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Definisi
Diabetes mellitus is a group of metabolic
diseases characterized by hyperglycemia
resulting from defects in insulin secretion,
insulin action, or both
(Expert Committee on the Diagnosis and Classification of Diabetes mellitus 2002)
Kelainan Fungsi /
Jumlah Sel Genetik
Tipe I (Autoimun)
Faktor Lingkungan
Sistim imun
(Ab anti pankreas)
Marker :
Insulin auto Ab
Islet cell auto Ab
Glutamic acid
dicarbosaflase
Au Ab (GAD. Abs)
Ideopatik
INSUFISIENSI
INSULIN
Virus
Diet
Obesitas
Hamil
Symptoms :
Polyuria
Polydipsia
Weight loss
Sometimes polyphagia
Blurred vision
Diagnosis
Symptoms of diabetes plus glucose > 200 mg/dl
or
Fasting plasma glucose > 126 mg/dl
or
2-h plasma glucose > 200 mg/dl during an OGTT
Fasting
1-h
2-h
3-h
mg/dl
mmol/l
95
180
155
140
5.3
10.0
8.6
7.8
Fasting
1-h
2-h
mg/dl
mmol/l
95
180
155
8.6
5.3
10.0
DIABETES vs PRE-DIABETES
Fasting
Blood
Glucose
Normal
< 100 *
Pre-Diabetes 100 * 125
Diabetes
126
2 hours post
prandial (mg/dl)
< 140
140 199
200
UKPDS :
100
75
Th/Expectation
Postprandial
Hyperglycemia
50
25
IFG
IGT
Facts
T2 DM
phase I
T2DM
phase II
-12 10 -6 -2 0 2
Years from Diagnosis
10
14
T2DM
-cell
Dysfunction
-Cell Failure
Insulin
Concentration
Insulin
Action
Euglycaemia
Normal
IGT+Obesity or IFG
Dx T2DM
Progression to T2DM
Insulin Resistance
Hyperinsulinemia
Glucose
intolerance
Increased
triglyceride
Increased
Uric acid
Coronary heart
disease
Increased blood
pressure
Increased
PAI - 1
Keluhan klasik -
>126
<126
>126
>200
<200
>200
110-<126
<110
mg/dl
GDS
110-200
mg/dl
<126
TTGO 2 jam
<200
>200
DIABETES MELLITUS
140-200
TGT
GDPT
<140
NORMAL
D. Endokrinopati
Acromegali, sindroma
Cushing, Feokromositoma,
hipertiroidisme
E. Karena obat/zat kimia
Vacor, pentamidin, asam
nikotinat, Glukokortikoid,
hormontiroid, tiazid, Dilantin,
interferon alfa
F. Infeksi : rubellakongenital, CMV
G. Sebab imunologi yang jarang :
Antibodi anti insulin
H. Sindroma genetik lain:
Sindroma Down, Klinefelter,
Turner dll.
