DIABETES MELLITUS

DIABETES MELITUS
Current

issue perkembangan diabetes melitus Konsep medik diabetes melitus Penatalaksanaan dan Pencegahan diabetes melitus

Diabetes Melitus
Definisi :
Suatu sindrom yang ditandai dengan adanya hiperglikemi kronis serta terganggunya metabolisme karbohidrat, lemak dan protein yang berkaitan dengan kurangnya jumlah atau kerja dari insulin secara relatif maupun absolut
Ref. : Peter H. Bennett; Definition, Diagnosis, and Classification of Diabetes Mellitus and Impaired Glucose Tolerance; Joslins Diabetes Mellitus; 13th ed.; 1994; hal. 193

DIABETES MELITUS
PENYAKIT MENAHUN TIDAK BISA DISEMBUHKAN DIKENDALIKAN TIDAK BERGEJALA PENGOBATAN DILALAIKAN TIDAK TERKENDALI KOMPLIKASI AKUT DAN MENAHUN KEMATIAN

World View
177 million worldwide 4th leading cause of death by disease India 33 million people with diabetes China 23 million people with diabetes Population of diabetes will double to triple by 2025 One out of every three Americans born today will develop diabetes
Time magazine December 2003; CDC

BERAPA BANYAK DIABETISI?

Tergantung ras, umur, keturunan, pola hidup Negara berkembang meledak, dibanding negara maju Indonesia; rata-rata 4-5% 6 % Makassar 42 pengunjung26 DM dengan hanya gula darah puasa.

The worldwide pandemic of type 2 diabetes

350
World wide diabetes prevalence (millions)

300 300 250 200 150 150 100

2000 2010 2025

221

International Diabetes Federation Diabetes Atlas 2000; Amos et al. Diabet Med 1997;14 (Suppl 5):S1-S85.

U.S. Diabetes Prevalence

18 Million

Diabetes kills 1 American every 3 minutes

New case diagnosed every 40 seconds More deaths than AIDS and breast cancer combined

Average life expectancy: 15 years less than non-diabetes population

Two Worlds: Developed and Developing

Estimated number of diabetics (millions)

1995
350 300 250 200 150 100 50 0 developed

2000

2025

developing

world

King H et al. Diabetes Care.1998; 21: 1414-1431

120

2000 2025 DEVELOPED COUNTRIES

80
Millions

40

20-44
120 2000 2025 Millions

45-64

>65

DEVELOPING COUNTRIES

80

40

Age Group (years)

Number of people with IGT and diabetes in Indonesia (2070 y age group) IDF - Diabetes Atlas, 3rd Edition 2006
million 25
20 15 10 5 0 2007 2025
14.144 rank no. 4 worldwide 5.129 2.888 rank no. 3 worldwide

+ 45.6 %
20.597

Diabetes IGT

+ 77.6 %

DM tipe 2: A silent killer

30% dari penduduk DMT2 tidak terdiagnosis 50% pasien baru diagnosis DMT2 sudah menderita komplikasi
65-80% pasien DMT2 meninggal o/k PKV

2-4X pasien DMT2 untuk mendapat PJK dan 2 X stroke

National Institute of Diabetes and Digestive and Kidney Diseases. http://diabetes.niddk.nih.gov/ dm/pubs/statistics/index.htm#7 [Accessed 1 December 2005] Wingard DL et al. Diabetes Care 1993;16:1022-5

Crude one-year mortality 1995 to 2002 in patients with and without diabetes
Mortality improvement was seen in both groups but a fatal outcome remained higher among patients with diabetes.
30 25 20 15 10 5 Diabetic Non-diabetic 0 1995 1996 1997 1998 1999 2000 2001 2002

Year
Norhammar A. Heart Jan, 2007

N = 70.882 21%(14.873)had diabetes

Environmental factors
Overeating Inactivity Smoking Diabetogenic drugs

Environmental factors Genetic factors Unknown Genetic factors Unknown

Pregnancy Endocrine diseases Diabetogenic drugs Malnutrition in utero

Insulin resistance Glucose toxicity Hyperglycaemia

B- cell defects

Impaired glucose tolerance

Worsening B-cell functions ? Amyloid deposition

Malnutrition in utero

NIDDM

Diabetes Melitus
Patogenesis DM Tipe 2

Defisiensi Insulin

Aksi / Kerja Insulin

Hiperglikemi
DeFronzo RA.Diabetes.37:667,1988 Saltiel J.Diabetes.45:1661-1669,1996 Robertson RP. Diabetes.43:1085,1994 Tokuyama Y. Diabetes 44:1447,1995

Stages of type 2 Diabetes in relationship to 100 -cell function

75
Beta cell function (%)

50

IGT
25

Postprandial Hyperglycemia

Type 2 Diabetes Phase 1

Type 2 Diabetes Phase 2

2 6 10

Type 2 Diabetes Phase 3

0
- 12 - 10 -6 -2 0 14

Years from diagnosis hypoX-jsk-7-99

Diabetes Mellitus
Genetic susceptibility, obesity, Western lifestyle

Insulin resistance

IR

-cell dysfunction

Macrovascular complication

Type 2 diabetes

Microvascular

complication

(Expert Committee on the Diagnosis and Classification of Diabetes mellitus 2002)

