Pleno Skenario B Blok 14 30 Des 2013

7/21/2019 Pleno Skenario B Blok 14 30 Des 2013

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Pleno Skenario B Blok 14“Coma hypoglycemic”

30 Desember 2013Oleh

Dr.Liniyanti D.Oswari,MS,MS!."

Dr.#lwi Shahab S$PD %&MD



Skenario B Blok 14

• 'n. D, () tah*n, +ibawa ke r*an awat +ar*rat -SMoleh kel*aranya karena koma se/ak 3 /am yan lal*.Pasien meni+a$ DM ti$e 2 se/ak ) tah*n yan lal* +ansetia$ hari menons*msi obat libenklami+ ) m.Men*r*t kel*aranya, sebel*m koma, $asien merasa+inin, berkerinat, $al$itasi, ba+an lemas +an merasa

!emas, setelah min*m obat sebel*m makan $ai.• • Pemeriksaan sik• %esa+aran koma, 'D 040 mm, na+i 124 5menit,

s*h* 3(O6.• 'i+ak +item*kan kelainan lain $a+a $emeriksaan sik.• %a+ar l*kosa +arah sewakt* 78DS9 +enan alat

l*kometer 40 m+l.•



Key

• DM ti$e 2 anti +iabetes oral $en*r*nan ka+ar l*kosa+arah koma hi$olikemik.

• Tujuan pembelajaran :• Mahasiswa +a$at memahami tentan $atosioloi +an

kom$likasi DM ti$e 2

• Mahasiswa +a$at memahami tentan $enyebab +an

mani:estasi klinik +ari hi$olikemi.• Mahasiswa +a$at menerankan tentan $enatalaksanaan

DM ti$e 2 +an koma hi$olikemik.

• Mahasiswa +a$at memahami tentan :armako+inamik +an

:armakokinetik serta e:ek sam$in obat;obat anti+iabetes.

• Mahasiswa +a$at men/elaskan tentan $en!eahanterha+a$ hi$olikemi $a+a $asien Diabetes Melit*s.



• <ns*lin – = !ells se!rete +*e

to hih bloo+l*!ose le>els

– 8l*!ose *$take intotiss*es in!reases

• 8l*!aon – ? !ells se!rete when

bloo+ l*!ose is low

– 8l*!ose is release+:rom tiss*es ba!kinto bloo+

Pancreaticaxis



• 8l*!ose homeostasis

@i*re 2(.A

Insulin

Beta cellsof pancreas stimulatedto release insulin intothe blood

Bodycellstake up moreglucose

Blood glucose leveldeclines to a set point;stimulus for insulinrelease diminishes

Liver takesup glucoseand stores it asglycogen

High bloodglucose level

STIMULUS!ising blood glucoselevel "e#g#$ after eatinga carbohydrate%richmeal& Homeostasis 'ormal blood glucose level

"about () mg*+)) mL& STIMULUS,eclining bloodglucose level"e#g#$ after skipping a meal&

-lphacells of pancreas stimulatedto release glucagoninto the blood

.lucagon

Liver breaks do/nglycogen andreleases glucoseto the blood

Blood glucose levelrises to set point;stimulus for glucagonrelease diminishes



Normal

LPL

Triglyceride

LipolysisGlycerol

Free fatty acids

Free fatty acids

Glucose

Synthesis

Insulin

Insulin



G l u c o s e

Insulin

I

I

I

I

I

I

I

I

G

G

G

G

G

G

G

GI

G

G

G

β CellDysfunction

Increase

splanchnic glc

output

!xxagerate lipol

Insulin Resistance

DecreaseGlucose"pta#e

'y$e 2 Diabetes Patho$hysioloy

Pancreas



ormal 8l*!ose 6ontrol

• <n the $ost;absor$ti>e $erio+ o: a normal in+i>i+*al,

low basal le>els o: !ir!*latin ins*lin aremaintaine+ thro*h !onstant = !ell se!retion. 'hiss*$$resses li$olysis, $roteolysis an+ ly!oenolysis.#:ter inestin a meal a b*rst o: ins*lin se!retion

o!!*rs in res$onse to ele>ate+ l*!ose an+ aminoa!i+ le>els. hen l*!ose le>els ret*rn to basal

le>els, ins*lin se!retion ret*rns to its basal le>el.• 'y$e < DM La!k o: :*n!tional =;!ells $re>ents

mitiation o: ele>ate+ l*!ose le>els an+asso!iate+ ins*lin res$onses. 'he onset an+$roression o: ne*ro$athy, ne$hro$athy an+

retino$athy are +ire!tly relate+ to e$iso+i!hy$erly!emia.• 'y$e << DM 'he $an!reas retains some =;!ell

:*n!tion b*t eCe!ti>e ins*lin res$onse isina+e*ate :or the l*!ose le>el. #!t*al ins*linle>els may be normal or s*$ra;normal b*t it is

ineCe!ti>e 7ins*lin resistan!e9.



