Epidemiology, Early Detection, Management and

Standart Diabetes Monitoring

Pradana Soewondo
Division of Metabolism and Endocrinology,
Department of Internal Medicine Faculty of Medicine
University of Indonesia / Cipto Mangunkusumo
National Referral Hospital Jakarta, Indonesia
 Overview
 Epidemiology Type 2 DM in Indonesia and ASEAN

Countries

 Early Detection and Community-based Intervention

 Management Type 2 DM

 Standart Glucose Monitoring

 Conclusion
Diabetes Facts
 Diabetes imposes a large economic burden on individuals
and families, national health systems, and countries.
 Health spending on diabetes accounted for 10.8% of
total health expenditure worldwide in 2013.
 Health expenditure includes medical spending on
diabetes by health systems, as well as by people living
with diabetes and their families.

IDF Atlas sixth edition 2013

 Diabetes Is an Increasing Healthcare Epidemic Throughout The World

IDF. Diabetes Atlas 6th Edition – 2013

IDF. Diabetes Atlas 6th Edition – 2013
 Estimates of Diabetes cases (age 20-79) and Diabetes
Prevalence in ASEAN Countries in 2013
Number (age National DM
Country
20–79) Prevalence (%)
1. Indonesia 8.554.170 5,55
2. Vietnam 3.299.210 5,37
3. Philippine 3.256.210 6,01
4. Thailand 3.150.670 6,42
5. Myanmar 1.988.850 5,7
6. Malaysia 1.913.240 10,11
7. Singapore 498.190 12,28
8. Cambodia 221.430 2,54
9. Laos People’s Democratic 157.880 4,44
Republic
10. Timor Leste 26.710 5,85
11. Brunei Darussalam 22.070 8,03
IDF Atlas sixth edition 2013
 Estimates of Diabetes cases, IGT & Diabetes
Prevalence, and Diabetes Cost in ASEAN Countries
Diabetes
Diabetes cases IGT national Mean diabetes-related
Countries national
(20-79) in prevalence expenditure / person
prevalence
1000s (%) with diabetes (USD)
(%)
Indonesia
Indonesia 8,554.17
8,554.17 5.55 5.55
9.15 9.15 143 143
Vietnam 3,299.11 5.37 0.92 128
Phillipines 3,256.21 6.01 6.07 154
Thailand 3,150.67 6.42 8.42 256
Myanmar 1,988.85 5.70 8.44 32
Malaysia 1,913.24 10.11 14.95 468
Singapore 498.19 12.28 13.65 2,508
Cambodia 221.43 2.54 9.06 81
Laos 157.88 4.44 * 7.78 62
Timor Leste 26.71 5.85 * 6.95 90
Brunei Dar. 22.07 8.03 * 10.76 1,344
WORLD 381,834.36 8.35 6.92 1,436
IDF Atlas sixth edition 2013
Obesity in Adults, ASEAN Region

Adapted from Global status report on non-

communicable diseases, WHO 2010
 Estimates of the Prevalence of
Type 2 Diabetes in Indonesia

Population
Population::240
230million
million
GDP/capita++1900
GDP/capita 3500 USD

Known
KnownDM
DM Undiagnosed DM Total DM
Total DM IGT
IGT

1,5%
2,1 % 4,2 %
4,8 % 5,7
6,9 %
% 10,2
29,9%
%
National Health Survey 2013
2007
24.417 subjects, >15 years old, from 33 provinces in Indonesia.
Provinces’ Prevalence of DM and IGT With Higher
Than The Average of National Figure

Indonesian National Health Survey, 2007

 Epidemiological Transition – Cause of death

59,5 No. Cause of Death (2007) %

49,9 1. Stroke 15.4

44,2 2. TB 7.5
41,7
3. Hypertension 6.8
31,2 4. Trauma 6.5
28,1
5. Perinatal disorder 6.0
6. Diabetes mellitus 5.7
7. Malignancy 5.7
8. Liver disease 5.1
9. Ischemic heart disease 5.1
Communicable Un-communicable
Lower respiratory tract
Disease Disease 10. 5.1
infection
1995 2001 2007

Departemen Kesehatan Republik Indonesia. 2007.

