DR. D.N. PRASTOWO, SP.

PD

BAGIAN PENYAKIT DALAM

RS. HANA CHARITAS ARGA MAKMUR
BENGKULU
2017
Classification of Diabetes
1. Type 1 diabetes
-cell destruction
2. Type 2 diabetes
Progressive insulin secretory defect
3. Gestational Diabetes Mellitus (GDM)
4. Other specific types of diabetes
1. Monogenic diabetes syndromes
2. Diseases of the exocrine pancreas, e.g., cystic fibrosis
3. Drug- or chemical-induced diabetes

American Diabetes Association Standards of Medical Care in Diabetes.

Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
CRITERIA FOR THE DIAGNOSIS OF DIABETES

Fasting plasma glucose (FPG)

126 mg/dL
OR
2-h plasma glucose 200 mg/dL
during an OGTT
OR
A1C 6.5%
OR
Classic diabetes symptoms + random plasma
glucose 200 mg/Dl

American Diabetes Association Standards of Medical Care in Diabetes.

Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Prediabetes*
FPG 100125 mg/dL : IFG
OR

2-h plasma glucose 140199 mg/dL : IGT

OR

A1C 5.76.4%

* For all three tests, risk is continuous, extending below the lower limit of
a range and becoming disproportionately greater at higher ends of the
range.

American Diabetes Association Standards of Medical Care in Diabetes.

Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Mean Glucose Levels for Specified A1C Levels
Mean Glucose
Mean Plasma
Fasting Premeal Postmeal Bedtime
Glucose*
A1C% mg/dL mg/dL mg/dL mg/dL mg/dL
6 126
<6.5 122 118 144 136
6.5-6.99 142 139 164 153
7 154
7.0-7.49 152 152 176 177
7.5-7.99 167 155 189 175
8 183
8-8.5 178 179 206 222
9 212
10 240
11 269
12 298
American Diabetes Association Standards of Medical Care in Diabetes.
Glycemic targets. Diabetes Care 2017; 40 (Suppl. 1): S48-S56
Approach to the Management of
Hyperglycemia
more A1C less
Patient/Disease Features stringent 7% stringent
Risk of hypoglycemia/drug adverse effects
low high
Disease Duration
newly diagnosed long-standing
Life expectancy
long short
Relevant comorbidities
absent Few/mild severe
Established vascular complications
absent Few/mild severe

Patient attitude & expected

treatment efforts highly motivated, adherent, excellent less motivated, nonadherent, poor
self-care capabilities self-care capabilities

Resources & support system

readily available limited

American Diabetes Association Standards of Medical Care in Diabetes.

Glycemic targets. Diabetes Care 2017; 40 (Suppl. 1): S48-S56
Glycemic Recommendations for Nonpregnant Adults
with Diabetes

A1C <7.0%*
Preprandial capillary
plasma glucose 80130 mg/dL*

Peak postprandial capillary plasma

glucose <180 mg/dL*

Patient safety is first priority

* Goals should be individualized.
Postprandial glucose measurements should be made 12 hours after the
beginning of the meal.

American Diabetes Association Standards of Medical Care in Diabetes.

Glycemic targets. Diabetes Care 2017; 40 (Suppl. 1): S48-S56
Glycemic Goals in Adults

A1C <7%
Stringent goals (e.g. <6.5%) without significant hypos
or other adverse effects.
Less stringent goals (e.g. <8%) for patients :
History severe hypoglycemia,
limited life expectancy or
other conditions that make <7% difficult to attain.

American Diabetes Association Standards of Medical Care in Diabetes.

Glycemic targets. Diabetes Care 2017; 40 (Suppl. 1): S48-S56
Risk factors for Prediabetes and T2D

A1C > 5.7%, IGT, or IFG on HDL cholesterol (<35 mg/dL)

previous testing &/ triglyceride (>250 mg/dL)
first-degree relative with POS
diabetes physical inactivity
high-risk race/ethnicity other associated with insulin
GDM resistance
history of CVD
hypertension

American Diabetes Association Standards of Medical Care in Diabetes.

Classification and diagnosis of diabetes. Diabetes Care 2017; 40 (Suppl. 1): S11-S24
Criteria for testing in asymptomatic adults

1. Overweight / obese with risk factor

2. Age > 45 years

3. Repeat minimum 3 years, minimun 1

years with risk factor
COMPREHENSIVE MEDICAL EVALUATION

Confirm the diagnosis + classify diabetes.