Diabetes Mellit*s• 'his is a +isease !a*se+ by ele>ate+ l*!ose

le>els

• 2 'y$es o: +iabetes 'y$e < +iabetes 710E o: !ases9“6hil+hoo+F +iabetes

– De>elo$s s*++enly, *s*ally be:ore ae 1).

– Loss o: $an!reati! = !ells

– 6a*se+ by ina+e*ate $ro+*!tion o: ins*lin be!a*se '!ell;me+iate+ a*toimm*ne res$onse +estroys beta !ells. – 6ontrolle+ by ins*lin in/e!tions.

'y$e << +iabetes 70E o: !ases9 #+*ltF +iabetes – Gs*ally o!!*rs a:ter ae 40 an+ in obese in+i>i+*als, b*t

eneti!s, ain, an+ $eri$heral ins*lin resistan!e also. – <ns*lin le>els are normal or ele>ate+ b*t there is either a+e!rease in n*mber o: ins*lin re!e$tors or the !ells!annot take it *$.

– 6ontrolle+ by +ietary !hanes an+ re*lar e5er!ise.



Triglyceride

LPL

Type 1 Diabetes Mellitus

LipolysisGlycerol

Free fatty acids

Free fatty acids

Glucose

Synthesis



G l u c o s e

Insulin

I

I

I

I

I

I

I

I

G

G

G

G

G

G

G

GI

G

G

G

Insulin$ecretion

Insulin Efects

%&&D

Pancreas

'estrainof (G& "pta#e of

glucose

$torage In %at DepoInhibition of )ipolysi



GLUT1 GLUT3

blood brain

barrier

neuronal

cell membrane

KM ~ plasma [glucose]

low KM

regulates entry

into neurons

glc glc

glc

.lucose uptake by the brain



:roperties of glucose transporters



30

<PO8L<%&M< <PO8L<%&M<

- Pen*r*nan ka+ar l*kosa +arah ata* $en*r*nan *tilisasil*kosa oleh /arinan t*b*h yan menimb*lkan tan+a2+an e/ala2 klinis.

- Ber>ariasi se!ara in+i>i+*al 7 4) H I) m+l9

- Batas teren+ah ka+ar l*kosa +arah I0 m+l

- i$olikemi bila J )0 m+l

- %a+ar l*kosa +arah J I0 m+l +i$akai sebaai +asar

tatalaksana hi$olikemi terbar*

- anita lebih serin

- Gsia lan/*t lebih m*+ah terkena



31

8e/ala2 +an tan+a2 hi$olikemi 8e/ala2 +an tan+a2 hi$olikemi

- #+renerik #kibat $en*r*nan ka+ar l*kosa +arah

yan !e$at

- e*roliko$enik #kibat ka+ar l*kosa otak yan ren+ah

8e/ala2 a+renerik menawali $er*bahan2ne*robeha>ior $ertan+a awalhi$olikemi.



32

G!*+)+, D+- T+-D+, (IP&G)IK!.I :G!*+)+, D+- T+-D+, (IP&G)IK!.I :

+D'!-!'GIK :+D'!-!'GIK :

- PG6#'- %&-<8#' D<8<

- '#%<%#-D<- -#S# L#P#-- 6&M#S- <--<'#B<L<'#S- S#%<' %&P#L#

- PGS<8

-!"'&G)IK&P!-IK :-!"'&G)IK&P!-IK :

- B<8G8- SG#-# P#-#G- '<8%# L#%G #&- %&L&L##- D<SO-<&'#S<- P&G-G# %&S#D#-#- %&K#8- P&G-G# -&SPOS 'D

-#8S#8#

Ph i l i '



Physiologic 'esponses to(ypoglycemia

Increased NE(palpitations,

tremor, arousal)

(PNS)

Decreasedglucose

CNS

Peripheralsensors

Muscle

Increasedneurogenic symptoms

(SNS)

Increased ACh(sweating, hunger)

Increasedglucagon

Decreasedinsulin

Pancreas

i!er

Increased glycogenolysis

"Increased gluconeogenesis

#eta Cell

Alpha

Cell

Decreasedinsulin

Increased sympathoadrenal out$low

Increasedepinephrine

Adrenalmedulla

%idney &at

Increasedlactate,

amino acids,glycerolIncreased

glucose production

Increasedglucose

Increasedingestion o$ car'ohydrates

Decreasedglucose clearance

(SNS)(SNS)