4. Diabetes Gestasional
Type 1 Diabetes
Type 2 Diabetes
Combination of :
Serological evidence of
autoimmune process
in the pancreatic islet
Genetic markers
Insulin prandial
(glukosa uptake/utilzation
Insulin
puasa
Makanan
Glukagon
Glukosa
puasa
Glukosa
prandial
Glukosa darah prandial
Glycemic Control
Management
A. Aim
Short term :
Eliminate symptoms
Maintain general well being
Longer term :
Prevent complications
Reduce morbidity
and mortality
Strategy :
Normalizing glucose,
lipid, and insulin levels
Activities :
Management with holistic
approach and self care
principles
Treatment Modalities
Education
Tujuan :
Perubahan perilaku pasien dan keluarganya
Cara :
Berikan dukungan dan nasehat positif
Berikan informasi secara bertahap
Mulai dengan hal hal yang sederhana
Gunakan alat bantu
Lakukan pendekatan dan simulasi
Berikan pengobatan sesederhana mungkin
Jangan terlalu memaksakan kehendak kita
Berikan motivasi, penghargaan dan diskusikan hasil
pengelolaan
A D A and B D A
10-15%
30%
60-70%
Carbohydrate
Fat
10-15%
55%
Protein
Carbohydrate
Fat
Protein
PERENCANAAN MAKAN
KOMPOSISI :
Karbohidrat : 60 70 %
Protein
: 10 15 %
Lemak
: 20 25 %
JUMLAH KALORI :
Hitung BMI ( IMT ) = BB ( kg ) / TB ( m )2
IMT wanita ( normal ) = 18,5 23,5 kg/ m2
IMT laki ( normal )
= 22,5 25 kg / m2
Status gizi
BB kurang
BB Normal
: 90 120% BBI
BB lebih
Gemuk
Exercise
30 minutes: 3 - 4 times / week
Continuous
Rhytmical
Interval
Progressive
Endurance training
PANKREAS
PRODUKSI
GLUKOSA
Biguanides
(Metformin)
Thiazolidinediones
JARINGAN
LEMAK
OTOT
SEKRESI INSULIN
Sulfonylureas
AMBILAN GLUKOSA
PERIFER
Meglitinides ; Repaglinide
Thiazolidinediones
Insulin
Biguanides
(Metformin)
SAL. CERNA
alpha-glucosidase inhibitors
ABSORBSI
GLUKOSA
GLYCOGENOLYSIS
3. Metformin
TZD
1. Insulin
HGP
GLUCOSE N
+
4. Acarbose
GLUCONEO
GENESIS
Intestine
Adipose tissue
3. Metformin
TZD
1a. Insulin
Insulin actions include :
Ability of insulin to lower circulating glucose
concentrations
Suppress glucose production : liver
Stimulate glucose utilization : muscle plus fat
Additional metabolic, vascular & mitogenic actions
LIVER
GLYCOGENOLYSIS
Insulin
HGP
GLUCOSE N
GLUCONEO
GENESIS
ADIPOSE TISSUE
LIVER
GLYCOGENOLYSIS
Insulin
G LYCOGEN
HGP
GLUCOSE N
GLUCONEO
GENESIS
Glucose
Uptake
FFA
+
ADIPOSE TISSUE
Lipogenesis
G L UC O S E
Pancreas
LIVER
GLYCOGENOLYSIS
Insulin
G LYCOGEN
HGP
GLUCOSE N
Glucose
Uptake
GLUCONEO
GENESIS
ADIPOSE TISSUE
G L UC O S E
Lispro Aspart
Regular
NPH
0.10-0.25
0.10-1.0
1.0-3.0
Peak
(h)
0.75-2.0
1.0-4.0
5.0-7.0
Yes w RI
+/- w lispro
Minimal
Moderate
High
Lente
Ultra lente
Glargine
1.5-4.0
2-6
2-4
4.0-8.0
8.0-12
None
13-20
18-30
-24
+/+/NO !!!
