Sie sind auf Seite 1von 54

PENATALAKSANAAN DAN PENGELOLAAN

PENYAKIT KRONIS

DIABETES MELLITUS TIPE 2

Dr FX Rudhi Harsono SpPD

MASALAH DM DI
INDONESIA
APA PERAN KITA

???

Increasing DM
Prevalence in Indonesia
NATIONAL
5.7%

1.7%

1985
WHO, Study Group 1985
RISKESDAS, 2007

2007

Attributable Risk of Several Predictive


Factors of Pre-diabetes in Indonesia
60%
50%
40%
30%
20%
10%
0%

47.30%
23.00%

56.50%

44.40%
23.00%

16.70%

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.

THE TOP 10 DM PREVALENCES OF THE 33 INDONESIAN PROVINCES AS REPORTED BY MINISTRY OF HEALTH 2007

(The Results of RISKESDAS-Indonesia Study-2007, Summarized and Illustrated : 2012-2014)

Diabetes Province Prevalencef (MILLIONS)

*) Indonesia (Population 230 Million) : DM


DM:
10 Million
DM 5.7% (Male 4.9% ; Female 6.4%), Total
Total
DM:
10 M

60

*
* 11.1
11.1

50

10.4

Indonesia : IGT 10.2% (Male 8.7%, Female 10%) Total


: 17.9
MillionM
TotalIGTIGT
: 17.9

8.6

40

DDM : Diagnozed DM (26.3%)


UDDM : UnDiagnozed DM
(73.7%)

8.5

8.1

Tot. DM 10M
RISKESDAS-2007
DM 5.7%, DDM 1.5%, UDDM 4.2%
(26.3%)
(73.7%)

7.8 7.7

30
20

6.8

6.6

SBY
7.0%

10
0

MAL-UT KAL-BAR RIAU

BKBLT

NAD

SUL-UT JATENG GRTLO JATIM

10
DKI

Study Data (33 Provinces of Indonesia): Age > 15 yrs, Samples 19.114, Urban
Population. Diagnosis, based on : Fasting 10-14 hrs, Oral Glucose Loading 75 g (WHO
1999-ADA 2003), IGT (if Postloading Glucose : 140-200 mg/dL), DM (if Postloading
Glucose : > 200 mg/dL)

Indonesia: Chronic Diseases


Suffered by ASKES Clients in 2010
Diagnosis

Total Cases Diagnosed


(Thousands)

Renal Failure

11,875

Hypertension

629,315

Diabetes Mellitus

420,743

Cancer

132,810

Heart Disease

247,203

Stroke

117,356

Asthma

105,689

Osteoporosis

15,084

Other Chronic Diseases

220,151

No.

ASKES= Indonesian national health insurance plan

Indonesia: Cause of Death


No.

Diseases (2007)

Stroke

15.4

Tuberculosis

7.5

Hypertension

6.8

Trauma

6.5

Perinatal Diseases

6.0

Diabetes Mellitus

5.7

Malignancy

5.7

Liver Diseases

5.1

Coronary Artery Diseases

5.1

10

Lower Respiratory Tract Infection

5.1

Ministry of Health, Republic of Indonesia. 2007.

Diabetic Complications
60

Microangiopathy >> Macroangiopathy

50
40

33.4

30

26.5

20
8.7

10
0.5
0
IDMPS Indonesia

10.9
7.4
1.3

5.3

Retinopathy
Neuropathy
Proteinuria
Dialysis
Foot Ulcer
Amputation
Angina
MCI
Heart Failure
Stroke
PAD

Peran 1 : bekerjasama dalam jejaring


layanan faskes BPJS
Dokter umum, Faskes primer,
Puskesmas
Dokter prolanis
Dokter Faskes sekunder
Dokter Faskes tersier

