1

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)

Long-term damage, dysfunction, and failure

of various organs especially the eyes, kidneys,
nerves, heart, and blood vessels

Complications :
Acute :

Ketoacidosis
Nonketotic Hyperosmolar
syndrome
Lactic asidosis
Hypoglikemi/koma.

Chronic :
Microangiopathy

Macroangiopathy

Retinopathy
Nephropathy
Neuropathy

CAD
PVD
Stroke

Coronary heart disease

Cerebrovascular disease

Peripheral vascular
disease

Major cause of increased

morbidity and mortality in
diabetes
Underlying abnormality:
atherosclerosis

It is more common and occurs earlier than in

people without diabetes

Ethnic differences
Caucasians: more myocardial infarctions
Chinese/Japanese: more strokes

Women lose gender protection

Myocardial infarction is often painless (silent)

Albuminuria increases risk of vascular event

Compared to people without diabetes, people

with type 2 diabetes have:
The same risk of heart attack as those who
have already had a heart attack
Two- to three-fold higher risk of heart failure

Sudden death occurs:

- 50% more often in men
- 300% more often in women
than in peers without diabetes but of the
same age

Research shows the benefits of

reducing the controllable risk factors
for atherosclerosis
Controllable risk factors are:
Dyslipidaemia (especially LDL or "bad"
cholesterol)
Smoking and exposure to tobacco smoke
High blood pressure
Diabetes
Obesity
Physical inactivity

Main predictors of CVD mortality

LDL and HDL cholesterol
Lipid profile in type 2 diabetes
raised triglycerides
low HDL
raised small dense LDL particles

IDF type 2
diabetes

LDL <2.5 mmol/L (<95 mg/dl)

Triglyceride <2.3 mmol/L (<200 mg/dl)
HDL cholesterol >1.0 mmol/L (>39 mg/dl)

Canada
Primary target
Secondary target

LDL-C </= 2.0 mmol/L

TC:HDL-C <4.0 mmol/L

United States

LDL <100 mg/dl

Triglycerides <150 mg/dl
HDL >40 mg/dl

Prevalence
Approximately twice that
of people without
diabetes
More common in men
than women before age
of fifty

Loss of day/night variation in blood

pressure
may be a sign of autonomic
neuropathy
Type 1: normotensive until renal
disease develops
Type 2: hypertensive before sign of
renal disease

JNC 7 and ADA recommendations

Hypertension blood pressure:

140/90mmHg

Target blood pressure goal in

diabetes: 130/80mmHg

Many people require three or

more drugs to achieve the
recommended target

ACE-inhibitors (-prils)
A2 Receptor blockers (Atacand,
Avapro, Karvea, Micardis, Teveten)
Calcium antagonists
(Dihydropyridine: Norvasc, Zanidip,
Adalat ; and non-dihydropyridine:
Verapamil, Diltiazem)
Diuretics
B-blockers

Strokes occur twice as often in

diabetes and hypertension than
those with hypertension alone

Transient Ischaemic Attacks

(TIAs) occur two to six times
more often

Prevention
Anti-hypertensive therapy
Aspirin therapy
Statin therapy (CARD Study)
ACE inhibitor therapy
(Progress Study)

In the retina, glomerulus, and vasa nervorum,

diabetes-specific microvascular disease is
characterized by similar pathophysiologic
features.

Clinical and animal model data indicate that

chronic hyperglycemia is the central initiating
factor for all types of diabetic microvascular
disease.

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Penyulit Menahun

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HYPERGLYCEMIA

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

Hiperglikemia Oxidative Stress Komplikasi vaskular menahun (Giugliano et al 1996, Modifikasi)

PENYEBAB PASTI BELUM DIKETAHUI

HIPERGLIKEMIA SEBAGA FAKTOR RESIKO UTAMA

TEORI BIOKIMIAJALUR POLIOL, GLIKASI

NONENZIMATIK, PEMBENTUKAN PROTEIN KINASE
C

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1.
2.
3.

FUNDUSKOPI
FUNDAL FLUORESCEIN ANGIOGRAPHY
(FFA).
3 STADIUM RD:
RD NONPROLIFERATIF
RD PROLIFERATIF
MAKULOPATI DIABETIL

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KONTROL GULA DARAH

KONTROL TEKANAN DARAH

ABLASI KELENJAR HIPOFISIS MELALUI PEMBEDAHAN ATAU

RADIASI HUBUNGAN GROWTH HORMON DENGAN RD

FOTOKOAGULASI DENGAN SINAR LASER

PANRETINAL RDP ATAU GLAUKOMA NEOVASKULAR
FOKAL EDEMA MAKULA

VITREKTOMI PENDARAHAN VITREUS ATAU ABLATIO

RETINA

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DEFINISI SINDROM KLINIS PADA PADIEN

DM YANG DITANDAI DENGAN ALBUMINURIA
MENETAP > 300 MG/24 JAM PADA MINIMAL 2
X PEMERIKSAAN DALAM KURUN WAKTU 3-6
BULAN.