precipitate
High
Very High
Moderate to
high
Penfil
Actrapid penfil
Insulatard penfil
Mixtard 30/40 penfil
Humulin R penfil
Humulin 30/70 penfil
1 b. Insulin Analogues
Genetic engineering
Main aim : Solubility reduction
Substitution/addition of amino acid residue of
insulin
Short acting :
Lispro: B28-lysine, B29-proline
X14 : B28-aspartate
Long acting:
B31-B32 arginine, A21-glycine
Immunogenicity
HbA1c (%)
Diet
and exercise
OAD
monotherapy
10
OAD
combinations
9
OADs
uptitration
OAD
+ basal insulin
8
HbA1c = 7%
7
HbA1c = 6.5%
Duration of diabetes
*OAD = oral antidiabetic
OHO
(Obat Hipoglikemic Oral)
2. Insulin Secretagogues
Induce insulin secretion
Potentiate nutrient-induced insulin
secretion
Antagonize inhibitors of insulin secretion
Calcium, Cyclic AMP and Adrenoreceptor
Manipulator
Other Insulin secretagogues
Short acting :
Repaglinide : Benzoic acid derivative
Nateglinide : Phenyl alanine derivative
Sulphonylureas
Have been a mainstay of type 2 diabetes treatment
for > 40 years
Bind to an SU receptor (SUR) on the -cell which
leads to depolarisation of -cell membrane and
stimulates insulin secretion
First generation
: chlorpropamide
Second generation
: glibenclamide, glipizide,
gliclazide
Third generation
: glimepiride
Attention : Hypoglycemia (less in glipizide GITS and
glimepiride)
ATP Sensitive
K+ Channel
Ca 2+
Voltage Dependent
Ca 2+Channel (VDCC)
SU
Islet cell
SUR
Closed
Open
Ca 2+
ATP
ADP
Glucose
Glucokinase
Metabolism
Am. acid
Proinsulin
INSULIN
C-PEPTIDE
SS 01
Metformin
Specific
Non-specific
Reduced carbohydrate
intake
Spreading carbohydrate
intake
Carbohydrate according
to 24 hr blood
glucose profile
Dietary fibres
Low glycemic index food
Acarbose
Repaglinide
Nateglinide
Insulin lispro
Nasal/pulmonary
insulin
Glucagon-like
peptide-1
Amylin analogues
Sulphonylurea
glipizide GITS
glimepiride
Metformin
Thiazolidinediones
Long acting insulin
Maximal dose
mg/day
Sulphonylurea
Glibenclamide
Gliclazide
Glipizide :
Glipizide GITS
Gliquidone
Chlorpropamide
Glimepiride
2,5
80
5
5
30
50
0,5
15-20
240
20
20
120
500
6
Meglitinide
Repaglinide
Nateglinide
1.5 mg
120 mg
8 mg
360 mg
Metformin
500
3000
300
Frequency of
administration /day
1-2 X
1-2 X
2-3 X
1-2 X
1X
1X
1X
3X
3X
1-3 X
3X
Normal
Average Preprandial
<110
Fasting Glucose (mg/dL)
Average Postprandial
Glucose (mg/dL)
HbA1C (%)
Goal
Further Action
Required*
80 to 120
<80
>140
<140
<160
>180
<6
<7
>8
HbA1c < 7 %
Consider oral
monotherapy
HbA1c 7- 8 %
Add
insulin sensitizer
or secretagoque
Target not Met
HbA1c > 8 %
Add
insulin sensitizer
and secretagoque
Target not Met
Start Insulin or
add Third oral agent
Complications :
Infeksi
Acute :
Chronic
Neuropathy
Ketoacidosis
Nonketotic Hyperosmolar
syndrome
Lactic asidosis
Hypoglikemi/koma.
Microangiopathy
Macroangiopathy
Retinopathy
Nephropathy
Neuropathy
CAD
PVD
Stroke
Penyulit Menahun
KOMPLIKASI DM
Glucose
Autoxidation
Polyol
Pathway
Polyol
Pathway
Oxidative Stress
Antioxidant
Defence
NO dependent Vasolidation
Ca2+
VSMC Proliferation
LDL
Oxidation
Hemorheologic alternations
Coagulation activation
Hipoxia
Vasculopathy
Oxidative
Factors
O2 / NO
Retinopathy
Heparan
Sulphate
NVC
Endoneural
Blood Flow
Neuropathy
Nephropathy
HYPERGLYCEMIA
G : Glycation
O : Oxidants
S : Sorbitol
C : Cytokines
Patogenesis
Ketoacidosis
Diabetik
Diet bebas
Infeksi
Protein
(Proteolisis)
Pelepasan FFA
Karbohidrat
Menuju hepar
Pelepasan A.A
Glukoneogenesis
hiperglikemia
Menuju hepar
Esterifikasi
Oksidasi
Ureum naik
HiperTrigliseridemia
Partial
Ketoanemia
Glukosuria
Diurese Osmotik Poliuiria
Ketosuria
Muntah
Dehidrasi
Asidosis
Ekskresi H+
Pernafasan
Kussmaul
Syok
AA : Asam Amino
G : Glukosa
FFA : Free Fatty Acid
DESCRIPTION
CLINICAL FEATURES
At in creased risk
12
Kidney Damage
Microalbuminuria :
Diabetes duration 5 10 years, retinopathy,
rising BP
Albuminuria :