!"#acetylc"oline$ !%&#central ner'ous system$ %(#norepinep"rine$ )%&#parasympat"etic ner'ous system$ &%&#sympat"etic ner'ous system*+epro,uce, wit" permission o merican &ociety or !linical .n'estigation/ rom !ryer )(* J Clin Invest * 02112425167–1673$ permission con'eye,

t"roug" !opyrig"t !learance !enter/ .nc*



1



33

Penyebab :Penyebab :

(ipogli#emi apat isebab#an :(ipogli#emi apat isebab#an :

- Sekresi ins*lin yan berlebihan

- Dosis ins*lin ata* O#D y terlal* tini$a+a $en+erita DM- #bnormalitas hi$osis ata* kelen/ar a+renal- #bnormalitas sim$anan karbohi+rat ata*

$ro+*ksi l*kosa oleh hati



34

%+KT&' 'I$IK& (IP&G)IK!.I :%+KT&' 'I$IK& (IP&G)IK!.I :

$!'I-G :$!'I-G :- '&-#P< <SGL< O#D 8 '<D#% S&SG#< D8 #SGP# M#%##

- -<##' <PO8L<%&M< S&B&LGM#- #&S'&S< GMGM- #SGP# O-#L 8 %G-#8- S#%<' %-<'<S - S<-OS<S #'<- P## K#'G8

- 8#8#L 8<K#L- S&PS<S- '-#GM# B&-#'

*+'+-G : *+'+-G :- D&@<S<&S< O-MO - 6O-'<SOL, 8-O' O-MO& %&DG##- <SGL<OM#- #L%OOL<SM&- P&8G-#8# DOS<S S'&-O<D '<B#2- &M&S<S- P&8&'<# G'-<S< &'&-#L P#-&'&-#L



35

P!-G+T"'+- K+D+' G)"K&$+/(&.!&$T+$I$ G)"K&$+0

S*mber eneri *tama SSP l*kosaBila s*$lainya k*ran +is:*nsi otak 7ne*ro$liko$eni9Bila berlan/*t ker*sakan otak $ermanen +eath.P+ oran +ewasa normal keb*t*an l*kosa otak 1mkmenit

#mbilan l*kosa otak +i:asilitasi oleh 8LG'1 +an 8LG'3 ti+ak +iat*r oleh ins*lin.

Dlm kea+aan $*asa, otak +a$at men*nakan ben+a2

keton 7O b*tirat +an asetoasetat9 sb s*mbereneri alternati:.

#mbilan ben+a2 keton oleh otak $ro$orsional +nka+arnya +i+alam +arah.

Oksi+asi ben+a2 keton sb s*mber eneri hanya ter$en*hi



36

Pato1siologi :Pato1siologi :

- Metabolisme otak ter*tama terant*n $a+a keterse+iaanl*kosa

- 8l*kosa otak berasal +ari - Sim$anan likoen +i+alam astrosit 7 terbatas, hanya bbr$menit9- S*$lai l*kosa +ari aliran +arah +i+alam SSP +an ne*ron

- Bila ka+ar l*kosa +arah ↓ otak oran *tama yter$enar*h.

-#kibat hi$olikemi - J () m+l $en*r*nan :*nsi mental rinan

- J 40 m+l $en*r*nan kesa+aran sam$ai ke/an- J 20 m+l %er*sakan ne*ron %OM#- 8an*an :*nsi otak menimb*lkan e/ala2 ne*roliko$eni

-Mekanisme $ertahanan t*b*h

- ↑sekresi hormon2 antaonis ins*lin 7!o*nter;re*latory



37

Mortalitas Morbi+itas Mortalitas Morbi+itas

%eterlambatan $enobatan sek*ele kematian

#k*t - %oma, aritmia /ant*n, kematian

%ronis - Desit ne*rolois $ermanen - emi$aresis- 8an*an memori- 8an*an bi!ara- 8an*an konsentrasi- #taksia



P&#'#L#%S###

38



2(

#loritma 'atalaksana i$olikemi



39

8D ≤ I0 m+l

%&S#D#-#M&G-G

<@GS D10EBOLGS D40E 2) ml <

6&% 8DN 1) M'

%&S#D#-#

M&G-GM&MB#<%

B#<%

'D% B<S#

M#%#

<@GS D10EBOLGS D40E 2) ml <

6&% 8DN 1) M'

B<S#M#%#

1);20 % O-#L

8D ≤ I0 m+l8D I0 m+l

; S#6% DLM 30 M'- 6#-< P&&B#B- &DG%#S<

1);20 % O-#L

6&% 8DN 1) M'

'D% B<S#M#%#

B<S#M#%#

8D I0 m+l 8D ≤ I0 m+l1);20 % O-#LMO<'O- %&'#'

MO<'O- %&'#'GL#8 <@GS D10EBOLGS D40E 2) ml <6#-< P&&B#B

#loritma 'atalaksana i$olikemimen*r*t Lo>ela!e Me+i!al 6enter Diabetes &$iso+es o: 6are