Risk Factors and Glycaemia Control
 Risk factors for the diabetes epidemic in Asia

 Increasing overall and abdominal obesity

 Nutrition transition and changes in diet and lifestyle
 Cigarette smoking
 Pancreatic beta cell function
 Developmental origins of diabetes
 Genetic susceptibility
 Other risk factors

Juliana Chan, et al. JAMA 2009

 Predictor Factor
Undiagnosed diabetes Pre-diabetes
 Male
Age  Old-age
Obesity  High socio-economic status
Central obesity  Low education level
Hypertension  Hypertension
Smoking habit  Obesity
 Central obesity
 Smoking

National Health Survey 2007

24417 subjects from 33 provinces in Indonesia.
 Attributable risk of several predictive factors of
pre-diabetes in Indonesia
60% 56,50%
50%
47,30% 44,40%
40%

30% 23% 23%

20% 16,70%
10%

0%
Obesity Central obesity Hypertension Physical inactivity High risk diet (less Smoking habit
fruits and
vegetables)

Priority :
decrease blood pressure (AR 56.5%),
reduce waist circumference (AR 47.3%)
stop smoking (AR 44.4%).
National Health Survey 2007
24417 subjects from 33 provinces in Indonesia.
International Diabetes Management Practices
Study (IDMPS)
 Primary aim: documenting the management of people with type 2
diabetes in clinical practice
 Secondary aims: to evaluate initiation, characteristics and
management of insulin therapy and to assess the health economic
impact of type 2 diabetes
 Demographics and clinical characteristics of type 2 diabetic pts

• IDMPS is an international registry, multicenter, observational study of patients with

type 2 diabetes mellitus
• Aims: to estimate diabetes-related resource use and investigate its predictors
among individuals with type 2 diabetes in 24 countries in Asia, Latin America, the
Middle East and Africa
• N = 15,016 people
IDMPS Indonesia
90
 715 DM patients
80 76,7
 686 met inclusion/exclusion criteria
 12 T1DM and 674 T2DM 70

 Location : 85% urban vs 15% rural 60

 Age : mean 55.16 (SD 10.20) years 50

 Sex : female 54.6% vs male 45.4% 40

 BMI : mean 24.78 (SD 4.02) kg/m2 30

20 16,8

10 6,4
BMI
60 52,6 0,1
0
34,3
40 <40 40-65 65-85 >85
20
3,5 8,6 1,1
0
Age Group
<18.5 18.5-25 25-30 30-35 >35
IDMPS Indonesia
 Diabetic Complications (73,7%)

60 54 Microangiopathy >> Macroangiopathy

Retinopathy
50 Neuropathy
Proteinuria
40 Dialysis
33,4
Foot Ulcer
26,5 Amputation
30
Angina
MCI
20
10,9 Heart Failure
8,7 7,4 Stroke
10 5,3 5,3
1,3 2,7 PAD
0,5
0

Comorbidities: Hypertension (47,6%);

Dyslipidaemia (53,5%) IDMPS Indonesia
 Treatment Pattern of Type 2
Diabetes in Indonesia

OGLD, oral glucose-lowering drug IDMPS Indonesia

Indirect Cost

Only 34.8% of diabetic patients had normal work

IDMPS Indonesia
Resource Use

IDMPS Indonesia
Education Session

IDMPS Indonesia
 A1c Level

40,6
Yes
No
59,4

HbA1c OGLD + Diet +

OGLD Insulin Total
Group Insulin Exercise
<7% 14.3 32.9 15.8 44.4 30.5
HbA1c Mean 8.49 8.12 8.58 7.04 8.27
(SD) (1.42) (2.12) (2.61) (1.18) (2.19)
IDMPS Indonesia
IDMPS Key points
DIABETES chronic condition with comorbidities and
complications needs huge resource use and significant cost
ACTION
early diagnosis,
prompt treatment,
effective metabolic control and
screening for diabetic complications

