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PENYAKIT KRONIS
MASALAH DM DI
INDONESIA
APA PERAN KITA
???
Increasing DM
Prevalence in Indonesia
NATIONAL
5.7%
1.7%
1985
WHO, Study Group 1985
RISKESDAS, 2007
2007
47.30%
23.00%
56.50%
44.40%
23.00%
16.70%
Priority:
Decrease blood pressure (AR 56.5%),
Reduce waist circumference (AR 47.3%)
Stop smoking (AR 44.4%).
National Health Survey 2007
24417 subjects from 33 provinces in Indonesia.
THE TOP 10 DM PREVALENCES OF THE 33 INDONESIAN PROVINCES AS REPORTED BY MINISTRY OF HEALTH 2007
60
*
* 11.1
11.1
50
10.4
8.6
40
8.5
8.1
Tot. DM 10M
RISKESDAS-2007
DM 5.7%, DDM 1.5%, UDDM 4.2%
(26.3%)
(73.7%)
7.8 7.7
30
20
6.8
6.6
SBY
7.0%
10
0
BKBLT
NAD
10
DKI
Study Data (33 Provinces of Indonesia): Age > 15 yrs, Samples 19.114, Urban
Population. Diagnosis, based on : Fasting 10-14 hrs, Oral Glucose Loading 75 g (WHO
1999-ADA 2003), IGT (if Postloading Glucose : 140-200 mg/dL), DM (if Postloading
Glucose : > 200 mg/dL)
Renal Failure
11,875
Hypertension
629,315
Diabetes Mellitus
420,743
Cancer
132,810
Heart Disease
247,203
Stroke
117,356
Asthma
105,689
Osteoporosis
15,084
220,151
No.
Diseases (2007)
Stroke
15.4
Tuberculosis
7.5
Hypertension
6.8
Trauma
6.5
Perinatal Diseases
6.0
Diabetes Mellitus
5.7
Malignancy
5.7
Liver Diseases
5.1
5.1
10
5.1
Diabetic Complications
60
50
40
33.4
30
26.5
20
8.7
10
0.5
0
IDMPS Indonesia
10.9
7.4
1.3
5.3
Retinopathy
Neuropathy
Proteinuria
Dialysis
Foot Ulcer
Amputation
Angina
MCI
Heart Failure
Stroke
PAD
Sistim Kesehatan
Nasional
Str
ata
-3
- Kemenkes
- Dinkes Propinsi
- RS Umum/Khusus Kota/Kab
- BP4, BKMM, Klinik/Praktek Dr. Spes
- Laboratorium Klinik
Strata-2
- Dinkes Kota/Kab
- BP4, BKMM, BKOM
- Puskesmas
- Klinik/Praktek Dokter Umum
- BP, BKIA, Praktek Bidan
Strata-1
- Puskesmas
- Posyandu, Polindes,
Posbindu, dll
Masyarakat
Perorangan/Keluarga
- UKBM: Posyandu,
Polindes, Posbindu, dll
Puskesmas
Dr Keluarga
RS Kab/
Dr Spesialis
RS Prop/
Dr Sp Konsultan
Deteksi dini
Pencegahan 1
pengobatan
Deteksi dini
Pencegahan 1,2,3
Pemeriksaan
lengkap awal
Pengelolaan
terpadu antar
bagian
PERSADIA
Deteksi dini
Pencegahan 1,2,3
Pemeriksaan
khusus
Pengelolaan
terpadu antar
bagian
Kasus kompleks
PERSADIA
Manager
Prescription
Family
Doctor
PROLANIS
Monitoring
Consultant
PERKENI: Screening
Screening is conducted on those who have
diabetes risks, but do not show any symptoms
of DM
FPG
atau
RBG
<12
6
<20
0
Diabetes Classic
Symptoms (-)
GDP
atau
GDS
12
6
>20
0
100-125
140199
<10
0
<14
0
FBG and
PPG
FPG
atau
RBG
>12
6
20
0
<12
6
<20
0
OGTT 2 hour
BG
>20
0
Diabetes Mellitus
Evaluation of Nutritional Status
Evaluation Diabetic Complications
Evaluation Dietary Need and Dietary
Planning
140199
IGT
<14
0
IFG
Education
Dietary Planning
Physical Exercise
Achieving Ideal Body
Weight
Norma
l
PERKENI: Diagnostic
Criteria for Diabetes
Mellitus
1 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.