Diabetes S$e!tr*m 200)Q1A1



40

Terima Kasih



41

Terima Kasih

http://ebook.com/eBooks/Medical/Diabetic_Ketoacidosis/inbrowser



• Diabetes is aheteroeneo*sro*$ o:

syn+romes!hara!teriRe+ bythe ele>ation o:l*!ose le>els+*e to a relati>e

or absol*te+e!ien!y o:ins*linQ:re*entlyina+e*ate

ins*lin release is!om$li!ate+ bye5!ess l*!aonrelease.



iabetes may be i2ie into

t3o large groups:

1. Ma!ro>as!*lar 'hese !om$li!ations areasso!iate+ with $atholoy o: the lare an+me+i*m;siRe+ >esselsQ this in!l*+es 6D,

stroke, PD2. Mi!ro>as!*lar 'hese !om$li!ations are

+*e to >as!*lar $atholoy o: the small>essels an+ in!l*+e ne*ro$athy,

ne$hro$athy, retino$athy



'reatment

• 'y$e < 'y$e 1s +e$en+ on e5oeno*s ins*lin to

$re>ent hy$erly!emia an+ a>oi+ ketoa!i+osis. 'heoal o: ty$e 1 thera$y is to mimi! both the basalan+ rea!ti>e se!retion o: ins*lin in res$onse tol*!ose le>els a>oi+in both hy$er; an+ hy$o;ly!emi! e$iso+es.

• 'y$e << 'he oal o: treatment is to maintain l*!ose!on!entrations within normal limits to $re>ent lonterm !om$li!ations. eiht re+*!tion, e5er!ise7in+e$en+ent o: weiht re+*!tion9 an+ +ietarymo+i!ation +e!rease ins*lin resistan!e an+ are

essential ste$s in a treatment reimen. @or manythis is ina+e*ate to normaliRe l*!ose le>els, thea++ition o: hy$oly!emi! aents is o:ten re*ire+,o:ten ins*lin thera$y is re*ire+.



<ns*lin se!retion

<ns*lin se!retion is re*late+ by l*!ose le>els,

!ertain amino a!i+s, hormones an+ a*tonomi!me+iators.

• Se!retion is most !ommonly eli!ite+ by ele>ate+l*!ose le>elsQ in!rease+ l*!ose le>els in =;!ellsres*lts in in!rease+ #'P le>els, this res*lts in a

blo!k o: % S !hannels !a*sin membrane+e$olariRation whi!h o$ens 6a2S !hannels.• 'he inT*5 o: 6a2S res*lts in a $*lsatile se!retion

o: ins*linQ !ontin*e+ 6a2S inT*5 res*lts ina!ti>ation o: trans!ri$tion :a!tors :or ins*lin.

• Oral l*!ose eli!its more ins*lin se!retion than <l*!oseQ oral a+ministration eli!its *t hormoneswhi!h a*ment the ins*lin res$onse.

• <ns*lin is normally !ataboliRe+ by ins*linase$ro+*!e+ by the ki+ney.



<SGL<

• <ns*lin is a $e$ti+e hormone synthesiRe+ as a$re!*rsor 7$ro;ins*lin9 whi!h *n+eroes$roteolyti! !lea>ae to :orm a +i$e$ti+eQ the!lea>e+ $oly$e$ti+e remnant is terme+

$rotein 6.• Both are se!rete+ :rom the =;!ell, normalin+i>i+*als se!rete both ins*lin an+ 7b*tm*!h less9 $ro;ins*lin.

• 'y$e 2s are :o*n+ to se!rete hih le>els o:

$ro;ins*lin 7$ro;ins*lin is ina!ti>e9 meas*rinthe le>el o: 6;$rotein is a more a!!*rateestimation o: normal ins*lin se!retion in ty$e2s.



Insulin• *man ins*lin !onsists o: )1

aa in two !hains !onne!te+

by 2 +is*l+e bri+es 7asinle ene $ro+*!t !lea>e+into 2 !hains +*rin $ost;translational mo+i!ation9.

• '12 U);10 min*tes,

+era+e+ by l*tathione;ins*lin transhy+roenase7ins*linase9 whi!h !lea>esthe +is*l+e links.

• Bo>ine ins*lin +iCers by 3aas, $ork ins*lin +iCers by 1aa.

• <ns*lin is store+ in a!om$le5 with Vn2 ions.



'he synthesis an+ releaseo: ins*lin is mo+*late+

by1. 8l*!ose 7mostim$ortant9, ##s, @#san+ ketone bo+iesstim*late release.

2. 8l*!aon an+somatostation

inhibit relases3. ?;#+reneri!

stim*lation inhibitsrelease 7mostim$ortant9.

4. =;#+reneri!

stim*lation$romotes release.). &le>ate+

intra!ell*lar 6a2 $romotes release.