IDMPS Indonesia
 Majority of type 2 DM patients in Asia
Pacific fail to achieve glycemic control
(HbA1c < 7.0%)
Australia Thailand Singapore India Indonesia
(St Vincent’s1) (Diab Registry2) (Diabcare3) (DEDICOM4) (Diabcare5)


30.0% 30.2% 33.0% 37.8% 32.1%
37.8
70.0% 69.8% 67.0% 62.2% 62.2 67.9%

Hong Kong China S. Korea Malaysia

(Diab Registry6) (Diabcare7) (KNHANES8) (DiabCare9)
HbA1c at or below
target
39.7% 41.1% 43.5% 22.0%
HbA1c above target
60.3% 58.9% 56.5% 78.0%

 DM, diabetes mellitus; HbA1c, glycated hemoglobin.

 1. Bryant W, et al. MJA 2006;185:305–9. 2. Kosachunhanun N, et al. J Med AssocThai 2006;89:S66–71. 3. Lee WRW, et
al. Singapore Med J 2001;42:501–7. 4. Nagpal J & Bhartia A. Diabetes Care 2006;29:2341–8. 5. Soewondo P, et al. Med J
Indoes 2010;19:235–44. 6. Tong PCY, et al. Diab Res Clin Pract 2008;82:346–52. 7. Pan C, et al. Curr Med Res Opin
2009;25:39–45. 8. Choi YJ, et al. Diabetes Care 2009;32:2016–20. 9. Mafauzy M, et al. Med J Malaysia 2011;66:175–81.
Awareness, agreement and adherence of physicians to
type 2 diabetes guideline in Indonesia
Indah S. Widyahening, Geert JMG van der Heijden, Pradana Soewondo,
Yolanda van der Graaf
 Background
Diabetes has been recognized as an emerging health problem in
Indonesia. While guideline on the management of type 2 diabetes
mellitus (T2DM) was available for almost two decades, 68% of the
patients were in poor control.
 Aim
To study the awareness, agreement and adherence of physicians to
T2DM guideline in Indonesia.
 Methods
Questionnaire survey of General Practices (GPs) regarding
recommendations in the Indonesian T2DM guideline based on the
‘awareness-to-adherence’ model of behavioral change.
(Unpublish data)
Characteristics n (%) Median Min-max
Age (n=399) 43 years 22-73 years
Year of practice (n=383) 15 years 0-45 years
Gender (n=399)
Male / Female 126 (32) / 273 (68)
Practice type (n=392)
Solo practice 208 (53)
Private clinic 64 (16)
Public health center 96 (22)
Private hospital 20 (5)
Public hospital (non academic) 8 (2)
Academic hospital 6 (2)
Practice location (n=359)
Jakarta 119 (33)
Outside Jakarta but within Java island 127 (35)
Outside java 113 (32)
 Characteristics n (%) Median Min-max
Participation in DM training (n=367)
Yes 234 (64)
Number of DM patients seen in a week 8 1-120
(n=343)
Proportion of DM patients among all
patients seen (n=381)
<10% 243 (64)
10-30% 117 (31)
>30% 21 (5)
Awareness to DM consensus (n=383)
Never know 43 (11)
Heard but never had 138 (36)
Had but never read 78 (20)
Read and implement 124 (33)
Guidelines recommendations assessed in the
questionnaire.
 Screening for T2DM should be performed to all patients with
any of the risk factor listed in the guidelines.
 In patients with classic DM symptoms, one random blood
glucose test with result >200 mg/dL is enough to confirmed the
diagnosis.
 For newly diagnosed patient, management should be started
with meal planning and exercise for 2-4 weeks.
 SU is the drug of choice for normal and underweight patients.
 Most patients should achieve Fasting Blood Glucose of <100
mg/dL and 2-hour post-prandial Blood Glucose of <140 mg/dL.
 Blood pressure should be reduced to below 130/80 mmHg.
 Statin should be prescribed to people with T2DM who are over
40 years old or have CVD risk.
Community-based Intervention
Ilustrasi Kasus
 ♂ 45 tahun datang dengan keluhan
DE + semutan pada kedua tungkai
sejak 2 bln yang lalu. 3 P (-)
 Belum diketahui DM .
 Hipertensi sejak 3 tahun lalu.

