DIABETES MELLITUS

DIABETES MELITUS

Current issue perkembangan diabetes melitus

Konsep medik diabetes melitusPenatalaksanaan 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; Joslin’s 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.

150

221

300

100

150

200

250

300

350

Wo

rld

wid

e d

iab

etes

pre

vale

nc

e (

mill

ion

s)

2000 2010 2025

The worldwide pandemic oftype 2 diabetes

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 New case diagnosed

every 40 seconds More deaths than AIDS

and breast cancer combined

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

18 Million

Two Worlds: Developed and Developing

0

50

100

150

200

250

300

350

developed developing world

1995 2000 2025

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

Estimatednumber of diabetics(millions)

120

80

40

0

2000

2025

120

80

40

0

2000

2025

DEVELOPED COUNTRIES

DEVELOPING COUNTRIES

Age Group (years)

20-44 45-64 >65

Mil

lio

ns

Mil

lio

ns

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

IDF - Diabetes Atlas, 3rd Edition 2006

0

5

10

15

20

25

2007 2025

Diabetes

I G T

2.888

5.129

million

14.144

20.597

+ 77.6 %

rank no. 4 worldwide

rank no. 3 worldwide

+ 45.6 %

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

1995 1996 19991997 1998 2000 20022001

Year

0

5

10

20

15

25

30

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.

Diabetic

Non-diabetic

Norhammar A. Heart Jan, 2007

N = 70.88221%(14.873)had diabetes

• Overeating• Inactivity• Smoking• Diabetogenic drugs

• Pregnancy• Endocrine diseases• Diabetogenic drugs• Malnutrition in utero

Unknown Unknown

B- cell defectsInsulin resistance

Genetic factorsGenetic factors

Glucose toxicity

Hyperglycaemia

Worsening B-cell functions• ? Amyloid deposition• Malnutrition in utero

Impaired glucose tolerance

NIDDM

Environmental factorsEnvironmental factors

PatogenesisDM Tipe 2

Aksi / KerjaInsulin

Defisiensi Insulin

Hiperglikemi

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

DiabetesMelitus

hypoX-jsk-7-99

IGT Postprandial Hyperglycemia Type 2

DiabetesPhase 1 Type 2

DiabetesPhase 2

Type 2DiabetesPhase 3

- 12 - 10 - 6 - 2 0 2 6 10 14Years from diagnosis

Bet

a ce

ll fu

nctio

n (%

)Stages of type 2 Diabetes in relationship to Stages of type 2 Diabetes in relationship to

--cell functioncell function

25

0

50

75

100

b-celldysfunction

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

Diabetes MellitusDiabetes Mellitus

IRIR Insulinresistance

Genetic susceptibility,obesity, Western

lifestyle

Type 2 diabetesMacrovascular

complication

Microvascular

complication

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________________________________________________________* May not be correct for all ethnic groups.

Diabetes care 2002;25 suppl1: S22

Diabetes care 2004;27:S12

Classification of Diabetes Mellitus

Type 1 diabetes Immune-mediated Idiopathic

Type 2 diabetes Gestational

Diabetes Mellitus (GDM)

Other Specific Types Genetic defects/syndromes Diseases of the exocrine

pancreas Endocrinopathies Drug-induced Infections Uncommon immune-

mediated

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

* Treatment goals and strategies must be tailored to the patient, with consideration given to individual risk factorsTo achieve an A1C 7.0%, patients should aim for

FPG, preprandial and postprandial PG targets

Target A1C (%)

FPG/preprandial (mg/dl)

2h-postprandial

(mg/dl)

Target for most patients

<7 80 - 130 100 - 180

Normal range (if it can be safely achieved)

< 6.0 80 – 110 100 - 140

DIABETISI

PENYAKIT JANTUNG KORONER

GAGAL GINJAL

KEBUTAAN

STROKE

LUKA KAKI

TBC PARU

KENDALIKAN GULA DARAH

LEMAK DARAH

ROKOK

HIPERTENSI

OLAHRAGA

BERAT BADAN

DIET

TABLET

INSULIN

PERIORITAS PENGOBATAN

Kendalikan glukosa darah

Kendalikan sindroma metabolik: Obesitas,dislipidemia,hipertensi, intoleransi glukosa, hiperinsulinemia

Gangguan mikrovaskul

er

Gangguan makrovaskul

er

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

Mikroangiopati diabetik

Makroangiopati diabetik

Koma diabetik

Koma hiperglikemik

Koma hipoglikemik

Major clinical manifestations of atherothrombosis

Adapted from: Drouet L. Cerebrovasc Dis 2002; 13(suppl 1): 1–6.

Transient ischemic attack

Angina:• Stable• Unstable

Ischemicstroke

Myocardial infarction

Peripheral arterialdisease:• Intermittent claudication• Rest Pain• Gangrene• Necrosis

Hiperglikemia

Glycation

Osmotic Effect

Oxidants Cytokines

AGES

Polyol Pathway

Tissue damage

Endothelial Cell Dysfunction

Chronic Complication (Atherosclerosis,etc)

DAG-PKC Pathway

DAG = Diacyl glycerol PKC = Proteinkinase

PENCEGAHAN DM

Pencegahan primerPencegahan sekunderPencegahan 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

prediabetes

Diabetes

TGT, GDPT

Hiperglikemia

Komplikasi

Kronis Akut

P. Primer

P.Sekunder

P.Tertier

Koma diabetik Jantung, kaki, otak, mata, ginjal

Sulaemana Mosquue Istambul

St Sophia- Istambul