MakanMakanPagi Pagi

MakanMakanSiang Siang

MakanMakanMalam Malam

Sebelum tidur Sebelum tidur

Levemir Levemir

NovoRapidNovoRapid

Insulin endogenInsulin endogen

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Profil Insulin Analog sangat mirip dengan Insulin Endogen

NovoMixNovoMix

Efektivitas : Superior mengendalikan GD 2 jam pp Superior mengendalikan GD puasa Superior mengendalikan HbA1c

Keamanan Risiko Hipoglikemi lebih minimalFleksibilitas Waktu penyuntikan lebih fleksibel

(tidak menunggu 30 menit)

Profil farmakokinetik analog yang lebih mirip insulin alami, sehingga menghasilkan : Efektivitas, Keamanan dan Flexibility lebih baik dibanding human Insulin

Analog vs Human Insulin

Dose to Dose (1:1)Sebelumnya Actrapid 6 unit 3x sehari NovoRapid 6 unit 3 x sehari

Mixtard 14 unit malam dan 16 unit siang NovoMix 14 unit malam dan 16 unit siangInsulatard 14 unit malam Levemir 14 unit malam

Pasien sudah menggunakan Human Insulin?

Presentation Point of View

1. Rationality of Insulin Therapy for Type 2 DM

2. What is Analogue Insulin? 3. How & Strategy of Insulin Treatment ?4. Barrier of using insulin5. Take Home Message

How to Start

Insulin Therapy ?

Glycemic Control: Recommended goals

1.1. Global guideline for type 2 diabetes clinical guidelines taskforce (Brussels: IDF,2005)Global guideline for type 2 diabetes clinical guidelines taskforce (Brussels: IDF,2005)2.2. Nathan DM Nathan DM et al. Diabetologiaet al. Diabetologia 2006;49:1711-21. 2006;49:1711-21.3.3. http://www.aace.com/pub/odimplementation/roadmap.pdfhttp://www.aace.com/pub/odimplementation/roadmap.pdf

Measurement Normal IDF1 ADA/EASD2 AACE3 PERKENI

A1c* <6% <6.5% <7% <6.5% <6.5%

Fasting Gluc <100 <110 90-130 <110 80-110

PP (2h) Gluc <140 <155 <180 <140 80-145

* * Realistic TargetRealistic Target: Lowest A1c possible without unacceptable adverse effects: Lowest A1c possible without unacceptable adverse effects

IDF = International Diabetes FederationIDF = International Diabetes Federation ADA = American Diabetes Association.ADA = American Diabetes Association. AACE = American Association of Clinical Endocrinology AACE = American Association of Clinical Endocrinology

Insulin can be initiated anytime

InadequateInadequateLifestyleLifestyle

+ + 1 OAD1 OAD

+ 2 OAD

++ 3 OAD3 OAD

Initiate Insulin

• Traditionally, insulin had been reserved as the last line of therapy• Considering the benefits of normal glycemic status,

insulin can be initiated earlier, as soon as is required.

Indication: Permanent Not permanent

T1DM Infection

OAD failure Pregnancy

OAD Contra Indication Hospitalized

Diabetic Ketoacidosis Perioperative

Strategy of

Insulin Treatment ?

1. If Fasting BG is elevated, start for basal insulin with long acting insulin (Levemir)

2. If Prandial BG is elevated, start for prandial /bolus insulin with rapid acting insulin (NovoRapid)

3. If Fasting and Post Prandial are elevated : - Oral agent with basal insulin - premix insulin (NovoMix) - basal/bolus as in multiple daily injection (MDI)

Treatment Based on Type of Hyperglycemia

BasalBasalPrandialPrandial

Prandial Insulin (NovoRapid) Basal Insulin (Levemir)

Treat fasting hyperglyc. first

Continue oral agent

SMBG is important

HyperglycemiaHyperglycemia

BASAL – PRANDIAL CONCEPTBASAL – PRANDIAL CONCEPT

Untuk men’simple’kan terapi gunakan NovoMix (30% : Prandial Insulin & 70% : Basal Insulin)

Strategies for initiation & intensification of insulin therapy in patients with type 2 diabetes mellitus

Basal once daily start*

Premix once daily start*

Increasing need to cover PPGDisease

progression

Basal bolustherapy

(+ Prandial Insulin)

Intensification

Premix twice-daily

Basal bolustherapy

(+ Prandial Insulin)

Intensification

Premix three- times daily

*continue with appropriate OAD

Recommendation

“Fix the Fasting First”Start with basal insulin