Beruflich Dokumente
Kultur Dokumente
Achmad Rudijanto
2011
2. Exercise
1. Diet
3. BW Management
5. Routinely Control
Type 2 diabetes
60
Myocardial
infarction
Microvascular
disease
50
40
30
20
10
0
<6
6-<7
7-<8
8-<9 9-<10
10+
<7.0
IDF
6.5
NICE
<6.5
AACE
6.5
France
<6.5*
Canada
7.0
Australia
7.0
Latin America
<6.5
*If on single or double therapy; if on triple therapy or insulin, then HbA 1c <7% Nathan
DM, et al. Diabetes Care 2009;32 193-203
http://www.idf.org/home/index.cfm?node=1457
http://www.nice.org.uk/nicemedia/pdf/CG66diabetesfullguideline.pdf
Endocrine Practice Vol 13 (Suppl 1) May/June 2007
GLYCEMIC TARGETS
Parameter
Premeal plasma
glucose (mg/dL)
Postprandial plasma
glucose (mg/dL)
Hb A1c
Normal
ADA
ACE
90-130
<110
<140
<180
<140
4%-6%
<7%
<6.5%
Maximum
dose (mg)
Maximum
effective
dose (mg)
HbA1c
reduction
(%)
Cost/year
($)
Glyburide
1.25, 2.5, 5
10 bid
10 qd
1.5 - 2.0
130
Glipizide
5, 10
20 bid
10 qd-bid
1.5 2.0
175
2.5, 5, 10
20 qd
5 20qd
1.5 2.0
300
Glimepiride
1, 2, 4
8 qd
4 qd
1.5 2.0
330
Repaglinide
0.5, 1, 2
4 tid
2 tid
1.5 2.0
910
Neteglinide
60, 120
120 tid
120 tid
0.5 1.0
1.100
Metformin*
850 tid
1000 bid
1.5 2.0
600
Glucophage-XR*
500
2000 qd
2000 qd
1.5 2.0
1.000
Rosiglitazone
4, 8
8 qd, 4 bid
4 bid
1.5
1.875
15, 30, 45
45 qd
45 qd
1.5
2.110
50, 100
100 tid
50 tid
0.5 1.0
700
100 tid
100 tid
0.75 1.2
880
Glucovance*
5/500, 2 bid
2.5/500, 2 bid
1.3
1.400
Avandamet*
2/500, 2 bid
2/500, 2 bid
N/A
2.170
5/500, 2 bid
5/500, 2 bid
2.1
1.400
Agent
Glipizide-GITS*
Pioglitazone
Acarbose
Miglitol
Metaglip*
At diagnosis:
Lifestyle
+
metformin
Step-1
Lifestyle + Metformin
+
Intensive insulin
Lifestyle + Metformin
+
Basal insulin
Lifestyle + Metformin
+
Sulfonylureaa
Step-2
Step-3
Lifestyle + Metformin
+
GLP1 agonistb
no hypoglycemia
weight loss
nausea/vomiting
Lifestyle + metformin
+
Pioglitazone
+
Sulfonylureaa
Lifestyle + Metformin
+
Basal insulin
Algorithm for the metabolic management of type 2 diabetes; Reinforce lifestyle interventions at every visit and check A1C every 3
months until A1C is 7% and then at least every 6 months. The interventions should be changed if A1C is 7%. a Sulfonylureas other
than glybenclamide (glyburide) or chlorpropamide. b Insufficient clinical use to be confident regarding safety.
Type-2 DM management
DIiagnosis
STEP-1
STEP-2
STEP-3
GHS
Oral mono-therapy
GHS
2 combo-therapy
GHS
2 combo-therapy
+
Basal insulin
3 combo-therapy
Perkeni, 2011
GHS
Intensive Insulin
Basal plus
Basal bolus
Policy
Postprandial hyperglycemia
Fasting hyperglycemia
Insulin resistant
Biguanides, glitazones,
-glucosidase inhibitors
Insulin deficiency
Target of Treatment
Mechanism of Hyperglycemia
-Cell defect
Insulin resistance
(liver, muscle, fat tissue)
Fasting - hyperglycemia
PP - hyperglycemia
Manifestation of Hyperglycemia
TZDs
insulin
Sulphonylureas
Metformin
Rosiglitazone
Pioglitazone
insulin
Acarbose
Miglitol
Voglibose
a-glucosidase
inhibitors
Meglitinides
Repaglinide
Nateglinide
Type-2 DM management
DIiagnosis
STEP-1
STEP-2
STEP-3
GHS
Oral mono-therapy
GHS
2 combo-therapy
GHS
2 combo-therapy
+
Basal insulin
3 combo-therapy
Perkeni, 2011
GHS
Intensive Insulin
Basal plus
Basal bolus
Onset (hr)
Peak (hr)
Duration (hr)
RAPID ACTING
Regular
0.5-1
2-4
6-8
Lispro
0.25
3-4
Aspart
0.25
3-4
Glulisine (apidra)
0.25
3-4
INTERMEDIATE ACTING
NPH
1-3
6-8
12-16
LONG ACTING
Glargine
NA
11-24
Detemir
3-9
6-23
Plasma glucose
(mg/dl)
300
200
Prandial BG
Prandial BG target
of treatment
Fasting BG
100
Normal BG
0600
1200
1800
Time (hours)
2400
0600
Plasma glucose
(mg/dl)
300
200
Prandial BG
Prandial BG target
of treatment
Fasting BG
100
Normal BG
0600
1200
1800
Time (hours)
2400
0600
Contribution (%)
80
60
40
Contribution (%)
100
fast. BG
pp BG
20
0
Woerle, H. J., et al; Diabetes Research and Clinical Practice 77 (2007) 280-285
BMI: < 18
<7
78
89
>9
Grade
< 126
Mild
126-200
200
Severe
250
Very
severe
what next
Contribution (%)
80
60
40
Contribution (%)
100
fast. BG
pp BG
20
0
Woerle, H. J., et al; Diabetes Research and Clinical Practice 77 (2007) 280-285
Plasma glucose
(mg/dl)
300
200
Prandial BG
Prandial BG target
of treatment
Fasting BG
100
Normal BG
0600
1200
1800
Time (hours)
2400
0600
Plasma glucose
(mg/dl)
300
200
Prandial BG
Prandial BG target
of treatment
Fasting BG
100
Normal BG
0600
1200
1800
Time (hours)
2400
0600
29
If FBG in target range, check BG before lunch, dinner, and bed. Depending on
BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)
If HbA1c < 7%
3.89-7.22 mmol/L
(70-130mg/dL)
If HbA1c 7%
If HbA1c < 7%
If HbA1c 7%
Recheck pre-meal BG levels and if out of range, may need to add another injection; if
HbA1c continues to be out of range, check 2-hr postprandial levels and adjust preprandial
rapid-acting insulin
or
or
Basal Bolus
Add prandial insulin before each meal
Basal Plus
Add prandial insulin at main meal
Basal
Add basal insulin and titrate
PREMIXED INSULIN
Premixed insulin x1
Premixed insulin x2
Basal-Plus therapy
e.g. glargine plus a prandial
rapid-acting insulin like glulisine
Premixed insulin x3
BasalBolus therapy
e.g. glargine plus 3 doses of a prandial rapidacting insulin like glulisine
No further options