Sistim Kesehatan
Nasional

UPAYA KESEHATAN PERORANGAN


private goods
- RS Umum/Khusus Pusat
- RS Umum/Khusus Propinsi

UPAYA KESEHATAN MASYARAKAT


public goods

Str
ata
-3

- Kemenkes
- Dinkes Propinsi

- RS Umum/Khusus Kota/Kab
- BP4, BKMM, Klinik/Praktek Dr. Spes
- Laboratorium Klinik

Strata-2

- Dinkes Kota/Kab
- BP4, BKMM, BKOM

- Puskesmas
- Klinik/Praktek Dokter Umum
- BP, BKIA, Praktek Bidan

Strata-1

- Puskesmas

- Posyandu, Polindes,
Posbindu, dll

Masyarakat
Perorangan/Keluarga

- UKBM: Posyandu,
Polindes, Posbindu, dll

Jejaring Layanan Pasien DM

Puskesmas
Dr Keluarga

RS Kab/
Dr Spesialis

RS Prop/
Dr Sp Konsultan

Deteksi dini
Pencegahan 1
pengobatan

Deteksi dini
Pencegahan 1,2,3
Pemeriksaan
lengkap awal
Pengelolaan
terpadu antar
bagian
PERSADIA

Deteksi dini
Pencegahan 1,2,3
Pemeriksaan
khusus
Pengelolaan
terpadu antar
bagian
Kasus kompleks
PERSADIA

Management of Chronic Disease Program


(PROLANIS)
Gatekeeper

Manager

Prescription

Family
Doctor

PROLANIS

Monitoring

Info Askes, edisi Mei 2010

Consultant

Peran 2 : Deteksi Dini


Skrining
diagnosis

PERKENI: Screening
Screening is conducted on those who have
diabetes risks, but do not show any symptoms
of DM

Screening seeks to capture undiagnosed DM


or prediabetes so it can be managed earlier
and more appropriately

Mass screening is not recommended considering


the costs, which are generally not followed by
action plan for those who were found abnormal.

Criteria for Testing for Diabetes in Asymptomatic Adult Individuals


(ADA-2014)
A Testing should be considered in all adults who are overweight (BMI>25
1.
kg/m2*) and have additional risk factors:
1 physical inactivity
2 first-degree relative with diabetes
3 high-risk race/ethnicity (e.g., African American, Latino, Native
American, Asian American, Pacific Islander)
4 women who delivered a baby weighing >9 lb or were diagnosed with
5 GDM
6 hypertension (>140/90 mmHg or on therapy for hypertension)
HDL cholesterol level <35 mg/dL (0.90 mmol/L) and/or a triglyceride
7 level >250 mg/dL (2.82 mmol/L)
8 women with polycystic ovarian syndrome
9 A1C >5.7%, IGT, or IFG on previous testing
other clinical conditions associated with insulin resistance (e.g.,
10 severe obesity, acanthosis nigricans)
B history of CVD
2. In the absence of the above criteria, testing for diabetes should begin
C at age 45 years.
3. If results are normal, testing should be repeated at least at 3-year
intervals, with consideration of more frequent testing depending on
initial results (e.g., those with prediabetes should be tested yearly)

PERKENI GUIDELINES 2011


Diabetes Symptoms
Diabetes Classic
Symptoms (+)
12
6
>20
0

FPG
atau

RBG

<12
6
<20
0

Diabetes Classic
Symptoms (-)
GDP
atau

GDS

12
6
>20
0

100-125
140199

FBG = Fasting Blood Glucose


RBG = Random Blood Glucose
IGT = Impaired Glucose
Tolerance
IFG = Impaired Fasting
Glucose

<10
0
<14
0

FBG and
PPG
FPG
atau

RBG

>12
6
20
0

<12
6
<20
0

OGTT 2 hour
BG
>20
0

Diabetes Mellitus
Evaluation of Nutritional Status
Evaluation Diabetic Complications
Evaluation Dietary Need and Dietary
Planning

