ENDOCRINE SYSTEM BLOCK

Click to edit Master subtitle style Ronald Chrisbianto Gani 405090223 Faculty of Medicine 2009 Tarumanagara University

CASE 1
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DIABETES MELLITUS
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DEFINISI

Sindrom kronik gangguan metabolisme karbohidrat, protein, dan lemak akibat ketidak cukupan sekresi insulin atau resistensi insulin pada jaringan yang dituju

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Dorland Medical Dictionary

EPIDEMIOLOGY

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Harrisons Principal of Medicine

TOP 10 COUNTRIES

Russia China Japan India Pakistan USA Bangladesh Indonesia Nigeria Brazil

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International Diabetes

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Nelsons Textbook of Pediatrics

Type I Diabetes (beta cell destruction, usually leading to absolute insulin deficiency)

CLASSIFICATION & ETIOLOGY

Immune-mediated Idiopathic

Type 2 diabetes (may range from predominantly insulin resistance with relative insulin deficiency to a predominantly insulin secretory defect with insulin resistance) 5/21/12

Harrisons Principal of Medicine

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Harrisons Principal of Medicine

CLASSIFICATION

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Harrisons Principal of Medicine

CLASSIFICATION

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Sherwoods Human Physiology

CLASSIFICATION

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Robbins Basic Pathology

DIAGNOSIS

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Harrisons Principal of Medicine

Diagnostic Criteria for Impaired Glucose Tolerance (IGT) and Diabetes Mellitus (DM)

Symptoms of DM DM Fasting Glucose IGT plus random 110-125 mg/dL plasma glucose (6,1-7,6mmol/L) >= 200mg/dL or 2-hr plasma Fasting during glucosePlasma Glucose >= OGTT 126mg/dL or <200mg/dL but <140mg/dL 2-hr plasma glucose during OGTT >= Nelsons Textbook of Pediatrics

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INSULIN SECRETION

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Harrisons Principal of Medicine

INSULIN ACTION

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Harrisons Principal of Medicine

TYPE I DIABETES
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PATHOGENESIS OF TYPE I DIABETES

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Nelsons Textbook of Pediatrics

PATHOGENESIS OF TYPE I DIABETES

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Harrisons Principal of Medicine

PATHO PHYSIOLOG Y OF TYPE I DIABETES

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Nelsons Textbook of Pediatrics

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Sherwoods Human Physiology

CLINICAL MANIFESTATION

Nocturnal Other Polyuria Classic Sign Enuresis Polydipsia Monolial Polyphagia Vaginitis Weight loss Diminished subcutaneous fat stores Complications
Nelsons Textbook of Pediatrics

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TREATMENT

GOAL : Eliminate symptoms related to hyperglycemia (<200mg/dL) Reduce or eliminate complications Allow the patient to achieve as normal a lifestyle 5/21/12 Harrisons Principal of Medicine as possible

NUTRITIONAL RECCOMENDATION

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Harrisons Principal of Medicine

EXERCISE

Benefits : Caution

Cardiovascular DM type I, pre-exercise plasma glucose risk Low ketone body formation ketoacidosis reduction BP reduction High hypoglycemia Maintaining muscle mass Body fat reduction Weight loss
Harrisons Principal of Medicine

Lowering plasma 5/21/12 glucose

EXERCISE

To avoid exercise related hypohyperglycemia

Monitor blood glucose before, during, after exercise Delay if BG >250mg/dL or ketone is present If BG <100mg/dL, ingest carbohydrate first

Decrease insulin dose before exercise and inject insulin into non-exercising 5/21/12

Harrisons Principal of Medicine

BLOOD GLUCOSE MONITORING

Self-Monitoring Blood Glucose (SMBG)

Used to modify doses of insulin Must be performed several times per day

Current Continuous Glucose Monitoring System (CGMS) Ketones monitoring, especially when blood glucose is >300mg/dL, blood 5/21/12 Harrisons Principal of Medicine -hydroxybutirate is preferred

BLOOD GLUCOSE MONITORING

Mean Plasma Glucose based on Mean Plasma Glucose HbA1c HbA1c

6% 7% 8% 135mg/dL 170mg/dL 205mg/dL

(1% increase of HbA1c ~ 35mg/dL blood glucose increase)

Reccomended to be performed at least twice a year

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Harrisons Principal of Medicine

