Professional Documents
Culture Documents
Nama
Tempat/Tanggal Lahir
Institusi
Pangkat
Riwayat Pendidikan
Dokter Umum
Spesialis Anak
Konsultan Endokrin
Doktor
:
:
:
:
FK UNUD 1986
FK UNDIP 1998
Kolegium IKA Indonesia 2005
Pasca Sarjana UNUD 2011
Jabatan /Pekerjaan
Ketua IDAI Cabang Bali ( 2008 2014)
Ketua UKK Endokrin IDAI ( 2011 - 2017)
Staf Pengajar Endokrinologi Anak FK UNUD
171 million1
2000
1.
2.
366 million2
2011
2010
552 million2
2030
Childhood T2DM:
disease in the child who typically
is overweight or obese(BMI 85th94th and >95th percentile
for age and gender, respectively)
has a strong family history of T2DM
has substantial residual insulin secretory capacity at diagnosis
has insidious onset of disease
demonstrates insulin resistance (including clinical evidence of
polycystic ovarian syndrome or acanthosis nigricans);
lacks evidence for diabetic autoimmunity (negative for
autoantibodies typically associated with T1DM).
1. Copeland.K.C, at all, Pediatrics 2013, Management of Newly
Diagnosed T2DM in Children and Adolescent
Slide 6
1.
2.
Undiagnosed
diabetes
Known
diabetes
Insulin resistance
Insulin secretion
Postprandial glucose
Fasting glucose
Microvascular complications
Macrovascular complications
1.
Adapted from: Ramlo-Halsted BA, Edelman SV. Clincial Diabetes 2000;18(2): http://journal.diabetes.org/clinicaldiabetes/v18n22000/pg80.htm
2.Management goals
3. Education
include a nutritionist, psychologist and/or
social worker, and exercise physiologist
greater emphasis on behavioral, dietary, and
physical activity changes
given by team members with expertise and
knowledge
education of youth and families with T2D.
4. Behavioral Change
The family and child should understand the
medical implications of obesity and T2D.
Clinicians must have an understanding of the
health.
Changes should be made in small achievable
increments and permanent.
The patient and family should be trained to
monitor the quantity and quality.
Any behavioral change, a dynamic and
sustainable reward system is essential for
success.
5. Dietary management
Initial focus on eliminating sugar-containing soft
drinks and juices
Increasing fruit and vegetable intake
Reducing the intake of foods made out of refined
Reducing meals eaten away from home
increased portions of fresh vegetables and
decreased portions of carbohydrate-rich noodles
Changing white rice and white flour to brown rice
and whole grain
Changing family diet behaviors
6. Exercise Management
Exercise is an important part of the diabetes
management plan.
Regular exercise has been shown to improve
blood glucose, reduce cardiovascular risk,
contribute to weight loss, improve well-being.
Youth with T2D should be exercise for at least 60
min daily.
A family or friend should be identified to
participate in physical activity with the patient.
8. Grycemic Monitoring
SMBG.
Patients on insulin or sulfonylureas need to
monitor for asymptomatic hypoglycemia.
HbA1c concentration should be determined at
least twice a year and quarterly if insulin is
being used or metabolic control is
unsatisfactory.
9. Pharmacologic therapy
Initial treatment of youth with T2D should
include metformin and/or insulin alone or in
combination. The specifics of the initial
treatment modality are determined by
symptoms, severity of hyperglycemia, and
presence or absence of ketosis/ketoacidosis
Diagnosis of diabetes in an
Obese adolescent
Asymptomatic HbA1c < 9%
No acidosis
Acidosis
Symptomatic or HbA1c > 9%
No acidosis
Likely type 2
Basal insulin
Metformin
Lifestyle change
Metformin
Lifestyle change
Insulin as in T1D
until
acidosis resolved
Likely type 1
Initiate MDI insulin
education
Diabetes autoantibodies
(-)
(+)
Continue metformin
Wean insulin
YES
At target
Fig. 1. Approach to initial and subsequent treatment of youth with type 2 diabetes.
Premixed
Insulin
(Twice daily
Treat to target)
Lifestyle +
Metformin
+-other OAD
or GLP-1
agonists
HbA1c 7.0%
Basal Insulin
(Basal + 3
prandial)
Basal Insulin
(Once-daily treatto-target)
Basal Insulin
(Basal + 1 or 2
prandial)
HbA1c %
Metformin
Insulin
Despite hyperinsulinemia and insulin
resistance,supplemental insulin is generally
effective in reducing hyperglycemia and attaining
glycemic targets.
If there is inadequate glycemic control on oral
agents, a long-acting (basal) insulin analog oncedaily NPH may provide satisfactory therapy.
if HbA1c target is not reached and postprandial
hyperglycemia persists, rapid or short acting
insulin can be added.
-------
endogen insulin
Long insulin
Rapid insulin
Mix insulin
Breakfast
Lunch
Dinner
Bed time
Inadequate Lifestyle
+ 1 OAD
INITIATE INSULIN
+ 2 OAD
+ 3 OAD
insulin resistance
Insulin resistance is a physiologic abnormality,
defined as an impaired response to the
physiologic effects of insulin, including effects on
glucose, lipid, protein metabolism, and on
vascular endothelial function.
Insulin resistance can occur in many tissues,
including hepatic, muscle, and adipose tissue,
some areas of the brain.
some tissues continue to respond to
hyperinsulinemia, such as the ovary and the
sympathetic nervous system innervating muscle.
insulin resistance
Dysglycemia
Lipid abnormalities
Endothelial dysfunction
Increased procoagulant factors
Hemodynamic changes
Inflammation
Increased plasma uric acid
Increased hepatic and intramyocellular lipid deposition
Mitochondrial dysfunction
Ovarian hyperandrogenism
Sleep-disordered breathing.
Obesity
Hypertension
Nephropathy
Dyslipidemia
Polycystic ovarian syndrome
Non-alcoholic fatty liver disease
Systemic inflammation
Obstructive sleep apnea
Depression
Myocardial infarction
Each HbA1c
percentage
point
reduction
counts3
HbA1c
-1%
1.
2.
3.
-14%
Microvascular complications
-37%
1.
2.
3.
EASD/ADA1
HbA1c
<7.0%
IDF2
HbA1c
<7.0%
EMA3
HbA1c
<7.0%
Thank You