140199
IGT

<14
0
IFG

Education
Dietary Planning
Physical Exercise
Achieving Ideal Body
Weight

Norma
l

PERKENI: Diagnostic
Criteria for Diabetes
Mellitus
1 Classic symptoms of diabetes + random glucose plasma
level
200 mg/dL. Random glucose plasma level is a test
which access glucose plasma level at a single time
without concerning about last meal schedule.
2

or

Classical symptoms of diabetes + fasting plasma

glucose
126 mg/dL. Fasting means patients not getting intake
calories
for minimum 8 hours.
or

2-h plasma glucose at glucose tolerance test 200


PERKENI Guideline 2011

mg/dL. Glucose tolerance test done by the WHO

11

PERKENI : DIABETES PREVENTION


Management
Early Detection
High-risk population at > 30-year
old
Family history of DM
Cardiovascular disorder
Overweight
Sedentary life style
Known IFG or IGT
Hypertension
Elevated triglyceride, low HDL
or both
History of Gestational DM
History of given birth
> 4000g
PCOS
2-hour OGTT is the most
sensitive method for early
detection and a recommended
screening test procedure

Lifestyle Changes

Medical
Nutritional
Therapy

Physical activity

Weight reduction

If overweight,
reduce body
weight by 5-10%

Physical exercise
for 30 minutes,
5 times/week

Pharmacology
Therapy
Not yet
recommended

Periodic Blood
Glucose & Risk
Factor Monitoring
Hypertension
Dyslipidemia
Physical health
Body weight control

H.D.L-CO
H : Hypertension
D : Diabetes
L : Lipid (Dyslipidemia)
C : Stop Cigarette
(Smoking)
O : Obesity (Weight
Control)

Peran 3 : pelayanan
komprehensip

Treat to target
Edukasi
Terapi Nutrisi
Terapi Olah Raga
OHO
Insulin
Peran dalam kegawatan akut
Peran dalam deteksi komplikasi kronik

TARGET OF TREATMENT
RISK CVD (-)
BMI (kg/m2)

RISK CVD (+)

18.5 <23

18.5 <23

FPG (mg/dL)

<100

<100

Post Prandial BG (mg/dL)

<140

<140

<7.0

<7.0

<130/80

<130/80

Total Cholesterol (mg/dL)

<200

<200

Triglyceride (mg/dL)

<150

<150

HDL Cholesterol (mg/dL)

>40 / >50

>40 / >50

LDL Cholesterol (mg/dL)

<100

<70

BLOOD GLUCOSE

A1C (%)
BLOOD PRESSURE
LIPID

PERKENI GUIDELINES 2011

PERKENI: Standards of Care


Diabetes care must be:
Continuous, not episodic
Proactive, not reactive
Planned, not sporadic
Patient centered rather than provider
centered
Population based, as well as individual
based
Team care

PERKENI: Standards of Care


Ideal core team members:
A physician or other primary care provider
A nurse
A dietician (at least one of whom is certified
diabetes educator)
Other team members will vary according to the
patient need, patient load, organization
constraints, resources, clinical setting and
professional skills
e.g.: podiatrist, pharmacist, psychological or
social workers
Mensing C. Diabetes Care
2000:23:682-9.

PERKENI: Patient Education


Daily Activities
Be active most of the time
Be productive

Self-Management Skills
Preparing pills, insulin
Follow drug schedule
Side effect awareness

Foot Care
Daily foot care & appropriate shoes

Medical Checkup

PERKENI: Patient Education


Healthy eating: healthy food choices, food composition
(carbs, protein, fat, fiber)

Body weight maintenance: achieved target of BMI or reduced


5 10% of body weight

Exercise
Monitoring: self-monitoring of blood glucose, A1C
Hypoglycemia: awareness & self-treatment

