Challenges in diabetes management:

The unmet needs and diabetes management in specialist provider

____________________

FACTS ON INDONESIA

Diabetes Mellitus is a disease that is on the rise

The diabetes population is increasing rapidly
throughout the world including Indonesia

Indonesia country profile

IDF Diabetes Atlas 2013

2013

National Survey RIKESDAS 2007

2007

5,7 %

8,500,000

>11,000,000

2780 internists*, 77 endocrinologists,

70,000 GPs 2000 diabetes educators
Updated data, January 2014

FACTS ON INDONESIA
Hospitals all over the country**

Type A
Type A
Type B

RSU 20
RSK 38
RSU 262

Type B
Type C
Type C
Type D
Type D

RSK 47
RSU 599
RSK 181
RSU 498
RSK 36

2780 internists* 1459 RS (type B-C-D)

2000 (?) diabetes educators

Updated data, January 2014.

** Ditjen BUK 2014: http://202.70.136.52/rsonline/report/report_by_catrs.php

Glycemic targets

ADA1

FPG
<130 mg/dL

HbA1c
< 7.0%

PPG
<180 mg/dL

IDF2

FPG
<110 mg/dl

HbA1c
< 6.5%

PPG
<145 mg/dL

HbA1c
< 7%

PPG
<140 mg/dl

PERKENI3

FPG
<100 mg/dl

1. American Diabetes Association Diabetes Care 2009;32 (Suppl 1):S1-S97

2. IDF Clinical Guidelines Task Force. International Diabetes Federation 2005. 3. PERKENI 2011 Konsensus .

DiabCare Asia 2008: Poor glycaemic control

(HbA1c) across South-East Asia

9.0

8.66

Mean HbA1c ( % )

8.60
8.5

8.15

8.03

8.0

8.18
7.87

7.5

Perkeni /
ADA
Target

7.0
6.5
6.0
Bangladesh

Indonesia

Malaysia

Philippines

Singapore

Thailand

Adapted from Mafauzy et al. Med J Malaysia 2011;66:175-81; Latif et al. Bangladesh Med Res Counc Bull
2011;37:11-16; Soewondo et al. Med J Indones 2010;19:235-44; Novo Nordisk data on file.

KADAR HbA1c
<7%

7-8%

GHS

GHS

Gaya Hidup
Sehat

8-9%

>9%

9-10%

>10%

+
Monoter
apiSU,
Met,

GHS

Konsensus
Pengelolaan dan Pencegahan
Diabetes Melitus tipe 2
di Indonesia
2011

+
Penurunan
GHS
berat
AGI,
Kombina
badan
Glinid,
si
+
Mengatur
TZD,
2 obat
GHS
diit
Kombina
Met,
SU,
Latihan
DPP-IV
si
+
AGI,
Jasmani
3 obat
teratur
Glinid,
Catatan
Kombina
Met,
SU,
1.Dinyatakan gagal bila
TZD,
si
AGI,
dengan terapi 2-3 bulan
DPP-IV
2 obat
tidak mencapai target
Glinid,
Met,
SU,
HbA1c <7%
TZD,
AGI,
2.Bila tidak ada
DPP-IV
pemeriksaan HbA1c
Glinid,
dapat digunakan
TZD
+
GHS
pemeriksaan glukosa
darah. Rata-rata glukosa
+
Basal
darah sehari
Insulin
dikonversikan ke HbA1c
Insulin
menurut kriteria ADA
Intensif*
*insulin intensif : penggunaan insulin basal bersamaan dengan insulin prandial
2010

Konsensus Perkeni 2011

DiabetesCare,Diabetologia.19April2012

Antihyperglycemic Therapy: General Recommendations

[Epubaheadofprint]

DiabetesCare,Diabetologia.19April2012

Antihyperglycemic Therapy: General Recommendations

[Epubaheadofprint]

DiabetesCare,Diabetologia.19April2012

Antihyperglycemic Therapy: General Recommendations

[Epubaheadofprint]

Basal
Insulin

Basal
Insulin

Basal
Insulin

DiabetesCare,Diabetologia.
19April2012[Epubaheadofprint]

Basal
Insulin

Insulin
(multiple daily dosages)