• Tinggi badan 160 cm dan berat badan 70 kg. Tekanan darah

150/100 mmHg.
• Pemeriksaan fisis dalam batas normal kecuali refleks
fisiologis patela dan akhiles menurun.
 Ilustrasi Kasus
• Labotrorium: glukosa darah puasa 135 mg% dan 2 jam setelah makan
210 mg%; HbA1c 7,2 %
• Kolesterol Total 280 mg %; Kadar Trigliserida 180 mg%; LDL Kol
160 mg%

 Masalah kasus ini

 Pengelolaan Kasus
PERKENI GUIDELINES 2010
Why Should Do POSBINDU PTM
o Most of the cases are not aware of having the risk factors (DM,
hypertension, hypercholesterol)
o Community health seeking behavior :
 Never check their health (52.2 %)
 Never check their blood pressure (51.3 %)
 Never check their blood glucose (88.8 %)
 Never check their blood cholesterol (90.4 %)
 Never check because economic factor
o NCD is assumed as genetic factor & elderly diseases
o Indonesia society like to have group activity for any social event
o Posbindu PTM is accessible & affordable
 Skrining Riwayat
Kesehatan

Sehat/Risiko rendah Risiko Tinggi

Perilaku hidup sehat Skrining Sekunder

(edukasi, olahraga) (Penegakan Dx)

High Risk but Diagnosa

Un-diagnosed as Chronic penyakit kronis

Pencegahan Primer Pencegahan Sekunder & Tersier

• Gaya hidup sehat (Disease Management Program
• Konseling pada Faskes primer  PROLANIS  PPDM - PPHT)

Peserta BPJSK: Peningkatan benefit (Promotif & Preventif), Peningkatan kualitas kesehatan
BPJS Kesehatan: Pengelompokan & pencegahan risiko sakit dan strategi pengendalian biaya
www.ptaskes.com
Kriteria Diagnosis DM

Pemeriksaan glukosa plasma puasa >126 mg/dl. Puasa adalah kondisi

tidak ada asupan kalori minimal 8 jam.(B)
Atau

Pemeriksaan glukosa plasma ≥200 mg/dl2 jam setelah Tes Toleransi

Glukosa Oral (TTGO) dengan beban 75 gram. (B)

Atau
Pemeriksaan glukosa plasma sewaktu ≥200 mg/dl dengan keluhan klasik.
Atau
Pemeriksaan HbA1c > 6,5% dengan menggunakan metode High-
Performance Liquid Chromatography (HPLC)yang terstandarisasi oleh
National Glycohaemoglobin Standarization Program (NGSP). (B)
Catatan : Saat ini tidak semua laboratorium memenuhi standard NGSP,
sehingga harus hati-hati dalam membuat interpretasi terhadap hasil
pemeriksaan HbA1c.

Konsensus Pengelolaan DM Tipe 2 Perkeni 2015

 Kadar Tes Laboratorium Darah Untuk
Diagnosis Diabetes Dan Prediabetes.