35
PROSENTASE
25

25

MAKAN PAGI SNACK MAKAN SIANG SNACKMAKAN MALAMSNACK

jadual dan porsi makan

5
MENIT

PEMANASAN

20
MENIT

LATIHAN INTI

5
MENIT

PENDINGINAN

PERKENI Guidelines 2011


< 7%

7 8%

Lifestyle
Modification

Lifestyle
Modification

+
Monotherap
y
Met, SU, AGI,
Glinid, TZD,
DPP IV-i

8 - 9%
Lifestyle
Modification

+
2 OADs
Combinatio
n
Met, SU, AGI,
Glinid, TZD,
DPP IV-i

> 9%

Lifestyle
Modification

+
3 OADs
Combinatio
n
Met, SU, AGI,
Glinid, TZD,
DPP IV-i

9 - 10%

Lifestyle
Modification

+
2 OADs
Combinatio
n
Met, SU, AGI,
Glinid, TZD,
DPP IV-i

Notes:
Fail: not achieving A1c target < 7%
after 2-3 months of treatment
(A1c = average blood glucose conversion,
ADA 2010)

> 10%

Basal
Insulin

Lifestyle
Modification

+
Intensive
Insulin

Algorithm Consensus ADA/EASD 2008


Tier 1:

well validated core therapies

Diagnosis:
Lifestyle
+
Metformin

Lifestyle + Metformin
+
Intensive insulin

Lifestyle + Metformin
+
Basal insulin
Lifestyle + Metformin
+
Sulfonylurea

Step 2
Step 1
Tier 2: Less well validated core therapies
Lifestyle + Metformin
+
Pioglitazone

(No hypoglycemia /edema (CHF)/ bone loss)

Lifestyle + Metformin
+
GLP-1 agonist b

(no hypoglycemia/weight loss /nausea/vomiting )

Nathan DM, et al. Diabetes Care 2008;31(12):1-11.

Step 3

Lifestyle + Metformin
+
Pioglitazone
+
Sulfonylurea a
Lifestyle + Metformin
+
Basal Insulin

MAP OF ORAL ANTI DIABETES (OAD) IN DAILY PRACTICE


(Summarized : Tjokroprawiro 1996-2014)
INSULIN SECRETAGOGUES

I
4
5

II
1
2

3
4

1 SUs : Gliquidone, Glipizide, Gliclazide, Glibenclamide, Glimepiride


2 NON-SUs (Metaglinides : Nateglinide, Repaglinide) 3 INCRETIN ENHANCERS

GLIMIN (new tetrahydrotriazine-containing class) : IMEGLIMIN (1500 mg twice/day) : Insulin, Muscle glucose uptake, HGP
GPR40 Agonist (TAK-875) : 50-200 mg once/day. The long-chain FAs amplify glucose-stimulated insulin secretion, GLP-1

INSULIN SENSITIZERS

(Rosi-*), Bala-, Rivo-, Lobe-, Pio-, Neto-, Dar-glitazone)


THIAZOLIDINEDIONES (TZDs): Glitazone Class
NON-TZDs :
*) Withdrawn
a Glitazar Class (Mura-*), Raga-, Ima-, Tesaglitazar) : MRIT
b Non-Glitazar Class (Metaglidasen : Non Edema and Non Weight Gain)
BIGUANIDE : - Metformin , Metformin XR (Glucophage XR), 3-Guanidinopropionic-Acid

5 Herb) ***) : Insulin Sensitizer and Incretin Enhancer


DLBS-3233 (Inlacin
Berberine
) (Chinese

III

INTESTINAL ENZYME INHIBITORS

IV

INCRETIN-ENHANCERS

FIXED DOSE COMBINATION (FDC) TYPES

1 -Glucosidase Inhibitor (AGI) : Acarbose


2 -Amylase Inhibitor (AMI) : Tendamistase

Sita-, Vilda- , Saxa- *) , Lina- , Alo-, Dena-,

DPP-4 INHIBITORS Duto-, Melo-, Teneli-gliptin, SYR-322, TA-666

Glucovance , Amaryl-M, Galvusmet, Janumet , Kombiglyze XR**) , Actosmet, Duet act