2
or
glucose
126 mg/dL. Fasting means patients not getting intake
calories
for minimum 8 hours.
or
11
Lifestyle Changes
Medical
Nutritional
Therapy
Physical activity
Weight reduction
If overweight,
reduce body
weight by 5-10%
Physical exercise
for 30 minutes,
5 times/week
Pharmacology
Therapy
Not yet
recommended
Periodic Blood
Glucose & Risk
Factor Monitoring
Hypertension
Dyslipidemia
Physical health
Body weight control
H.D.L-CO
H : Hypertension
D : Diabetes
L : Lipid (Dyslipidemia)
C : Stop Cigarette
(Smoking)
O : Obesity (Weight
Control)
Peran 3 : pelayanan
komprehensip
Treat to target
Edukasi
Terapi Nutrisi
Terapi Olah Raga
OHO
Insulin
Peran dalam kegawatan akut
Peran dalam deteksi komplikasi kronik
TARGET OF TREATMENT
RISK CVD (-)
BMI (kg/m2)
18.5 <23
18.5 <23
FPG (mg/dL)
<100
<100
<140
<140
<7.0
<7.0
<130/80
<130/80
<200
<200
Triglyceride (mg/dL)
<150
<150
>40 / >50
>40 / >50
<100
<70
BLOOD GLUCOSE
A1C (%)
BLOOD PRESSURE
LIPID
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, A1C
Hypoglycemia: awareness & self-treatment
35
PROSENTASE
25
25
5
MENIT
PEMANASAN
20
MENIT
LATIHAN INTI
5
MENIT
PENDINGINAN
7 8%
Lifestyle
Modification
Lifestyle
Modification
+
Monotherap
y
Met, SU, AGI,
Glinid, TZD,
DPP IV-i
8 - 9%
Lifestyle
Modification
+
2 OADs
Combinatio
n
Met, SU, AGI,
Glinid, TZD,
DPP IV-i
> 9%
Lifestyle
Modification
+
3 OADs
Combinatio
n
Met, SU, AGI,
Glinid, TZD,
DPP IV-i
9 - 10%
Lifestyle
Modification
+
2 OADs
Combinatio
n
Met, SU, AGI,
Glinid, TZD,
DPP IV-i
Notes:
Fail: not achieving A1c target < 7%
after 2-3 months of treatment
(A1c = average blood glucose conversion,
ADA 2010)
> 10%
Basal
Insulin
Lifestyle
Modification
+
Intensive
Insulin
Diagnosis:
Lifestyle
+
Metformin
Lifestyle + Metformin
+
Intensive insulin
Lifestyle + Metformin
+
Basal insulin
Lifestyle + Metformin
+
Sulfonylurea
Step 2
Step 1
Tier 2: Less well validated core therapies
Lifestyle + Metformin
+
Pioglitazone
Lifestyle + Metformin
+
GLP-1 agonist b
Step 3
Lifestyle + Metformin
+
Pioglitazone
+
Sulfonylurea a
Lifestyle + Metformin
+
Basal Insulin
I
4
5
II
1
2
3
4
GLIMIN (new tetrahydrotriazine-containing class) : IMEGLIMIN (1500 mg twice/day) : Insulin, Muscle glucose uptake, HGP
GPR40 Agonist (TAK-875) : 50-200 mg once/day. The long-chain FAs amplify glucose-stimulated insulin secretion, GLP-1
INSULIN SENSITIZERS
III
IV
INCRETIN-ENHANCERS
VI
Generik
Glibenclami
d
Glipizid
Sulfonilur
ea
Gliklazid
Glikuidon
Glimepirid
Glinid
Repaglinid
Nateglinid
Tiazolidindi
on
Pioglitazon
e
Nama
Dagang
Daonil
Acarbose
Lama Kerja
(jam)
Frek/har
i
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
24
Diamicron
Diamicron-MR
Glurenorm
Dexanorm
16
1.5 6
120
360
Actos
15 30
15 45
24
Deculin
15 30
15 45
24
Pionix
15 30
15 45
18 24
50 100
100 300
Starlix
Eclid
Glucophage
Metformin
Dosis Harian
(mg)
2.5 5
Glucobay
Penghambat
Gluckosidase
alfa
Mg/tab
50 100
100 300
500
850
250 3000
Waktu
Sebelum
makan
Tidak
bergant
ung
jadwal
makan
68
13
Bersama
suapan
pertama
Generik
Nama Dagang
Mg/tab
Frek/hari
50
50 100
12 24
12
Januvia
25 100
24
Onglyza
24
12 24
12
Vildagliptin
Galvus
Sitagliptin
Saxagliptin
Waktu
Tidak
bergantun
g jadwal
makan
250/1.25
Metformin +
Glibenclamid
Glucovance
500/2.5
Total glibenclamid
maksimal 20 mg/hari
500/5
Glimepirid +
Metformin
Obat Kombinasi
Tetap
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
Total pioglitazone
maksimal 45 mg/hari
18 24
Total sitagliptin
maksimal 100 mg/hari
50/500
Vildagliptin +
Metformin
Galvusmet
50/850
50/1000
Total vildagliptin
maksimal 100 mg/hari
12 24
Bersama /
sesudah
makan
Comorbid
Recurrent
HYPOs
Overweight /
Obese
Cardiovascular
Diseases
Congestive
Heart Failure
Drugs
Metformin / GLP-1RA / DPP4-inh /
AGI / TZD
GLP-1RA / DPP4-inh / Metformin / AGI
Metformin / TZD / incretin Tx (?)