Detect diabetes complications & potential
comorbid conditions.
Review previous treatment and risk factor control
in patients with established diabetes.
Begin patient engagement in the formulation of a
care management plan.
Develop a plan for continuing care
MEDICAL HISTORY
Age and characteristics of onset of diabetes
Eating patterns, nutritional status, weight history, sleep behaviors
(pattern and duration), and physical activity habits;
nutrition education and behavioral support history and needs
Complementary and alternative medicine use
Presence of common comorbidities and dental disease
Screen for depression, anxiety, and disordered eating using validated
and appropriate measures
Screen for diabetes distress using validated and appropriate measures
Screen for psychosocial problems and other barriers
History of tobacco use, alcohol consumption, and substance use
 Diabetes education, self-management, and support history and
needs
Review of previous treatment regimens and response to therapy
Assess medication-taking behaviors and barriers to medication
adherence
Results of glucose monitoring and patients use of data
Diabetic ketoacidosis frequency, severity, and cause
Hypoglycemia episodes, awareness, and frequency and causes
History of increased blood pressure, abnormal lipids
Microvascular complications: retinopathy, nephropathy, and
neuropathy (sensory, including history of foot lesions; autonomic,
including sexual dysfunction and gastroparesis)
Macrovascular complications: coronary heart disease,
cerebrovascular disease, and peripheral arterial disease
For women with childbearing capacity, review contraception and
preconception planning
Physical examination
Height, weight, and BMI; growth and pubertal development in children and
adolescents
Blood pressure determination, including orthostatic measurements when
indicated
Fundoscopic examination
Thyroid palpation
Skin examination (e.g., for acanthosis nigricans, insulin injection or infusion
set insertion sites
Comprehensive foot examination
Inspection
Palpation of dorsalis pedis and posterior tibial pulses
Presence/absence of patellar and Achilles reflexes
Determination of proprioception, vibration, and monofilament sensation
LABORATORY EVALUTION

A1C
If not performed/available within the past year
Fasting lipid profile, including total, LDL, and HDL
cholesterol and triglycerides, as needed
Liver function tests
Spot urinary albumintocreatinine ratio
Serum creatinine and estimated glomerular filtration rate
Thyroid-stimulating hormone in patients with type 1
diabetes
Benefits of Weight Loss
Delay progression from prediabetes to type 2 diabetes
Positive impact on treatment of type 2 diabetes
Most likely to occur early in disease development
Improves mobility, physical and sexual functioning &
health-related quality of life

American Diabetes Association Standards of Medical Care in Diabetes. Obesity management

for the treatment of type 2 diabetes. Diabetes Care 2017; 40 (Suppl. 1): S57-S63
Recommendations:
Assessment
At each patient encounter, BMI should be
calculated and documented in the medical record.
Discuss with the patient
Cutpoints:
 Overweight/Obesity Treatment

Body Mass Index Category (kg/m2)

23.0* or 25.0- 27.0-29.9 27.5* or 30.0- 35.0-39.9 40
Treatment 26.9 34.9
Diet,
physical activity &
behavioral therapy

Pharmacotherapy

Metabolic surgery

* Asian-American individuals
Treatment may be indicated for selected, motivated patients.
American Diabetes Association Standards of Medical Care in Diabetes. Obesity management
for the treatment of type 2 diabetes. Diabetes Care 2017; 40 (Suppl. 1): S57-S63
Pharmacologic Approaches
to
Glycemic Treatment
Recommendations: Pharmacologic
Therapy For T2DM

Metformin, : preferred initial pharmacologic agent

Consider insulin therapy (with or without additional
agents) :
in patients with newly dxd T2DM
who are markedly symptomatic
and/or have elevated blood glucose levels (>300 mg/dL) or
A1C (>10%).

American Diabetes Association Standards of Medical Care in Diabetes.

Approaches to glycemic treatment. Diabetes Care 2017; 40 (Suppl. 1): S64-S74
New Recommendation: Pharmacologic
Therapy For T2DM

Long-term use of metformin may be associated with

biochemical vitamin B12 deficiency

and periodic measurement of vitamin B12 levels should be

considered in metformin-treated patients, especially in
those with anemia or peripheral neuropathy.