VI

OTHER SPECIFIC (OS) TYPES

1 Sodium GLucose co Transporter-2 (SGLT2)-Inhibitors:


ASP1941, BI 10773 , Canagliflozin, Dapagliflozin, Seragliflozin, Remogliflozin, AVE-2268,
KGT-1681, LX-4211, TS-033, YM-543 2 Glucokinase Activator (GKA): MTBL1, MK-0941.
3 Oxphos-Blocker 4 FBPase Inhibitor 5 INCB13739 (11HSD1inhibitor) 6 Berberine ***) : Rhizomacoptidis

Oral Diabetes Drugs in


Indonesia
Golongan

Generik
Glibenclami
d
Glipizid

Sulfonilur
ea

Gliklazid
Glikuidon

Glimepirid

Glinid

Repaglinid
Nateglinid

Tiazolidindi
on

Pioglitazon
e

Nama
Dagang
Daonil

Acarbose

Lama Kerja
(jam)

Frek/har
i

2.5 15

12 24

12

Minidiab

5 10

5 20

10 16

12

Glucotrol-XL

5 10

5 20

12 16**

80

80 320

10 20

12

30 60

30 120

24

30

30 120

68

23

Amaryl

1-2-3-4

0.5 6

24

Gluvas

1-2-3-4

16

24

Amadiab

1-2-3-4

16

24

Metrix

1-2-3-4

24

Diamicron
Diamicron-MR
Glurenorm

Dexanorm

16

1.5 6

120

360

Actos

15 30

15 45

24

Deculin

15 30

15 45

24

Pionix

15 30

15 45

18 24

50 100

100 300

Starlix

Eclid

Glucophage
Metformin

Dosis Harian
(mg)

2.5 5

Glucobay
Penghambat
Gluckosidase
alfa

Mg/tab

50 100

100 300

500
850

250 3000

Waktu

Sebelum
makan

Tidak
bergant
ung
jadwal
makan

68

13

Bersama
suapan
pertama

Oral Diabetes Drugs in


Indonesia
Golongan
Penghambat
DPP-IV

Generik

Nama Dagang

Mg/tab

Dosis Harian (mg)

Lama Kerja (jam)

Frek/hari

50

50 100

12 24

12

Januvia

25, 50, 100

25 100

24

Onglyza

24

12 24

12

Vildagliptin

Galvus

Sitagliptin
Saxagliptin

Waktu
Tidak
bergantun
g jadwal
makan

250/1.25
Metformin +
Glibenclamid

Glucovance

500/2.5

Total glibenclamid
maksimal 20 mg/hari

500/5
Glimepirid +
Metformin
Obat Kombinasi
Tetap

Amaryl-Met FDC

Pioglitazone
+ Metformin

Pionix M

Sitagliptin +
Metformin

Janumet

1/250

2/500

2/500

4/1000

15/500
30/850
50/500
50/1000

Total pioglitazone
maksimal 45 mg/hari

18 24

Total sitagliptin
maksimal 100 mg/hari

50/500
Vildagliptin +
Metformin

Galvusmet

50/850
50/1000

Total vildagliptin
maksimal 100 mg/hari

12 24

Bersama /
sesudah
makan

Comorbid
Recurrent
HYPOs
Overweight /
Obese
Cardiovascular
Diseases
Congestive
Heart Failure

Drugs
Metformin / GLP-1RA / DPP4-inh /
AGI / TZD
GLP-1RA / DPP4-inh / Metformin / AGI
Metformin / TZD / incretin Tx (?)
Insulin / Metformin () / Incretin Tx

Chronic Kidney
Disease

Insulin / Metformin (creatinine


<1.5) / DPP4 Inh (adjust dose)

Liver diseases

Insulin, TZD (hepatosteatosis), DPP-4


inh (?)