Changing treatment paradigms

Early glycaemic control ( UKPDS, UKPDS 10 years post trial
follow up)

Treat to target ( DCCT, Kumamoto, UKPDS post trial )

Disease process
Individualized therapy approach (ADA/EASD 2013)

Challenges of blood glucose control in T2DM

Polypharmacies Complicated treatment schedule - The present of
comorbidities Diabetes self management SMBG Education

Polypharmacy

Drug interactions
Side
effects

Cost

- Hypoglycemia
- Weight gain
- GI disturbances

Longer
Consultation
Diabetic
education
Compliance/ adherence
15

The challenges to reach HbA1c goal

Hypoglycaemia/
weight gain
HbA1c

Jacob AN, et al. Diabetes Obes Metab 2007;9:38693;

Kahn SE ,et al. N Engl J Med 2006;355:242743;
Wright AD, et al. J Diabetes Complications 2006;20:395401

16

Fear of hypoglycaemia is a major concern for patients

Male Female

Severe hypoglycaemia
Male Female

Mild hypoglycaemia
Male

Female

Kidney problems
Male Female

Blindness
Not worried
Visual analogue scale showing patients worries about mild and severe
hypoglycaemic events, ranging from not worried to very worried
Pramming S, et al. Diabet Med 1991;8:21722

Very worried

18

Hypoglycaemia in T2DM: a possible link to increased CV

risk/events
Possible mechanisms1,2

Hypoglycaemia as link to tissue ischaemia3

Haemodynamic changes:

activation of autonomic nervous system

10-50 fold increased secretion of
adrenaline & noradrenaline

ECG changes:
longer QT interval
hypokalaemia

Haemorheological changes:
platelet activation
increased viscosity

*P <0.01 vs episodes during hyperglycaemia and normoglycaemia

1
Desouza CV et al. Diabetes Care 2010;33:13891394;
2
Robert TC et al. Diabetes 2003;52:146974;
3
Desouza C et al. Diabetes Care 2003; 26:14851489

Episodes accompanied by
cardiac symptoms (%)

20
15

10
5

0
Study of 72-h continuous glucose monitoring and
simultaneous cardiac Holter monitoring in patients with
T2DM treated with insulin and history of frequent
hypoglycaemia and coronary artery disease (n=19)
54 episodes of hypoglycaemia reported (BGL <70 mg/dl)
59 episodes of hyperglycaemia reported (BGL >200 mg/dl)

19

The risk of severe hypoglycemia:

Learning's from post hoc epidemiological analysis form ACCORD

Identification of baseline subgroups data with increased risk

for severe hypoglycaemia can provide guidance to clinicians
attempting to modify patient therapy on the basis of individual
risk

Miller ME et al. BMJ 2010; 340:b5444

20

The risk of severe hypoglycemia:

Learning's from post hoc epidemiological analysis form ACCORD

P<0.000
1

P=0.01
P<0.03

P=0.03

P<0.000
1

RR

P<0.000
1 P<0.000
1

Diabetes
duration

BMI
(kg/m2)

(years)
*History of peripheral neuropathy (yes vs. no); **per 1 year increase

Serum
creatinine
(mol/l)
Miller ME et al. BMJ 2010; 340:b5444

21

Weight gain in T2DM: a common side effect post

treatment
The vicious circle of type 2 diabetes

Weight gain is a common side effect

of diabetes treatments
OAD agents
Metformin13

Obesity

Weight change (kg)