Glukosa
Glukosa darah plasma 2 jam
HbA1c (%)
puasa (mg/dL) setelah TTGO
(mg/dL)

Diabetes > 6,5 > 126 mg/dL > 200 mg/dL

Prediabetes 5,7-6,4 100-125 140-199

Normal < 5,7 < 100 < 140

Konsensus Pengelolaan DM Tipe 2 Perkeni 2015

Kelompok dengan berat badan lebih (IMT ≥23 kg/m 2) yang
disertai dengan satu atau lebih faktor risiko sebagai berikut:
 Aktivitas fisik yang kurang.
 First-degree relative DM (Terdapat faktor keturunan DM dalam keluarga).
 Kelompok ras/etnis tertentu.
 Perempuan yang memiliki riwayat melahirkan bayi dengan BB >4 kg atau
mempunyai riwayat diabetes melitus gestasional (DMG).
 Hipertensi (≥140/90 mmHg atau sedang mendapat terapi untuk hipertensi).
 HDL <35 mg/dL dan atau trigliserida >250 mg/dL.
 Wanita dengan sindrom polikistik ovarium.
 Riwayat prediabetes.
 Obesitas berat, akantosis nigrikans.
 Riwayat penyakit kardiovaskular.

 Usia >45 tahun tanpa faktor risiko di atas.

Catatan : Kelompok risiko tinggi dengan hasil pemeriksaan glukosa plasma normal
sebaiknya diulang setiap 3 tahun (E), kecuali pada kelompok prediabetes
pemeriksaan diulang tiap 1 tahun (E).
Konsensus Pengelolaan DM Tipe 2 Perkeni 2015
 Advantages of Proposal to Use HbA1c for Diabetes Diagnosis
• Standardized and aligned to the DCCT/ UKPDS; measurement of
glucose is less well standardized
• Better index of overall glycemic exposure and risk for long-term
complications
• HbA1c level is not affected by short-term lifestyle changes
• Substantially less biologic variability
• Substantially less preanalytic instability
• No need for fasting or timed samples
• Relatively unaffected by acute (e.g., stress or illness related)
perturbations in glucose levels
• Currently used to guide management and adjust therapy
• Convenient for patients i.e. no fasting or other test preparation
required
• Accurate, precise measure of chronic glycaemic levels
• Lower between- and within-subject coefficients of variation and
reduced possibility of pre-analytic errors compared with glucose
• Correlates with risk of diabetes defining complications (retinopathy)
• Familiar test parameter i.e. already used to guide therapeutic decisions

Diabetes Care 2009; 32(7): 1327-1334

 Disadvantages of Proposal to Use HbA1c for Diabetes Diagnosis

• Relationship between HbA1c and glucose, whilst good, is not

perfect
• Whilst existing glucose based diagnostic criteria remain
valid, the current proposal does not advocate a confirmatory
check of glucose at any stage
• Point of care instruments currently considered inadequate for
diagnostic purposes
• Methods suffer from multiple interferences that clinicians
may not be aware of
• The proposed cut-off of 6.5% is predictive of retinopathy –
but is it the most appropriate outcome on which to choose a
diagnostic target?
• Not appropriate for diagnosis of gestational diabetes
• Upper limit of normal HbA1c (6.0%) leaves a diagnostic
hiatus between 6.1 and 6.5%, in addition to a discrepancy
between the typical treatment target of <7% and the
diagnostic level
• Racial disparities in HbA1c may exist that are independent of
blood glucose

Diabetes Care 2009; 32(7): 1327-1334

 Integrated Health Post of PC-NCD Risk
Factors,
WHAT POSBINDU PTM

Process Enabling people

Enhancing
community
Learning by Doing awareness and
skill in of NCD
From & by & for risk factors
community prevention and
Based on local control
social culture Integratedly

As Conducive
Social Environment
 WHERE HOUSE WHAT
Setting

The early • Anthropometric

SCHOOL detection & measurement
• Blood pressure
Setting Counseling measurement
activity will • Blood glucose and
be done cholesterol
POSBINDU through measurement.
PTM integrated
• Health counselling
and education
WORK risk factors (diet, stop
PLACE monitoring, smoking, stress,
in routine physical activity,
other health
and periodic
aspect)
time • Physical activities
together
PUBLIC
PLACE
Pos Bin Du PTM Activities
Pos Bin Du PTM Activities
Prevalence of NCD Risk Factors in
Abadi Jaya-Depok 2001-2006
 DISTRIBUTION OF POSBINDU-PTM IN INDONESIA