Insulin in
Indonesia
Awal Kerja
(Onset)

Puncak
Kerja
(Peak)

Lama Kerja
(Duration)

Kemasan

30-60 menit

30-90
menit

3-5 jam

Vial, pen/cartridge

Insulin Lispro (Humalog)

5-15 menit

30-90
menit

3-5 jam

Pen/cartridge

Insulin Glulisine (Apidra)

5-15 menit

30-90
menit

3-5 jam

Pen

Insulin Aspart (Novorapid)

5-15 menit

30-90
menit

3-5 jam

Pen, Vial

2-4 jam

4-10 jam

10-16 jam

Vial, Pen/cartridge

Insulin Glargine (Lantus)

2-4 jam

No Peak

20-24 jam

Pen

Insulin Detemir (Levemir)

2-4 jam

No Peak

16-24 jam

Pen

Sediaan Insulin
Insulin Prandial (Meal Related)
Insulin Short Acting
Reguler (Actrapid, Humulin
R)
Insulin Analog Rapid Acting

Insulin Intermediate Acting


NPH (Insulatard, Humulin N)
Insulin Long Acting

Insulin Campuran

PROFIL INSULIN SUBKUTAN


Humalog
(very fast)

7 am

Regular
(fast)

12 pm

NPH/Lente
(slow)

7 pm

Insulin
Glargine
(slow)

12 am

Ultralente
(very slow)

7 am

Insulin Regimen Consisting of Bedtime


Injection
of Intermediate-acting Insulin ( NPH or
LENTE )
INSULIN EFFECT

A
Morning

Evening
Afternoon

Night

NPH / LENTE

ORAL

MEALS

Insulin Regimen Consisting of


Bedtime Injection and Morning Injection
of Intermediate-acting Insulin ( NPH or LENTE )

INSULIN EFFECT

B
Morning

Evening
Afternoon

Night

NPH / LENTE

MEALS

NPH / LENTE

INSULIN EFFECT

Injections
of Short-acting Insulin ( LISPRO) before Meals
and
Basal flat-long-acting Insulin ( GLARGINE )
Morning

Evening
Afternoon

LISPRO LISPRO LISPRO


GLARGINE

MEALS

INSULIN INJECTION SITES : CLOCK WISE ROTATION


Sites of SC Insulin Injection should be at the Healthy Areas
Distance between the Two SITES of Injection : Minimally 2.5 cm
(Clinical Experiences : Tjokroprawiro 1993-2014)

76-90

1-15

61-75

16-30

46-60

31-45

Peran dalam kegawatan


akut
Koma hipoglikemi
Koma hiperglikemi

Komplikasi hipoglikemi
GD < 70
Lemes, gemetar, lapar, keringat dingin,
berdebar debar, gangguan kesadaran
Sadar minum manis gula biasa, makan
manis, premen, roti, nasi, karbohidrat
Tidak sadar : rumah sakit, infus glukosa

Practical Guideline of Hypoglycemia with Formula 3-2-1-1


for Pts with Diabetes Mellitus to Avoid Honey Moon Phenomena
(Clinical Experiences : Tjokroprawiro 1996-2014)

GlLUCOSE Treatment of Hypoglycemia with GLUCOSE 40%


1 FLACON : 25 mL
LEVEL
FORMULA
3-2-1-1
with 10 g Glucose
(mg/dL)
< 30 mg/dL *) : I.V GLUCOSE 40%, BOLUS 3 FLACONS FORMULA - 3
30-50 mg/dL *) : I.V GLUCOSE 40%, BOLUS 2 FLACONS FORMULA - 2
50-70 mg/dL *) : I.V GLUCOSE 40%, BOLUS 1 FLACON FORMULA - 1
70-90 mg/dL **): I.V GLUCOSE 40%, BOLUS 1 FLACON FORMULA - 1
After 15-30 minutes of Treatment, if SMBG Shows Continued
Hypoglycemia, the Treatment Should be Repeated

*) True Hypoglycemia : The 4 (Four) Hormones CGCG may be


Secreted (Catecholamine, Glucagon, Cortisol, Growth hormone)
**) Reactive Hypoglycemia : If Plasma Glucose Rapidly to be
Lowered and Drops Steeply f.e. from 400 to 70-90 mg/dL

Management of DKA:
Evaluation
Complete Initial Evaluation
Including (but not limited to):
Medical history and physical
examination

Urine for urinalysis and


ketones

Complete blood count with


differential

Cultures as indicated (wound,


blood, urine, etc.)