Insulin secretion ; <ns*lin se!retion in beta !ellsis triere+ by risin bloo+ l*!ose le>els.Startin with the *$take o: l*!ose by the 8LG'2trans$orter, the ly!olyti! $hos$horylation o:l*!ose !a*ses a rise in the #'P#DP ratio. 'hisrise ina!ti>ates the $otassi*m !hannel that+e$olariRes the membrane, !a*sin the !al!i*m

!hannel to o$en *$ allowin !al!i*m ions to Towinwar+. 'he ens*in rise in le>els o: !al!i*m



Me!hanism o: <ns*lin #!tion• <ns*lin bin+s to s$e!i!

hih aWnity membrane

re!e$tors with tyrosinekinase a!ti>ity

• Phos$horylation !as!a+eres*lts in translo!ation o:8l*t;4 7an+ some 8l*t;19trans$ort $roteins into the

$lasma membrane.• <t in+*!es the trans!ri$tion

o: se>eral enes res*ltinin in!rease+ l*!ose!atabolism an+ inhibits thetrans!ri$tion o: enes

in>ol>e+ inl*!oneoenesis.• <ns*lin $romotes the

*$take o: % into !ells.



'he 8oal o: <ns*lin 'hera$y#+ministration o: ins*lins are arrane+ to mimi! the

normal basal, $ran+ial an+ $ost;$ran+ial se!retion o:ins*lin. Short a!tin :orms are *s*ally !ombine+with loner a!tin $re$arations to a!hie>e this eCe!t.

-a$i+ Onset an+ Gltrashort a!tin



-a$i+ Onset an+ Gltrashort;a!tinPre$arations1. -e*lar ins*lin short a!tin, sol*ble, !rystalline Rin! ins*lin is

*s*ally i>en s*b!*taneo*slyQ it ra$i+ly lowers l*!ose le>els. #llre*lar ins*lin is now ma+e *sin eneti!ally enineere+ ba!teriaQ

!ow an+ $i no loner *se+.2. Lis$ro, #s$art " 8l*lisine $re$arations are !lassie+ as *ltrashort

a!tin :orms with onset more ra$i+ than re*lar ins*lin an+ ashorter +*ration. 'hese are less o:ten asso!iate+ withhy$oly!emia. Lis$ro ins*lin is i>en 1) min*tes $rior to a mealan+ has its $eak eCe!t 30;0 min*tes a:ter in/e!tion 7>s. )0;120min*tes :or re*lar ins*lin9.

3. 8l*lisine !an be i>en anywhere :rom 1) min*tes $rior to 20min*tes a:ter beinnin a meal.



<nterme+iate Ha!tin <ns*linPre$arations

1. Lente ins*lin 'his is aamor$ho*s $re!i$itate o:ins*lin with Rin! ion!ombine+ with I0E*ltralente ins*lin. Onset isslower b*t more s*staine+than re*lar ins*lin. <t

!annot be i>en < 7 this hasnot been $ro+*!e+ sin!e200)9.

2. <so$hane P ins*line*tral $rotamine ae+ornins*lin is a s*s$ension o:!rystalline Rin! ins*lin

!ombine+ with $rotamine 7a$oly$e$ti+e9. 'he!on/*ation with $rotamine+elays its onset o: a!tion an+$rolons it eCe!ti>eness. <t is*s*ally i>en in !ombinationwith re*lar ins*lin.



Prolone+;a!tin ins*lin$re$arations

1.Gltralente as*s$ension o: Rin!ins*lin :ormin lare$arti!les whi!h+issol>e slowly,+elayin onset an+

$rolonin +*rationo: a!tion.2.<ns*lin larine

Pre!i$itation at thein/e!tion site e5ten+sthe +*ration o: a!tiono: this $re$aration.

3. Detemir ins*lin has a@# !om$le5e+ withins*lin res*ltin inslow +issol*tion.

Pump 2s4 $tanar InsulinTherapy



• <ns*lin Pre$arations an+ 'reatment

• ario*s ty$es o: ins*lin are !hara!teriRe+by their onset an+ +*ration o: a!tion



#!tion o: <ns*lin on ario*s 'iss*es

Li'er Muscle ,ipose

8 glucose pro,uction 9 Glucose transport 9 glucose transport

9 glycolysis 9 glycolysis 9 lipogenesis:lipoprotein lipaseacti'ity

9 TG synt"esis 9 glycogen ,eposition 8 intracellular lipolysis

9 )rotein synt"esis 9 protein synt"esis



#+>erse &Ce!ts o: <ns*lin1. y$oly!emia may o!!*r +*e to ins*lin

o>er+ose, ins*W!ient !alori! intake 7misse+meal, im$ro$er meal !ontent, +elaye+ meal,etc.9. &thanol !ons*m$tion $romoteshy$oly!emi! res$onse. Sym$toms X -,+ia$horesis, MS !hanes, anythin 7+iabeti!s are