Simple Health
Total Number of Posbindu- Equipment :
1. Digital tensimeter
PTM 3.314 clubs (2011) 2. Waist
Aceh
35
Measurements
Kaltim 3. Body height -
Sumut 58
120 KEPRI
weight Scale
35
Sulut 4. Glucose meter
RIAU
Kalbar 70
56
175
Malut
Gorontalo 35
Sumsel 12
20
Kalteng
Sumbar Jambi BABEL 15
127 26 Sulbar
12
9
DKI Papua
175 Sultra 15
Kalsel
9
Bengkul Lampun 136 Sulsel
Jateng
u g 120
160
86 18 Jatim
135 NTB
12
Banten DI
100 Ygya
16
Jabar
1.360 Bali
120
 Prevention and Control of Diabetes Based on
Community Integration
 Focus on health promotion, use multiple interventions
to create supportive environments, promote behavioural change
and reorient health services
 The community as setting for interventions, agent with
developmental capacity/resources with a high degree
of participation
 Use multiple interventions, target change among individuals,
groups, and organizations
 Integrated & comprehensive (across risk factors, diseases, services,
disciplines, levels of prevention
and care) and not limited to clinical care settings
Indonesian Ministry of Health 2012
 Self Monitoring of Blood Glucose (SMBG)

Tools to assess treatment in diabetic patients that is

recommended especially in:
1. Patients that will undergo insulin therapy
2. Patients receiving insulin therapy
3. Patients with A1C level did not reach the target
4. Women planned for pregnancy / pregnant women
with hyperglycemia,
5. Patients with recurrent hypoglycemia.

PERKENI Guidelines 2010

Penapisan Komplikasi
 Penapisan komplikasi harus dilakukan pada setiap penderita
yang baru terdiagnosis DMT2 melalui pemeriksaan :
 Profil lipid pada keadaan puasa: kolesterol total, HDL, LDL,
dan trigliserida.
 Tes fungsi hati
 Tes fungsi ginjal: Kreatinin serum dan GFR
 Tes urin
 Albumin urin kuantitatif
 Rasio albumin-kreatinin sewaktu.
 Elektrokardiogram.
 Foto Rontgenthoraks (bila ada indikasi: TBC, penyakit jantung
kongestif).
 Pemeriksaan kaki secara komprehensif.

Konsensus Pengelolaan DM Tipe 2 Perkeni 2015

 52

Main pathophysiological defects in type 2 DM

Brain
Intestines Pancreas
pancreatic
incretin insulin
effect secretion

pancreatic
glucagon
secretion ?
gut
carbohydrate
delivery and
absorption Hyperglycemia
Muscle
Liver

peripheral
glucose
uptake

hepatic Adipose
glucose
production
DM, diabetes mellitus.
Adapted from : Inzucchi SE, Sherwin RS. Diabetes Mellitus. In: Goldman L, Ausiello D, eds. Cecil Textbook of Medicine. 23rd Edn.
Philadelphia, Pa: Saunders Elsevier; 2007.
 Profil Obat Antihiperglikemia Oral Di Indonesia

Penurunan
Golongan Obat Cara Kerja Utama Efek Samping Utama
HbA1c

Sulfonilurea Meningkatkan sekresi insulin BB naik hipoglikemia 1,0-2,0%

Glinid Meningkatkan sekresi insulin BB naik hipoglikemia 0,5-1,5%

Menekan produksi glukosa

Dispepsia, diare, asidosis
Metformin hati & menambah sensitifitas 1,0-2,0%
laktat
terhadap insulin

Penghambat
Menghambat absorpsi glukosa Flatulen, tinja lembek 0,5-0,8%
Alfa-Glukosidase