3.80.5
0.41.7

SUs14

0.94.6

TZDs46

Insulin
resistance

Treatment

Metformin + SU

Type 2
diabetes

0.33.0

Meglitinides4,7,8
13

Metformin + TZD5,6,9

0.31.9
0.82.1

5 4 3 2 1 0 1
Weight
Weight
loss
neutral

4 5
Weight
gain

OAD=oral antidiabetic drug; SU=sulfonylurea; TZD=thiazolidinedione

Glucophage [package insert]. Princeton, NJ: Bristol-Myers Squibb Company, 2004. 2Glucovance [package insert]. Princeton, NJ:
Bristol-Myers Squibb Company, 2004. 3Metaglip [package insert]. Princeton, NJ: Bristol-Myers Squibb Company, 2002. 4Malone M.
Ann Pharmacother 2005; 39: 20462055. 5Actos [package insert]. Indianapolis, Ind: Eli Lilly and Company, 2004. 6Avandia [package
insert]. Research Triangle Park, NC: GlaxoSmithKline, 2005
7
Starlix [package insert]. East Hanover, NJ: Novartis Pharmaceuticals Corporation; 2004
8
Prandin [package insert]. Princeton, NJ: Novo Nordisk, Inc, 2004
9
Avandamet [package insert]. Research Triangle Park, NC: GlaxoSmithKline, 2005
1

22

Compliance Study
Prospective Study in 11,896 T 2 DM Patients
11 %

6%

46 %

37 %

Compliance

1-3/month

1/week

>1/week

Guillausseau, Influence of Oral Antidiabetic drug compliance on metabolic Control in T2 DM, Diabetes Metab
2003, 29, 79 - 81

23

Individualized
Approach to therapy
management of
Approach
hyperglycemia

Patient attitude and

expected treatment
efforts
Risks potentially
associated with
hypoglycemia, other
adverse events
Disease
duration
Life
expectancy

Less
string
ent

More
stringen
t
Highly motivated,
adherent, excellent selfcare capacities

Less motivated, nonadherent, poor self-care

capacities

Low

High

Long standing diabetes

Newly diagnose

long

Short

Absent

Few/Mild

Severe

Absent
Established vascular
complications

Few/Mild

Severe

Important
comorbidities

Resources, support

Readily

Diabetes Care Publish Ahead of Print, published onlineavailable

April 19, 2012

Limited

Challenges towards good management of type 2 Diabetes

Knowledge Diabetes Self Management - Resources Health System

Polypharmacies Complicated treatment schedule - The present of

comorbidities Diabetes self management SMBG Education

Challenges of blood glucose control in T2DM

Quality of Life (QoL) in T2DM:

Body Mass Index (BMI), Hypoglycemia related to QoL
The relationship between Quality of life (EQ5D) , BMI and Hypoglycemia

Higher the BMI =

Lower the Quality of life

Higher the hypoglycemia =

Lower the Quality of life

McEwan P Etal (2010) Diab, Obesity and Metab 12:431-6

32

Poor tolerability contributes to poor adherence

Adherence

Helping
patients stick
to their
therapy!

Drug
prescription

End
Discontinuation prescription

Compliance
Persistence (days)

Time

Each additional tolerability issue* is associated with

28% greater likelihood of medication non-adherence
Symptoms of hypoglycaemia : non-adherence by 76%
Constipation/diarrhoea : non-adherence by 47%

* Tolerability issues include symptoms of hypoglycaemia, constipation/diarrhoea, headaches, weight gain & water retention
Pollack MF et al. Diabetes Research & Clinical Practice 87 (2010) 204-210

33

Patient-Related Barriers to Effective Treatment

Limited access to health care
Lack of health insurance
Lack of a regular provider

Non-adherence to therapy

Knowledge deficit
Medication cost
Complicated regimens
Side effects

Medication not taken by

patient
Poor physician-patients
communication
Lack of social support

Wang TJ, Vasan RS. Circulation. 2005;112:1651-1662;

Chobanian AV, et al. JAMA. 2003;289:2560-2572.

34

Diabetes is a huge and growing problem

Adapted from Diabetes Atlas (IDF, 2013)

35

35

Diabetes is a huge and growing problem

Adapted from Diabetes Atlas (IDF, 2013)

36

36

Top 10 Countries by Diabetes Cases in the

Western Pacific Region
Country

Cases(million)

1. China

92.3

2. Indonesia

7.6

3. Japan

7.1

4. Philippines

4.3

5. Thailand

3.4

6. Republic of Korea

3.2

7. Vietnam

3.2

8. Malaysia

2.1

9. Australia

1.9

10. Myanmar

1.8

Adapted from International Diabetes Federation. Diabetes Atlas Update 2012 .Available from
http://www.idf.org/sites/default/files/IDF_WP_5E_Update_FactSheet.pdf (accessed 9 Jan 2013)

37