*s*ally really oo+ at re!oniRin hy$oly!emi!sym$toms9.2. y$okalemia ins*lin +raws % S into the !ell with

l*!ose 7hy$erly!emia with normal % S9.3. #na$hyla5is when sensitiRe+ to non;h*man

ins*lin ets non;h*man ins*lin 7now rare9.4. Li$o+ystro$hy at in/e!tion site). eiht ain(. <n/e!tion !om$li!ations



Oral y$oly!emi!s

• 'hese aents are *se:*l in the treatment o:ty$e 2s who +o not res$on+ a+e*ately tonon;me+i!al inter>entions 7+iet, e5er!ise an+weiht loss9.

• ewly +ianose+ 'y$e 2s 7less than ) years9o:ten res$on+ well to oral aents, $atientswith lon stan+in +isease 7o:ten +ianose+late9 o:ten re*ire a !ombination o: aentswith or witho*t ins*lin.

• 'he $roressi>e +e!line in =;!ell :*n!tiono:ten ne!essitates the a++ition o: ins*lin atsome time in 'y$e << +iabetes. Oral aents arene>er in+i!ate+ :or 'y$e <s.



S l: l



S*l:onyl*rea 'hese aents $romote the release o:

ins*lin :rom =;!ells 7se!retoo*es9Q

tolb*tami+e, lyb*ri+e, li$iRi+e an+lime$iri+e.• Me!hanism

– 'hese aents re*ire :*n!tionin=;!ells, they stim*late release byblo!kin #'P;sensiti>e % !hannelsres*ltin in +e$olariRation with

6a2 inT*5 whi!h $romotes ins*linse!retion. – 'hey also re+*!e l*!aon

se!retion an+ in!rease the bin+ino: ins*lin to taret tiss*es.

– 'hey may also in!rease then*mber o: ins*lin re!e$tors

• Pharma!okineti!s 'hese aents bin+to $lasma $roteins, are metaboliRe+in the li>er an+ e5!rete+ by the li>eror ki+ney. 'olb*tami+e has theshortest +*ration o: a!tion 7(;12 hrs9the other aents are eCe!ti>e :or U24

hrs.



$ulfonylurea#+>erse &Ce!ts 'hese aents ten+ to

!a*se weiht ain, hy$erins*linemia an+hy$o$ly!emia. e$ati! or renalins*W!ien!y !a*ses a!!*m*lation o:these aents $romotin the risk o:hy$oly!emia. 'here are a n*mber o:+r*;+r* intera!tions. &l+erly $atients

a$$ear $arti!*larly s*s!e$tible to theto5i!ities o: these aents.

• 'olb*tami+e is aso!iate+ with a 2.)Y X in!ar+io>as!*lar mortality.

Onset an+ D*ration

• Short a!tin 'olb*tami+e 7Orinase9• <nterme+iate a!tin 'olaRami+e

7'olinase9, 8li$iRi+e 78l*!otrol9,8lyb*ri+eZ 8liben!lami+e7Daonil9

• Lon a!tin 6hloro$ro$ami+e,8limer$iri+e

Melitini+e analos



Melitini+e analos 'hese aents 7re$alini+e 7Pran+in9 an+ natelini+e

7Starli599 a!t as se!retoo*es.

• Me!hanism 'hese aents bin+ to #'P sensiti>e%!hannels like s*l:onyl*reas a!tin in a similar :ashionto $romote ins*lin se!retion howe>er their onset an++*ration o: a!tion are m*!h shorter. 'hey are$arti!*larly eCe!ti>e at mimi!kin the $ran+ial an+ $ost;$ran+ial release o: ins*lin. hen *se+ in !ombinationwith other oral aents they $ro+*!e better !ontrol thanany monothera$y.

• Pharma!okineti!s 'hese aents rea!h eCe!ti>e $lasmale>els when taken 10;30 min*tes be:ore meals. 'heseaents are metaboliRe+ to ina!ti>e $ro+*!ts by 6P3#4an+ e5!rete+ in bile.

• #+>erse &Ce!ts Less hy$oly!emia than s*l:onyl*reasQ+r*s that inhibit 6P3#4 7keto!onoRole, T*!onaRole,erythromy!in, et!.9 $rolon their +*ration o: eCe!t.Dr*s that $romote 6P3#4 7barbit*rates,!arbamaRe$ine an+ ri:am$in9 +e!rease theireCe!ti>eness. 'he !ombination o: embroRil an+

re$alini+e has been re$orte+ to !a*se se>erehy$oly!emia.

<ns*lin SensitiRers



<ns*lin SensitiRers 'wo !lasses o: oral hy$oly!emi!s work by im$ro>in

ins*lin taret !ell res$onseQ the bi*ani+es an+thiaRoli+ine+iones.