Menambah sensitifitas
Tiazolidindion Edema 0,5-1,4%
terhadap insulin
Meningkatkan sekresi insulin,
Penghambat DPP-IV Sebah, muntah 0,5-0,8%
menghambat sekresi glukagon

Konsensus Pengelolaan DM Tipe 2 Perkeni 2015

 Current Available Treatments:
Unmet Needs in T2DM Management

Insulin Resistance Pancreatic Islet Dysfunction

(Impaired insulin action)

Inadequate Insufficient Progressive

glucagon Insulin decline of β-
suppression secretion cell function
(-cell (β-cell
dysfunction) dysfunction)

Metformin TZDs Sulfonylureas

Glinides

DPP-4 Inh

Weight of red arrows reflects the degree to which DPP-4 inhibitors influence the disease mechanisms.
DPP-4=dipeptidyl peptidase-4; TZD=thiazolidinedione; T2DM=type 2 diabetes mellitus.
Adapted from DeFronzo RA. Br J Diabetes Vasc Dis. 2003; 3(suppl 1): S24–S40.
54
 Principles in selecting antihyperglycemic

interventions:
 Effectiveness in lowering glucose

 Extraglycemic effects that may reduce long-

term complications
 Safety profiles

 Tolerability

 Ease of use

 Expense

Nathan DM, et al. Diabetes Care 2009;32 193-203.

Algoritme Pengelolaan DM Tipe-2 di Indonesia

Konsensus Pengelolaan DM Tipe 2 Perkeni 2015

 Sasaran Pengendalian DM
Parameter Sasaran
IMT (kg/m2) 18,5 - < 23*
Tekanan darah sistolik (mmHg) < 140 (B)
Tekanan darah diastolik (mmHg) < 90 (B)

Glukosa darah preprandial kapiler 70-130**

(mg/dl)
Glukosa darah 1-2 jam PP kapiler <180**
(mg/dl)
HbA1c (%) < 7 (atau individual) (B)
Kolesterol LDL (mg/dl) <100 (<70 bila risiko KV sangat tinggi)
(B)
Kolesterol HDL (mg/dl) Laki-laki >40 Perempuan >50 (C)
Trigliserida (mg/dl) <150 (C)

Keterangan : KV = Kardiovaskular, PP = Post prandial

*The Asia-Pacific Perspective: Redefining Obesity and Its Treatment, 2000
** Standards of Medical Care in Diabetes, ADA 2014

Konsensus Pengelolaan DM Tipe 2 Perkeni 2015

Comparative Effectiveness and Safety of Oral
Medications for Type 2 Diabetes Mellitus

Compared with newer agents, metformin and

second-generation sulfonylureas share 3
additional advantages:
 lower cost,

 longer use in practice,

 more intensive in long-term trials with

clinically relevant end points.

Ann Intern Med. 2007;147:386-399.

What should be a guidelines
 Consensus
 Evidence based
 Reasonable
 Feasible
 Attainable
 and achievable by the patients.

Who is the target of the national guidelines

 Primary care doctors
 Others health personnel
 Treat T2DM early for long-term benefits1
 Long-term benefits in reducing cardiovascular risk can be achieved with good
control from diagnosis1

50% of patients with T2DM with complications

already have them at diagnosis2

Myocardial infarction
-14%
Each HbA1c
percentage
point Microvascular complications
reduction -37%
counts3
Death related to diabetes
HbA1c -21%

-1%

1. Holman, et al. NEJM 2008;359:1577–89

2. UKPDS 6. Diabetes Res 1990;13(1):1-11
3. Stratton, et al. BMJ 2000;321(7258):405-12
Conclusion
 Prevalence of Diabetes Mellitus and its Risk Factors are
increasing globally as well as in Indonesia due to
improving social and economic condition
 Facing burden of NCD – Diabetes Mellitus needs
activities of capacity building for all health personnel and
the facilities improvement of health care
 Community based intervention approach should be
taken to control Risk Factor of NCD
 A multi-disciplinary approach for management should be
adopted