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DIABETES MELLITUS

STANDAR OF MEDICAL
2010

Harsinen Sanusi
Division of Endocrinology and Metabolic Departement
of Internal Medicine Faculty of Medicine RS dr Wahidin
Sudirohusodo
Makassar

Kuliah Tamu Politeknik Kesehatan Makassar


tgl 16 Oktober 2010
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
prevalence (millions)
World wide diabetes

300
300

250 221

200
150
150

100 2000 2010 2025

International Diabetes Federation Diabetes Atlas 2000;


Amos et al. Diabet Med 1997;14 (Suppl 5):S1-S85.
U.S. Diabetes Prevalence
Diabetes kills 1
American every 3
minutes
18 Million
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 1995 2000 2025


number of
diabetics 350
(millions)
300

250
200
150
100

50
0
developed developing world

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


120
2000
2025 DEVELOPED COUNTRIES
80
Millions

40

0
20-44 45-64 >65
120
2000
2025 DEVELOPING COUNTRIES
80
Millions

40

0
Age Group (years)
Number of people with IGT and diabetes in Indonesia (20-
70 y age group)

IDF - Diabetes Atlas, 3rd Edition 2006

million
25 + 45.6 %

20.597
20

14.144
15
Diabetes
rank no. 4 rank no. 3 IGT
10 worldwide worldwide

5.129
5
2.888

0
2007 2025

+ 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
N = 70.882
21%(14.873)had diabetes
Norhammar A. Heart Jan, 2007
Environmental factors Environmental factors
Overeating Genetic factors Genetic factors Pregnancy
Inactivity Endocrine diseases
Smoking Unknown Unknown
Diabetogenic drugs
Diabetogenic drugs Malnutrition in utero

Insulin resistance B- cell defects

Glucose toxicity

Hyperglycaemia

Impaired glucose Worsening B-cell functions


tolerance
? Amyloid deposition
Malnutrition in utero

NIDDM
Diabetes Melitus

Patogenesis DM Tipe 2

Defisiensi Aksi / Kerja


Insulin 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 Postprandial
Hyperglycemia Type 2
Type 2
25 Diabetes
Diabetes
Phase 1 Type 2
Phase 3
Diabetes
Phase 2
0
- 12 - 10 -6 -2 0 2 6 10 14
Years from diagnosis
hypoX-jsk-7-99
Diabetes Mellitus
Genetic susceptibility,
obesity, Western
lifestyle

Insulin
resistance IR -cell
dysfunction

Macrovascular Microvascular
Type 2 diabetes
complication 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 140-
199 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 Other Specific
Immune-mediated
Types
Genetic defects/syndromes
Idiopathic Diseases of the exocrine
pancreas
Type 2 diabetes Endocrinopathies
Drug-induced
Gestational Infections
Diabetes Mellitus Uncommon immune-
mediated
(GDM)
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 FPG/preprandial 2h-
(%) (mg/dl) postprandial
(mg/dl)
Target for most <7 80 - 130 100 - 180
patients

Normal range < 6.0 80 110 100 - 140


(if it can be
safely achieved)

* 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 PENYAKIT
HIPERTENSI JANTUNG
KORONER
OLAHRAGA
BERAT BADAN STROKE

DIABETISI KEBUTAAN

DIET GAGAL
KENDALIKAN GINJAL
TABLET GULA DARAH
INSULIN LUKA KAKI

TBC PARU
PERIORITAS PENGOBATAN

Kendalikan Kendalikan sindroma metabolik:


Obesitas,dislipidemia,hipertensi,
glukosa darah intoleransi glukosa, hiperinsulinemia

Gangguan Gangguan
mikrovaskuler 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 Transient
stroke ischemic attack

Myocardial Angina:
infarction 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 DAG-PKC Oxidants Cytokines


Pathway Pathway

AGES Osmotic
Effect 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 Hiperglikemia

prediabetes TGT, GDPT

Diabetes
P.Sekunder

Komplikasi
P.Tertier

Akut Kronis

Koma diabetik Jantung, kaki, otak, mata, ginjal


Sulaemana Mosquue Istambul
St Sophia- Istambul

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