Bi*ani+es• Met:ormin is !lassie+ as an ins*lin sensitiRer, it

in!reases l*!ose *$take an+ *tiliRation by tarettiss*es. <t re*ires the $resen!e o: ins*lin to be eCe!ti>eb*t +oes not $romote ins*lin se!retion. 'he risk o:hy$oly!emia is reatly re+*!e+.

• Me!hanism Met:ormin re+*!es $lasma l*!ose le>els byinhibitin he$ati! l*!oneoenesis. <t also slows theintestinal absor$tion o: s*ars. <t also re+*!eshy$erli$i+emia 7[LDL an+ LDL !holesterol an+ X DL9.Li$i+ lower re*ires 4;( weeks o: treatment. Met:orminalso +e!reases a$$etite. <t is the only oral hy$oly!emi!shown to re+*!e !ar+io>as!*lar mortality. <t !an be *se+in !ombination with other oral aents an+ ins*lin.

• #+>erse eCe!ts y$oly!emia o!!*rs only when!ombine+ with other aents. -arely se>ere la!ti! a!i+osisis asso!iate+ with met:ormin *se $arti!*larly in +iabeti!swith 6@. Dr* intera!tions with !imeti+ine, :*rosemi+e,

ni:e+i$ine an+ others ha>e been i+entie+.



Insulin $ensiti5ers 'hiaRoli+ine+iones

78litaRones9

• 'hese aents areins*lin sensitiRers,they +o not $romote

ins*lin se!retion:rom =;!ells b*tins*lin is ne!essary:or them to beeCe!ti>e.

PiolitaRone an+rosilitaRone arethe two aents o:this ro*$.



• Me!hanism o: #!tion 'hese aents a!t thro*h the a!ti>ation

o: $ero5isome $roli:erator;a!ti>ate+ re!e$tor;\ 7PP#-;\9.Lian+s :or PP#-;\ re*late a+i$o!yte $ro+*!tion, se!retion o::atty a!i+s an+ l*!ose metabolism. #ents bin+in to PP#-;\res*lt in in!rease+ ins*lin sensiti>ity is a+i$o!ytes, he$ato!ytesan+ skeletal m*s!le. y$erly!emia, hy$ertrily!eri+emia an+ele>ate+ b#1! are all im$ro>e+. DL le>els are also ele>ate+.

#!!*m*lation o: s*b!*taneo*s :at o!!*rs with these aents.



• <n the li>er [l*!ose o*t$*t

• <n m*s!le Xl*!ose *$take

• <n a+i$ose Xl*!ose *$take , [@# release

• Only $iolitaRone may be *se+ in !ombination withins*linQ the ins*lin +ose m*st be mo+ie+.-osilitaRone may be *se+ with other hy$oly!emi!b*t se>ere e+ema o!!*rs when !ombine+ with ins*lin.

• Pharma!okineti!s Both are e5tensi>ely bo*n+ toalb*min. Both *n+ero e5tensi>e P4)0 metabolismQmetabolites are e5!rete+ in the *rine the $rimary!om$o*n+ is e5!rete *n!hane+ in the bile.

• #+>erse &Ce!ts @atal he$atoto5i!ity has o!!*rre+with these aentsQ he$ati! :*n!tion m*st bemonitore+. Oral !ontra!e$ti>es le>els are +e!rease+with !on!omitant a+ministration, this has res*lte+ insome $renan!ies.



?;8l*!osi+ase <nhibitors

'his enRyme hy+rolysesoliosa!!hari+es tomonosa!!hari+es whi!hare then absorbe+.#!arbose also inhibits$an!reati! amylase.

'he normal $ost;$ran+ial l*!ose rise isbl*nte+, l*!ose le>elsrise mo+estly an+remain slihtly ele>ate+:or a $rolone+ $erio+,less o: an ins*lin

res$onse is re*ire+an+ hy$oly!emia isa>oi+e+Q *se with otheraents may res*lt inhy$oly!emia. S*!raseis also inhibite+ by

these +r*s.



?;8l*!osi+ase <nhibitors

#!arbose an+ militol are two aents o: this!lass *se+ :or ty$e 2 +iabetes.Me!hanism o: a!tion 'hese aents are oliosa!!hari+e

+eri>ati>es taken at the beinnin o: a meal +elay!arbohy+rate +iestion by !om$etiti>ely inhibitin ?;

l*!osi+ase, a membrane bo*n+ enRyme o: theintestinal br*sh bor+er.

Pharma!okineti!s #!arbose is $oorly absorbe+remainin in the intestinal l*men. Miitol is absorbe+an+ e5!rete+ by the ki+ney. Both aents e5ert their

eCe!t in the intestinal l*men.#+>erse &Ce!ts 8G&SS 7Tat*len!e, +iarrhea, !ram$in9.