INSULIN

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Harrisons Principal of Medicine

CONTINUOUS SUBCUTANEOUS INSULIN INFUSION (CSII) Advantages

Multiple basal infusion rates can be programmed to accomodate nocturnal vs daytime basal insulin requirement Basal infusion rates can be altered during periods of exercise Different waveforms of insulin infusion with meal related bolus allow better matching of insulin depending meal composition

Programmed algorithm consider prior 5/21/12 insulin administration and Harrisons Principal of Medicine blood glucose

INSULIN REGIMENT

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Harrisons Principal of Medicine

Pramlintide

OTHER AGENTS THAT IMPROVE GLUCOSE CONTROL

Analogue of amylin (peptide cosecreted with insulin) Injected before meal Slows gastric emptying Supress glucagon Does not alter insulin level Side effect : nausea and vomiting (dose-dependent)
Harrisons Principal of Medicine

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PREVENTION

Many prevention has been performed and success in animals, but no satisfactory results in human

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Type ii diabetes
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RISK FACTOR

Individual with high risk is recommended to do a screening test 5/21/12

PATHO GENESI S OF TYPE II DIABET ES MELLIT US

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MECHANIS M OF INSULIN RESISTANC E

PATHOPHYSIOLOGY

Metabolic Abnormalities

Abnormal Muscle and Fat Metabolism Impaired insulin secretion Increased Hepatic Glucose and Lipid Production

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TREATMENT

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TREATMENT

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ONGOING CARE

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ANTIDIABETIC AGENT

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ANTIDIABETIC AGENT

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INSULIN SECRETAGOGUE

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ANTIHIPERGLYCEMIC ORAL

Insulin Sensitizing

Glitazone

Biguanid

Agonist PPAR Merangsang ekspresi bbrp protein u/ memperbaiki sensitivitas insulin Rosiglitazone : meningkatkan LDL dan HDL Pioglitazon : menurunkan TG meningkatkan HDL

Contoh : metformin Meningkatkan pemakaian glukosa oleh sel dan menstimulasi produksi GLP1menekan fungsi sel alfa

DOC pd awal pengelolaan 5/21/12 diabetes

ANTIHYPERGLICEMIC ORAL

Sekretagok Insulin

Glinid

Sulfonilurea

Mirip SU, masa kerja pendek Obat prandial (23x/day)

Merangsang sel B pankreas melepas insuli SU gen I : acetohexamide, tolbutamide SU gen II : glibenclamide gen III :

Penghambat Alfa Glukosidase

SU 5/21/12

Menghambat kerja enzim alfa glukosidase penurunan penyerapan

ANTIHYPERGLYCEMIC ORAL

Incretin

Penghambat DPP-IV

Memperpanjang masa kerja GLP-1 (menekan kerja sel alfa dan menghambat pengsongan lambung) Sitagliptin dan vildaglitin ES: nasofaringitis, resiko infeksi sal kemih, sakit kepala

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KETOASIDOSIS DIABETIC AND HYPERGLYCEMIC HYPEROSMOLAR STATE

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DKA & HHS

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CLINICAL MANIFESTATION

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MANAGEMENT

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DIABETIC RETINOPATHY
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DIABETIC RETINOPATHY

Leading causes for blindness in US Risk for blind diabetic : non diabetic = 25 : 1 Classified into :

Proliferative Non-Proliferative

Treatment : prophilactic photocoagulation, proliferative : panretinal laser 5/21/12

DIABETIC NEPHROPATHY

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SCREENING DIAGNOSIS

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INTERVENTION

Normalization of hyperglycemia Strict blood pressure control Administration of ACE inhibitor or ARB, if not possible, CCB, B-Blocker, or diuretic Dyslipidemia should be treated Nephrologist consult if GFR <60mL/min
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DAFTAR PUSTAKA

Fauci AS, Braunwald E, Kasper DL, Longo DL, Jameson JL, et al, editors. Harrisons Principle of Internal Medicine. 18th ed. USA : McGraw Hill Medical, 2011 Sudoyo AW, Setiyohadi B, Alwi I, Simadibrata M, Setiadi S, et al, editors. Buku Ajar Ilmu Penyakit Dalam 5th ed. Jakarta : Pusat Penerbitan Ilmu Penyakit Dalam FKUI, 5/21/12