Fingerstick blood glucose

Chest abdominal x-ray

Serum chemistries
(electrolytes, BUN, Cr; serum
ketones)

12-lead ECG

Concurrently, begin empirical fluid resuscitation with


0.9% NaCl at 1000 mL/hr.
Consider volume expansions if hypovolemic shock is
present.
Continue fluid resuscitation until volume status and
cardiovascular parameters (pulse, BP) have been
restored.

Adult
patient
with DKA

Complete
Initial
Evaluation

K+ Repletion

IV Fluids

Insulin
Therapy
Bicarbonate?

When Serum
Glucose Reaches
200 mg/dL
Continuing
Management

47

Peran dalam deteksi dan


penatalaksanaan komplikasi kronik
Leading cause of
blindness in adults
24000 new cases
each year in US

2 to 4-fold
Increase in
cerebrovascular
Disease and Stroke

Diabetic
Retinopath
y

Stroke

Leading cause of
end-stage renal
disease in adults
44% new cases/yr

Diabetic
Nephropat
hy

Cardiovascular
Disease
8 out of 10 diabetic
patients die from
cardiovascular events

Leading cause of
Non-traumatic
Limb amputations
60% new cases/yr

Diabetic
Neuropat
hy

Peripheral
Peripheral
Arterial
Arterial
Disease
Disease
NIDDK, National Diabetes Statistics fact sheet. HHS, NIH,

PENGELOLAAN DM TIPE 2

Kendali
glukosa
GHS/Diet
Latihan
Jasmani
Obat
OHO/Insulin

Skrining dan
pengelolaan
komplikasi

Komorbid

Dislipidemi
Hipertensi
Obesitas
PJ Koroner

Retinopati
Nefropati
Neuropati
P
kardiovaskule
r
Komplikasi
lain

KOMPLIKASI KRONIK DM

komplikasi

Deteksi

Pengelolaan

. Retinopati

Funduskopi

Kendali GD, laser terapi

. Nefropati

Mikroalbumin

Kendali GD, Tek Darah,


batasi protein

Neuropati

Mikrofilamen

Duloxetin, gabapentin,
antidep trisiklik

. Pbl drh jantung

EKG

Nitrat, statin, aspirin

. Pbl drh tepi

Tes ASO, ABI,


arteriografi

Vasodillator,
hemoreologi

. Pbl drh otak

CT scan

citicholin

Microangiopati

Makroangiopati

Tantangan dalam praktik sehari hari

Kendali
mutu

Kendali
biaya

penutup
DM penyakit kronik progresif :
morbiditas, mortalitas, komplikasi,
biaya tinggi
Peran dokter BPJS : deteksi dini dan
diagnosis, bekerjasama dalam
jejaring, sistem rujukan
Peran dalam pelayanan :
diet,OR,OHO, Insulin
Peran dalam kegawatan dan deteksi
komplikasi kronik

LARANING LARA
ORA KAYA
WONG KANG SAKIT GULA
MANGANE DOYAN
NGOMBE TERUSAN
NENG AWAK LEMES

YO MERTAMBA
OLAH RAGA , DIET ,
NGOMBE OBAT
OJO DO LALI
PRIKSA GULA
BEN NGERTI HASILE

MUNG KUDU NGUYUH


KEJU KEMENG
TANGAN SIKILE
GRINGGINGEN
APA RA TRENYUH
SAWANGEN IKI
AWAKKU SING KURU

BEN LARA GULA


YEN TERATUR
ANGGONE MERTAMBA
URIPE MULYA
KALIS RUBEDA
NGANTI BESUK TUWO

Terima
kasih