Diagnosis Diabetes melitus

Diagnosis DM
Hb A1C >6,5% Gula darah puasa > 126 mg/dL Gula darah 2 jam postprandial setelah beban glukosa 75 gr >200 mg/dL Gula darah sewaktu disertai gejala klinis khas >200mg/dL

ADA 2010

Diagnosis Pre Diabetes

Pemeriksaan gula darah puasa 100-125 mg/dL Glukosa Darah Puasa Terganggu (GDPT) Pemeriksaan gula darah 2 jam post prandial pada TTGO 140199 mg/dl Toleransi Glukosa Terganggu (TGT)

Risk factors for type 2 diabetes

Umur >45 tahun Obese inaktifitas fisik ibu/bapa diabetes Sebelumnya sudah TGT atau GDPT Pernah diabetes waktu hami (DM Gestasi) atau melahirkan bayi >4kg Hipertensi (> 140/90 mm Hg) HDL cholesterol < 35 mg/dl and/or trigliseride level > 250 mg/dl Polycystic ovary syndrome Hystory of vascular disease
________________________________________________________ Diabetes care 2002;25 suppl1: S22 * May not be correct for all ethnic groups. Diabetes care 2004;27:S12

Classification of Diabetes Mellitus

Type 1 diabetes
Immune-mediated Idiopathic

Other Specific Types

Type 2 diabetes Gestational Diabetes Mellitus (GDM)

Genetic defects/syndromes Diseases of the exocrine pancreas Endocrinopathies Drug-induced Infections Uncommon immunemediated

Manifestasi klinis
3 P (Poliuri, Polifagi, Polidipsi) BB turun Gatal-gatal Lesu, loyo Kesemutan Impotensi Luka sukarsembuh

Tujuan pengobatan DM tipe 2:

Menekan/mengurangi

gejala klinik

hiperglikemia Mencegah onset / progresivitas komplikasi vaskuler diabetik dengan kontrol metabolik jangka lama

Charbonnel V Therapeutique des Entretitiens1997;187-192

Targets for Glycemic Control

Target A1C (%) <7 FPG/preprandial 2h(mg/dl) postprandial (mg/dl) 80 - 130 100 - 180

Target for most patients Normal range (if it can be safely achieved)

< 6.0

80 110

100 - 140

* Treatment goals and strategies must be tailored to the patient, with consideration given to individual risk factors

To achieve an A1C 7.0%, patients should aim for FPG, preprandial and postprandial PG targets

LEMAK DARAH

ROKOK
HIPERTENSI OLAHRAGA

PENYAKIT JANTUNG KORONER STROKE KEBUTAAN

BERAT BADAN

DIABETISI
DIET TABLET INSULIN

KENDALIKAN GULA DARAH

GAGAL GINJAL

LUKA KAKI
TBC PARU

PERIORITAS PENGOBATAN
Kendalikan glukosa darah
Kendalikan sindroma metabolik:

Obesitas,dislipidemia,hipertensi, intoleransi glukosa, hiperinsulinemia

Gangguan mikrovaskuler

Gangguan makrovaskuler

OBAT OBAT ANTI DIABETES

Tablet:
Kerja pendek:3 kali perhari:
Novonorm, Starlix, Glucobay, Glucophage

Kerja sedang 2 kali perhari

Glibenklamid, Daonil,Gluronerm

Kerja lama 1 kali perhari

Glucotrol XL, Diamicron MR

Suntik

insulin:

Kerja pendek : Actrapid, Humulin R, novorapid, apidra Kerja sedang : Insulitard, Humulin N, Kerja lama Lantus,levemir Kombinasi humalo mix, novomix

Koma diabetik Koma hiperglikemik Koma hipoglikemik

Mikroangiopati diabetik
Makroangiopati diabetik

Major clinical manifestations of atherothrombosis

Ischemic stroke Myocardial infarction
Transient ischemic attack

Angina:
Stable Unstable

Peripheral arterial disease:

Intermittent claudication Rest Pain Gangrene Necrosis

Adapted from: Drouet L. Cerebrovasc Dis 2002; 13(suppl 1): 16.

Hiperglikemia

Glycation

Polyol Pathway Osmotic Effect

DAG-PKC Pathway

Oxidants

Cytokines

AGES

Tissue damage

Endothelial Cell Dysfunction

Chronic Complication (Atherosclerosis,etc)
DAG = Diacyl glycerol PKC = Proteinkinase

PENCEGAHAN DM
Pencegahan

primer Pencegahan sekunder Pencegahan tertiair

Pencegahan Primer
Pola hidup olahraga, diet, stress Exersice intensif mengurangi DM Obat-obat : glucobay, metformin, pioglitazone. Obat penurun berat badan

Pencegahan sekunder
Edukasi Diet Olahraga Obat anti diabetes ( oral atau insulin) Kontrol teratur

Normal P. Primer prediabetes

Hiperglikemia
TGT, GDPT

Diabetes

P.Sekunder
Komplikasi P.Tertier Akut Koma diabetik Kronis Jantung, kaki, otak, mata, ginjal

Sulaemana Mosquue Istambul

St Sophia- Istambul