Insulin / Metformin () / Incretin Tx
Chronic Kidney
Disease
Liver diseases
Insulin in
Indonesia
Awal Kerja
(Onset)
Puncak
Kerja
(Peak)
Lama Kerja
(Duration)
Kemasan
30-60 menit
30-90
menit
3-5 jam
Vial, pen/cartridge
5-15 menit
30-90
menit
3-5 jam
Pen/cartridge
5-15 menit
30-90
menit
3-5 jam
Pen
5-15 menit
30-90
menit
3-5 jam
Pen, Vial
2-4 jam
4-10 jam
10-16 jam
Vial, Pen/cartridge
2-4 jam
No Peak
20-24 jam
Pen
2-4 jam
No Peak
16-24 jam
Pen
Sediaan Insulin
Insulin Prandial (Meal Related)
Insulin Short Acting
Reguler (Actrapid, Humulin
R)
Insulin Analog Rapid Acting
Insulin Campuran
7 am
Regular
(fast)
12 pm
NPH/Lente
(slow)
7 pm
Insulin
Glargine
(slow)
12 am
Ultralente
(very slow)
7 am
A
Morning
Evening
Afternoon
Night
NPH / LENTE
ORAL
MEALS
INSULIN EFFECT
B
Morning
Evening
Afternoon
Night
NPH / LENTE
MEALS
NPH / LENTE
INSULIN EFFECT
Injections
of Short-acting Insulin ( LISPRO) before Meals
and
Basal flat-long-acting Insulin ( GLARGINE )
Morning
Evening
Afternoon
MEALS
76-90
1-15
61-75
16-30
46-60
31-45
Komplikasi hipoglikemi
GD < 70
Lemes, gemetar, lapar, keringat dingin,
berdebar debar, gangguan kesadaran
Sadar minum manis gula biasa, makan
manis, premen, roti, nasi, karbohidrat
Tidak sadar : rumah sakit, infus glukosa
Management of DKA:
Evaluation
Complete Initial Evaluation
Including (but not limited to):
Medical history and physical
examination
Serum chemistries
(electrolytes, BUN, Cr; serum
ketones)
12-lead ECG
Adult
patient
with DKA
Complete
Initial
Evaluation
K+ Repletion
IV Fluids
Insulin
Therapy
Bicarbonate?
When Serum
Glucose Reaches
200 mg/dL
Continuing
Management
47
2 to 4-fold
Increase in
cerebrovascular
Disease and Stroke
Diabetic
Retinopath
y
Stroke
Leading cause of
end-stage renal
disease in adults
44% new cases/yr
Diabetic
Nephropat
hy
Cardiovascular
Disease
8 out of 10 diabetic
patients die from
cardiovascular events
Leading cause of
Non-traumatic
Limb amputations
60% new cases/yr
Diabetic
Neuropat
hy
Peripheral
Peripheral
Arterial
Arterial
Disease
Disease
NIDDK, National Diabetes Statistics fact sheet. HHS, NIH,
PENGELOLAAN DM TIPE 2
Kendali
glukosa
GHS/Diet
Latihan
Jasmani
Obat
OHO/Insulin
Skrining dan
pengelolaan
komplikasi
Komorbid
Dislipidemi
Hipertensi
Obesitas
PJ Koroner
Retinopati
Nefropati
Neuropati
P
kardiovaskule
r
Komplikasi
lain
KOMPLIKASI KRONIK DM
komplikasi
Deteksi
Pengelolaan
. Retinopati
Funduskopi
. Nefropati
Mikroalbumin
Neuropati
Mikrofilamen
Duloxetin, gabapentin,
antidep trisiklik
EKG
Vasodillator,
hemoreologi
CT scan
citicholin
Microangiopati
Makroangiopati
Kendali
mutu
Kendali
biaya
penutup
DM penyakit kronik progresif :
morbiditas, mortalitas, komplikasi,
biaya tinggi
Peran dokter BPJS : deteksi dini dan
diagnosis, bekerjasama dalam
jejaring, sistem rujukan
Peran dalam pelayanan :
diet,OR,OHO, Insulin
Peran dalam kegawatan dan deteksi
komplikasi kronik
LARANING LARA
ORA KAYA
WONG KANG SAKIT GULA
MANGANE DOYAN
NGOMBE TERUSAN
NENG AWAK LEMES
YO MERTAMBA
OLAH RAGA , DIET ,
NGOMBE OBAT
OJO DO LALI
PRIKSA GULA
BEN NGERTI HASILE
Terima
kasih