Met:ormin bioa>ailability is se>erely +e!rease+ when*se+ !on!omitantly. 'hese aents sho*l+ not be *se+in +iabeti!s with intestinal $atholoy.



'y$e 2

• #n easy 7an+ o>er;sim$lie+9 way toa$$roa!h ty$e 2+iabeti!s is their

“l*!ostatF is set at ahiher le>el.8l*!aon remainshiher than normal to

maintain the hiherl*!ose le>el, b*t theins*lin res$onse is less$rono*n!e+.

Post Pran+ial 8l*!ose



Post Pran+ial 8l*!ose-e*lation

<n!retin 'hera$y



<n!retin 'hera$y• Incretins are naturally occurring hormones that the

gut releases throughout the ay6 the le2el of acti2eincretins increases signi1cantly 3hen foo isingeste4

• !nogenous incretins G)P78 /glucagon7li#e peptie80 an GIP /glucose7epenent insulinotropicpeptie0 facilitate the response of the pancreasan li2er to glucose 9uctuations through theiraction on pancreatic β cells an cells4

• GIP an G)P78 are the , major incretin hormones inhumans: 8 – 8<P is a 42;aa $e$ti+e +eri>e+ :rom a larer $rotein

7Pro8<P9 an+ is se!rete+ by en+o!rine % !ells mainly$resent in the $ro5imal astrointestinal 78<9 tra!t

7+*o+en*m an+ $ro5imal /e/*n*m9. – 8LP;1 is a 30; or 31;aa $e$ti+e +eri>e+ :rom a larer$rotein 7$rol*!aon9 an+ is se!rete+ by L !ells lo!ate+$re+ominantly in the +istal 8< tra!t 7ile*m an+ !olon9. 'his $rotein was rst isolate+ :rom sali>ary lan+>enom o: the 8ila monster 7in>estiatin how theseliRar+s are able to tolerate lon $erio+s betweenmeals9.

< ti 'h



<n!retin 'hera$y

Kan*>ia 7sitali$tin9

These incretins are release from the gut inresponse to ingestion of foo an collecti2ely



response to ingestion of foo an collecti2elycontribute to glucose control by:Stim*latin l*!ose;+e$en+ent ins*lin release :rom$an!reati! beta !ells 78LP;1 an+ 8<P9

De!reasin l*!aon $ro+*!tion :rom $an!reati! al$ha!ells 78LP;19 when l*!ose le>els are ele>ate+.The combination of increase insulin prouction

an ecrease glucagon secretion reuceshepatic glucose prouction 3hen plasma glucoseis ele2ate4

The physiologic acti2ity of incretins is limite bythe en5yme ipeptiyl peptiase7; /DPP7;0<3hich rapily egraes acti2e incretins aftertheir release4

The Incretin !=ect Is Diminishe in Type , DiabetesLe>els o: 8LP;1 are +e!rease+. 'he ins*linotro$i! res$onse to 8<P is +iminishe+ b*t notabsent.De:e!ti>e 8LP;1 release an+ +iminishe+ res$onse to8<P may be im$ortant :a!tors in ly!emi! +ysre*lationin ty$e 2 +iabetes.



Stan+ar+ vs <ntensi>e



Stan+ar+ vs. <ntensi>e 'reatment

'he tra+e oC between stan+ar+ an+ intensi>e thera$y ismore :re*ent hy$oly!emi! e>ents 7hy$oly!emi! e>ents,seiR*res an+ !oma9 :or a marke+ +elay in the onset o:+iabeti! !om$li!ations both mi!ro>as!*lar an+ma!ro>as!*lar.b#1! Z emolobin #1! is a *se:*l meas*re o: l*!ose!ontrol o>er the $rior 3;( months, hy$erly!emi! e$iso+esres*lt in the nons$e!i! ly!osylation o: >ario*s $roteins.



Sym$tomati! y$oly!emia

• # note on the treatment o: hy$oly!emia Orall*!ose!arbohy+rate a+ministration res*lts in a more ra$i+rise in bloo+ l*!ose than < a+ministrationQ this is +*e tothe in>ol>ement o: astrointestinal hormones.



P&-%&< 2011

•

1 S*mber karbohi+rat +ikons*msi 3;I

$orsi$en*kar sehari7terant*n stat*s iRi92.. S*mber >itamin +an mineral say*ran 2;3

$orsi$en*kar,b*ah 2;4 $orsi$en*kar sehari.

3. S*mber $rotein la*k hewani 3 $orsi$en*kar,

la*k nabati2;3 $orsi$en*kar sehari4.Batasi kons*msi *la, lemak minyak +an aram.

Pleno Skenario B Blok 14 30 Des 2013

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