American Diabetes Association Standards of Medical Care in Diabetes.

Approaches to glycemic treatment. Diabetes Care 2017; 40 (Suppl. 1): S64-S74
Recommendations:
Pharmacological Therapy For T2DM

If noninsulin monotherapy at maximal tolerated dose does not

achieve or maintain the A1C target over 3 months, add a
second oral agent, a GLP-1 receptor agonist, or basal insulin.

Use a patient-centered approach to guide choice of

pharmacologic agents.

Dont delay insulin initiation in patients not achieving glycemic

goals.

American Diabetes Association Standards of Medical Care in Diabetes.

Approaches to glycemic treatment. Diabetes Care 2017; 40 (Suppl. 1): S64-S74
Insulin Therapy in T2DM

The progressive nature of T2DM should be

regularly & objectively explained to T2DM patients.

Avoid using insulin as a threat, describing it as a

failure or punishment.

Give patients a self-titration algorithm.

American Diabetes Association Standards of Medical Care in Diabetes.

Approaches to glycemic treatment. Diabetes Care 2017; 40 (Suppl. 1): S64-S74
 Combination Injectable Therapy in T2DM

American Diabetes Association Standards of Medical Care in Diabetes.

Approaches to glycemic treatment. Diabetes Care 2017; 40 (Suppl. 1): S64-S74
 Recommendations for Statin Treatment in
People with Diabetes
Age Risk Factors Statin Intensity*
None None
<40 years ASCVD risk factor(s) Moderate or high
ASCVD High
None Moderate
ASCVD risk factors High
4075 years
ACS & LDL 50 or in patients with history of ASCVD
Moderate + ezetimibe
who cant tolerate high dose statin
None Moderate
ASCVD risk factors Moderate or high
>75 years ASCVD High
ACS & LDL 50 or in patients with history of ASCVD
Moderate + ezetimibe
who cant tolerate high dose statin

American Diabetes Association Standards of Medical Care in Diabetes.

Cardiovascular disease and risk management. Diabetes Care 2017; 40 (Suppl. 1): S75-S87
Doses of statin therapy
MANAGES THE EMERGENCY
IN DIABETES

HYOGLICEMIC
HYPERGLICEMIA
Classification of Hypoglycemia

American Diabetes Association Standards of Medical Care in Diabetes.

Glycemic targets. Diabetes Care 2017; 40 (Suppl. 1): S48-S56
Recommendations: Hypoglycemia
Individuals at risk for hypoglycemia should be asked about
symptomatic and asymptomatic hypoglycemia at each encounter.
Glucose (1520 g) preferred treatment for conscious individual with
blood glucose < 70 mg/dL.
Glucagon should be prescribed for those at increased risk of
clinically significant hypoglycemia, defined as blood glucose < 54
mg/dL, so it is available if needed.
Hypoglycemia unawareness or episodes of severe hypoglycemia
should trigger treatment re-evaluation.

American Diabetes Association Standards of Medical Care in Diabetes.

Glycemic targets. Diabetes Care 2017; 40 (Suppl. 1): S48-S56
 Insulin-treated patients with hypoglycemia
unawareness or an episode of severe
hypoglycemia :
advised to raise glycemic targets
strictly avoid further hypoglycemia

Ongoing assessment of cognitive function

American Diabetes Association Standards of Medical Care in Diabetes.

Glycemic targets. Diabetes Care 2017; 40 (Suppl. 1): S48-S56
Benefits of Weight Loss
Delay progression from prediabetes to type 2
diabetes
Positive impact on treatment of type 2 diabetes
Most likely to occur early in disease development

Improves mobility, physical and sexual

functioning & health-related quality of life

American Diabetes Association Standards of Medical Care in Diabetes. Obesity management

for the treatment of type 2 diabetes. Diabetes Care 2017; 40 (Suppl. 1): S57-S63
Diagnostic criteria for DKA and HHS
PATHOGENESIS OF DKA AND HHS

Fayfman et al, 2016, Management of Hyperglycemic Crises Diabetic ketoacidosis and Hyperglycemic
Hyperosmolar State
PRECIPITATING CAUS OF DKA
Clinical features of hyperglycemic emergencies
MANAGEMENT OF HYPERGLYCEMIC CRISES

Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care
2009;32(7):1339
Guidelines

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