PENYEBAB UTAMA GAGAL GINJAL TERMINAL

DI AMERIKA DAN EROPA.

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KLASIFIKASI

MOGENSEN KRITERIA:

TAHAP 1 HIPERTROFI DAN HIPERFILTRASI. LFG DAN EKSKRESI

ALBUMIN URIN MENINGKAT.

TAHAP 2 SECARA KLINIS BELUM TAMPAK KELAINAN YANG

BERARTI. LFG TETAP MENINGKAT PENEBALAN MEMBANA
BASALIS YANG TIDAK SPESIFIK DENGAN PENINGKATAN MATRIK
MESANGIUM.

TAHAP 3 INSIPIEN MIKROALBUMINURIA (30-300 MG/24

JAM). TEKANAN DARAH MULAI MENINGKAT.

TAHAP 4 NEFROPATI LANJUT SINDROM NEFROTIK

BIASANYA TERJADI PADA STADIUM INI LFG MENURUN.

TAHAP 5 GAGAL GINJAL TERMINAL

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TERGANTUNG STADIUM.

PENDEKATAN UTAMA:
PENGENDALIAN BS
PENGENDALIAN TEKANAN DARAH
PERBAIKAN FUNGSI GINJAL DIET, ANTI
HIPERTENSI ACE DAN ATAU ARB
PENGENDALIAN FAKTOR-FAKTOR KOMORBID
LAIN OBESITAS, KADAR LEMAK.

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DEFINISI MERUPAKAN SUATU ISTILAH

DESKRIPTIF YANG MENUNJUKKAN ADANYA
GANGGUAN BAIK KLINIS MAUPUN SUB KLINIS
YANG TERJADI PADA DIABETES MELITUS TANPA
PENYEBAB NEUROPATI PERIFER LAINNYA.

GANGGUAN INI TERMASUK MANIFESTASI

SOMATIK DAN ATAU OTONOM DARI SARAF
PERIFER.

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POLINEUROPATI SENSORI MOTORI DISTAL YANG

SIMETRIS ATAU DISTAL SYMMETRICAL SENSORYMOTOR
POLYNEUROPATHY (DPN)

TERJADI PENGURANGAN FUNGSI SENSORIK YANG

PROGRESIF DAN FUNGSI MOTORIK (LEBIH JARANG)
YANG BERLANGSUNG DARI BAGIAN DISTAL KE
PROKSIMAL.

SANGAT TERGANTUNG KETELITIAN PENGAMBILAN

ANAMNESIS DAN PEMERIKSAAN FISIK.
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EVALUASI TAHUNAN:
REFLEK MOTORIK
FUNGSI SERABUT SARAF BESAR TES KUANTIFIKASI
SENSASI KULIT SEPERTI RASA GETAR
(BIOTENSIOMETER) DAN RASA TEKAN (ESTESIOMETER)
FUNGSI SERABUT SARAF KECIL DENGAN TES SENSASI
SUHU
ELEKTROMIOGRAFI

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PERAWATAN UMUM KAKI

PENGENDALIAN GLUKOSA DARAH

MEDIKAMENTOSA

BELUM ADA BUKTI KUAT

ALDOLASE REDUKTASE INHIBITOR MENCEGAH PEMBENTUKAN SORBITOL DAN FRUKTOSA

PENGHAMBAT ACE

NEUROTROPIN

NERVE GROWT FACTOR

BRAIN DERIFED NEUROTROPIC FACTOR

ALPHA LIPOIC ACID

PENGHAMBAT PKC

GANGLIOSIDES

GAMMA LINOLEIC ACID

AMINOGUANIN PENGHAMBAT AGEs

HUMAN INTRAVENOUS IMUNOGLOBULIN

KIE
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PENGELOLAAN NYERI
NSAID(IBUPROFEN 4X600 MG/HARI, SULINDAC 2X200
MG/HARI)
TRISIKLIK ANTIDEPRESANT ( AMITRIPTILIN 50-150 MG,
IMIPRAMI 100 MG/HARI, NORTRIPTILIN 50-150 MG/HR)
ANTIKONVULSI ( GABAPENTIN 3 X900 MG/HR,
KARBAMAZEPIN 4 X200 MG/HR)
ANTIARITMIA (MEXILLETIN 150-450 MG/HR)
TOPIKAL (CAPSAISIN 4 X 0,075%) FLUPHENAZINE 1 X3
MG/HR
TRANSCUTANEUS ELECTRICAL NERVE STIMULATION
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