Diabetes duration 10 15 years, retinopathy,
HBP
34
Decreased GFR
Kidney Failure
KOMA PADA DM
1. Hipoglikemi o.k. over Tx. Insulin, OHO.
2. Hipoglikemi
Severe defisiensi insulin Ketoasidosis
Mild / moderate hiperglikemi, hiper osmolar.
Laktik asidosis pada severe infekti,
cardiovaskuler collaps.
DIABETIK KETOASIDOSIS
Essentials of Dx :
Symtom + Sign :
3 P and marked fateque, nausea, vomiting
mental stupor coma.
Dehydrasi, stupor, rapid deep breathing
Fruity breath odor of acitone.
Laboratory Finding
Tx :
(Na+)
Glucose (mg/dL)
+
18
cerebral edema.
Insulin :
Regular insulin bolus 0,1 unit/kg dilanjutkan 0,1 unit/kg/jam
infus/i.m.
Bila resistensi insulin (+) dosis dapat dinaikkan
2 x setiap 2-4 jam
Antibiotika ~ dengan indikasi
( CHO )
LACTIC ACIDOSIS
ESS DX :
Severe acidosis with hyperventilation
pH darah < 7.30
Serum bicarbonat < 15 meq/l
Anion gap > 15 meq/l
Absent serum keton
Serum lactat > 5 mmol/l
ANION GAP
Erithrosit
Otot
Kulit
Otak
Asam Lactat
Hati
Ginjal
Glukose
Treatment Priority
of Type 2 DM
Glucose control as
near to normal as
reasonably possible
Microvascular
disease
Macrovascular
disease
Intervention/Control
Dyslipidemia
Insulin
resistance
Hypertension
Obesity
Pro-coagulant State
Cardiovascular
disease
Waist
circumference
Waist to hip
ratio
World Health
Organisation 1999
In men 94 cm
In womwn 80 cm
< 0,90 in men
< 0,85 in womwn
Reduced HDL
cholesterol
Elevated
Triglycerides
Elevated Blood
Pressure
140 / 90
130 / 85
Urinary Albumin
Excretion
Serum glucose
> 20 mg/min
1. Lingkar perut
wanita
pria
80 cm
90 cm
2. Trigliserida
3. HDLkolesterol
150mg/dL
wanita
pria
< 50mg/dL
4. Tekanan Darah
5. Gula Darah Puasa
< 40mg/dL
130/85mmHg
110mg/dL. (sekarang > 100)
ACTH, Cortisol
( Salivary Cortisol)
Insulin Resistance
2 Hyperinsulinemia
VISCERAL
ADIPOSE TISSUE
10
Hyperuricemia 9
Inflammatory Markers 8
(CRP, TNF, IL - 1, IL - 6)
Vascular Abnormalities 7
- Urinary Albumin Excretion
- Endothelial Dysfunction
GABRA-6 ?
6
Prothrombotic State
PAI-1 (Esp. Omental Fat)
Factor VII
Fibrinogen
vWF
Adhesion Molecules
IFG
IGT
DM
4 Atherogenic Dyslipidemia
Triglycerides
HDL-Cholesterol
Apolipoprotein-B
Small Dense LDL
5
Hypertension
LVH
CHF
2. Sekunder, mencegah/menghambat
komplikasi.
3. Tertier, mencegah kecacatan
Age 45 years
2.
3.
4.
5.
Member of a high-risk ethnic population (e.g., AfricanAmerican, Latino, Native American, Asian-American,
Pacific Islander)
6.
7.
8.
9.
10. PCOS
11. History of vascular disease.