
? Pancreatitis
Urticaria
No hypoglycemia
Durability
TGs, HDL-C
? CVD (pio)
High
Mechanism
Advantages DisadvantageCost
s
-GIs
Inhibits
glucosidase
Slows
carbohydrate
absorption
No hypoglycemia
Nonsystemic
Post-prandial
glucose
? CVD events
Gastrointestinal
Dosing frequency
Modest A1c
Mod.
GLP-1
receptor
agonists
Insulin
Activates GLP-1 R
Insulin,
glucagon
Activates
gastric insulin
receptor
emptying
peripheral
satiety
glucose
uptake
Weight loss
No hypoglycemia
? Beta cell mass
? CV protection
Universally
effective
Unlimited efficacy
Microvascular
risk
GI
? Pancreatitis
? Medullary
Hypoglycemia
cancer
Injectable
Weight
gain
? Mitogenicity
Injectable
Training
requirements
Stigma
High
Vari
able
AACE 2012
NICE 2009
IDF 2012
<7-8%
HLS
HLS
Healthy Lifestyle
>10%
+
HLS
Monotherapy
Reduced
BW
Healthy Diet
Exercise
9-10%
<8-9%
Met, SU,
AGI, Glinid,
TZD, DPP IV
+
2 drugs
combination
HLS
Met, SU,
AGI, Glinid,
TZD, DPP IV
3 drugs
combination
Met, SU,
AGI, Glinide,
TZD, DPP IV
HLS
+
2 drugs
combination
Met, SU,
AGI, Glinid,
TZD
+
Basal Insulin
HLS
GSH
+
Intensive
Insulin *
Treatment approach
DIABETES
TARGET of TREATMENT
< 7%
(more stringent)
8%
(less stringent)
CO-CONDITIONS
DRUGS CHOICES
Recurrent HYPOs
Overweight / obese
Liver disease