Beruflich Dokumente
Kultur Dokumente
in type 2 diabetes
Hikmat Permana
Division Endocrinology and Metabolism
Department of Internal Medicine
Padjadjaran University Medical School/
Hasan Sadikin Hospital
Bandung
1
50
65%
40
40
30
20
10
0
15
13
13
10
4
p=0.029
p=0.0099
p=0.052
Microvascular
disease
Incidence per
1000 patient-years
60
Myocardial infarction
40
20
0
0 5
UKPDS 35. BMJ 2000; 321: 405-12.
10
11
15
Nephropathy
Relative Risk
13
11
9
Neuropathy
7
5
Microalbuminuria
3
1
6
10
HbA1c (%)
Skyler JS. Endocrinol Metab Clin. 1996;25:243254.
11
12
ADVANCE
VADT
No. of participants
10,251
11,140
1791
62
66
60
Duration of diabetes at
study entry, years
10
11.5
HbA1C at Baseline, %
8.1
7.5
9.4
35
32
40
Duration of follow-up,
years
3.4
5.0
ADVANCE
VADT
10,251
11,140
1791
62
66
60
HbA1C at Baseline, %
8.1
7.5
9.4
Significant Effect on
Macrovascular
Outcomes?
No
No
No
Significant Effect on
Microvascular
Outcomes?
NA
Significant for
nephropathy, not
retinopathy
No
85% vs.
78%
3.4
5.0
No. of participants
Rosiglitazone use,
(intensive vs. standard)
Duration of follow-up,
years
1997
2007
RRR: 12%
P: 0.029
9%
0.040
Microvascular disease
RRR:
25%
P: 0.0099
24%
0.001
Myocardial infarction
RRR:
P:
16%
0.052
15%
0.014
All-cause mortality
RRR:
P:
6%
0.44
13%
0.007
Yes
If early and sustained glycemic control started
before atherosclerosis is established
AACE
<7
<6.5
Preprandial (mg/dl)
80-120
<110
Postprandial (mg/dl)
140-180
<140
Bedtime (mg/dl)
100-140
100-140
A1c (%)
NHANES1
44.5%
35.8%
1988-1994
N=1215
AACE survey
2003-20042
A1c <7%
1999-2000
N=372
33%
A1c 6.5%
et al. Diabetes Care. 2004;27:17-20; 2 State of Diabetes in America, American Association of Clinical
Endocrinologists, 2003-2004. Available at: http://www.aace.com/public/awareness/stateofdiabetes/
DiabetesAmericaReport.pdf. Accessed January 6, 2006.
Clinical Inertia:
Failure to Advance Therapy When Required
Percentage of subjects advancing when A1C >7% < 8%
100
% of Subjects
80
60
44.6%
35.3%
40
18.6%
20
0
Diet
Sulfonylurea
Metformin
Combination
Combination therapy:
2 drugs
Efficacy (A1C)
Hypoglycemia
Weight
Side effects
Costs
Combination therapy:
3 drugs
More-complex
insulin strategies
Reprinted with permission from Inzucchi SE et al. Diabetes Care. 2012;35:
1364-1379. Copyright 2012 American Diabetes Association. All rights reserved.
Slide Source:
Lipids Online Slide Library
www.lipidsonline.org
Pathophysiological basis of
management of diabetes
Optimization of OHA (T2DM)
Addition of GLP-1 RA (T2DM)
Timely initiation of insulin(T2DM)
Basal insulin analogs
Premixed analogs
NPH (pregnancy)
Slide 21
% contribution to HbA1c
Most insulin is
initiated when
HbA1c >8.5%
100
PPG
80
60
45%
40%
50%
55%
60%
7.38.4
8.59.2
9.310.2
50%
70%
40
20
30%
70%
30%
0
<7.3
>10.2
FPG
long-acting insulin
+/- OAD
Targets:
- HbA1c
- Fasting glucose
Conventional
Insulin Therapy
Prandial/Intensified
Insulin Therapy
Usually 2 injections
of a mixture of regular
insulin/short-acting insulin
analog and long-acting
insulin
Targets:
- HbA1c
- Fasting glucose
- Postprandial glucose
Insulin
Level
Basal Insulin
SLEEP
Breakfast
Lunch
Dinner
Basal Insulin
(mmol)
6
3
0
7
10
11
12
AM
7
PM
time
Basal Insulin
Fasting Hypos
(mmol)
6
3
0
7
10
11
12
AM
PM
time
Levemir insulin
Pre mix insulin
NPH
----
Insulin endogen
Basal Insulin
----
Rapid Insulin
Kelemahannya :
Makan
Makan
Makan
Sebelum tidur
1. Pasien
tidak
menyukainya
karena
4 x suntik
Pagi
Siang
Malam
Bolus
Correction
corrects pre-meal hyperglycemia
QID dosing, based on BG & sensitivity
TID-
Novorapid
Apidra
humalog
Humulin R
Actrapid
Novomix
70/30
Humalog Mix
75/25
Humulin
70/30: Mixtrad
70/30
Summary
Insulin therapy provides many benefits to patients with
T2DM
Timely Initiation of Insulin Is Critical
Early initiation of insulin therapy, as insulin acts to
significantly lower plasma glucose levels while minimizing
the long-term complications associated with chronic
hyperglycemia Basal Insulin
Early intensification of diabetes therapies can minimize the
risk of long-term complications associated with exposure to
chronic hyperglycemia Basal bolus
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