Standards of

Medical Care
Kreisty S. Z. Saerang
 DIABETES MELLITUS
Diabetes is a complex, chronic illness requiring:
continuous medical care
Multifactorial strategies
self-management education and support to
preventing acute complications and reducing risk
of long-term complications.

Significant evidence: supports a range of

interventions improve diabetes outcomes.
Pathofisiology
 Standards of Care: PERKENI and ADA

PERKENI created Diabetes Mellitus National

Clinical Practice Guidelines (2015)

ADA Standards of Medical Care in Diabetes

2016 composes all current and key clinical
recommendations from the ADA
 PERKENI: Standards of Care
Diabetes care must be:
Continuous, not episodic
Proactive, not reactive
Planned, not sporadic
Patient centered rather than provider
centered
Population based, as well as individual based
Team care
 Ideal core team members:
A physician
A nurse
A dietician
at least one of whom is certified diabetes educator

Other team members will vary according to the patient

need, patient load, organization constraints,
resources, clinical setting and professional skills
e.g.: podiatrist, pharmacist, psychological or social
workers
Mensing C. Diabetes Care 2000:23:682-9.
 PERKENI: Screening
Screening is conducted on those who have
diabetes risks, but do not show any
symptoms of DM.
Screening seeks to capture undiagnosed DM or
prediabetes so it can be managed earlier and
more appropriately.
Mass screening is not recommended
considering the costs, which are generally not
followed by action plan for those who were
found abnormal.
Prevention/ Delay of T2DM
PERKENI: Diabetes Prevention
Diagnosis
Screening/Testing for Diabetes in
Asymptomatic Patients
PERKENI Guidelines 2011
 PERKENI: Diagnostic Criteria for
Diabetes Mellitus
Classic symptoms of diabetes + random glucose plasma
level 200 mg/dL.
or
Classical symptoms of diabetes + fasting plasma glucose
126 mg/dL.
or
2-h plasma glucose at glucose tolerance test 200
mg/dL. Glucose tolerance test (WHO) using 75g
anhydrous glucose which solvent in the 100 cc water
or
HbA1c 6.5%
PERKENI GUIDELINES 2015
 PERKENI: Standard Values of Random Blood
Glucose and Fasting Blood Glucose for
Screening and Diagnosis of DM (mg/dL)

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.

PERKENI GUIDELINES 2015

 HbA1c
Check at first visit
Used as tool for diagnosis (6.5%)
Every 3 months later on (at least every 6 months
or / month in ps HbA1c > 10%)
For blood control evaluation
Not for: anemia, hemoglobinopati, post blood
transf for 2-3 mo before), ckd.

PERKENI GUIDELINES 2015

Diabetes Care
Target of Treatment
Diabetes Self-Management
 PERKENI: Patient Education
Daily activities
Be active most of the time
Be productive
Self-management skills
Preparing pills, insulin
Follow drug schedule
Side effect awareness
Foot care
Daily foot care & appropriate shoes
Medical checkup
 PERKENI: Patient Education
Healthy eating:
healthy food choices, food composition (carbs,
protein, fat, fiber)
Body weight maintenance:
achieved target of BMI or reduced 5 10% of body
weight
Exercise
Monitoring:
self-monitoring of blood glucose, A1C
Hypoglycemia: awareness & self-treatment
 Self-Monitoring of Blood Glucose
(SMBG)
SMBG: one tool to assess therapy in diabetic
patients that is recommended especially in:

Patients that will undergo insulin therapy

Patients receiving insulin therapy
Patients with A1C level did not reach the target
Women planned for pregnancy / pregnant women
with hyperglycemia
Patients with recurrent hypoglycemia.
 Impact of Intensive Therapy for
Diabetes: Summary of Major Clinical
Trials
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, other combination
 Hypertension
Initiation therapy when BP: >140/90 mmHg
Target of treatment: < 140/90 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
 Anti Platelet coagulation

Low dose aspirin (75-160 mg/day), is used for:

Diabetic patients with cardiovascular risk
Patient male > 50 years old, female > 60 yo.
Not recommended for patient < 21 years old
Combination with other anti-platelet use for
patient with high risk ( 1 yr after MCI)
Other anti-platelet is used for patient with
intolerance to aspirin
 Nephropathy
Assess urine albumin excretion annually
Persistence micro-albuminuria (30-299 mg/24
hrs) indicated DN
Measure albumin/creatinine ratio annually
Control blood glucose
Control blood pressure
Diet: Prot > 0,8 gr / bw/d
Recommendations: Hypoglycemia
Glucose (15 20g) preferred treatment for
conscious individual with hypoglycemia
Check blood glucose 15 minute after glucose
therapy (oraly/iv)
Glucagon should be prescribed for all individuals
at significant risk of severe hypoglycemia and
caregivers/family members instructed in
administration
Those with hypoglycemia unawareness or 1
episodes of severe hypoglycemia should raise
glycemic targets to reduce risk of future episodes

ADA. V. Diabetes Care. Diabetes Care 2012;35(suppl 1):S27.

 Summary

According to the most recent PERKENI and ADA

Standards of Care:
optimal diabetes care requires appropriate and
evidence-based prevention, screening,
diagnosis, treatment and educational
strategies.
THANK YOU