Diabetes

Mellitus

Erik Suhendra
Titis Hadiyanti Setyadi

Pembimbing : dr. Hermina Novida Sp.PD K-EMD FINASIM

 2

OVERVIEW

Introduction

Classification
Diabetes
Mellitus Risk Factors

Diagnosis

Treatment

Summary
 INTRODUCTION
 Definition:
 chronic metabolic disorder of multiple
etiology in which the body can’t
metabolize carbohydrate, fats and
proteins
 because of defects in insulin secretion
and/or action.

Classification and Diagnosis of Diabetes:

Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S13-S27
 INTRODUCTION
 As of 2015, an estimated 415 million
people had diabetes worldwide, with
type 2 DM making up about 90% of
the cases.
 Diabetes at least doubles a person's risk
of early death.
 From 2012 to 2015, approximately 1.5
to 5.0 million deaths each year resulted
from diabetes.
 Epidemiology Type 2 DM in
Surabaya

Series 1
30,000

25,000

20,000

15,000

10,000

5,000

0
2009 2010 2011 2012
Series 1

Pusat Data dan Informasi Departemen Kesehatan RI Tahun 2014

CLASSIFICATION
 Classification of DM 7

I. Type 1 DM
β-cell destruction
II. Type 2 DM
Progressive insulin secretory defect\
III. Gestational Diabetes Mellitus (GDM):
IV. Other specific types of diabetes due to
other causes:
 Monogenic diabetes syndromes
 Diseases of the exocrine pancreas, e.g., cystic
fibrosis
 Drug- or chemical-induced diabetes
Classification and Diagnosis of Diabetes:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S13-S27
 9

Etiology
 Etiology of Type 1
Diabetes:
 Autoimmune disease
 Selective destruction of
cells by T cells
 Several circulating
antibodies against
cells
 Cause of autoimmune
attack: unknown
 Both genetic &
environmental factors are
important
 Etiology
 Etiology of Type 2 Diabetes:
 Response to insulin is decreased
glucose uptake (muscle, fat)
glucose production (liver)
 The mechanism of insulin resistance is
unclear
 Both genetic & environmental factors are
involved
 Post insulin receptor defects
Pathogenesis of Type 2 DM

DeFronzo RA. Current issues in the treatment of type 2 diabetes. Overview of newer agents:
Where treatment is going. Am J Med 2010;123 3 Suppl:S38-48.


RISK FACTORS
Risk Factors

 For Type 1 DM
 Genetic predisposition
 In an individual with a
genetic predisposition,
an event such as virus or
toxin triggers
autoimmune destruction
of β-cells probably over
a period of several
years.
 Risk Factors
 For Type 2 DM
 Family History
 Obesity
 Habitual physical inactivity
 Previously identified impaired glucose
tolerance (IGT) or impaired fasting
glucose (IFG)
 Hypertension
 Hyperlipidemia
DIAGNOSIS
 Criteria for the Diagnosis of Diabetes

Classification and Diagnosis of Diabetes:

Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S13-S27
 Criteria for the Diagnosis of Diabetes

“Prediabetes” is the termused for individuals

whose glucose levels do not meet the criteria
for diabetes but are too high to be considered
normal

Classification and Diagnosis of Diabetes:

Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S13-S27
 Clinical manifestations
 Type 1 DM:
 Polyuria
 Polydipsia
 Polyphagia
 Weight loss
 Weakness
 Dry skin
 Ketoacidosis
 Clinical manifestations
 Type 2 DM:
 Patients can be asymptomatic
 Polyuria
 Polydipsia
 Polyphagia
 Fatigue
 Weight loss
 Most patients are discovered while
performing urine glucose screening
Clinical manifestations
 Complications
 Acute Complications
 Hypoglycemia
 Diabetic ketoacidosis
 Hyperosmolar hyperglycemic
nonketotic syndrome
 Complications
 Chronic Complications
 Macrovascular complications:
 Coronary heart disease, stroke and
peripheral vascular disease

 Microvascular Complications:
 Retinopathy, nephropathy and
neuropathy
 Tissue Damage in Many Organ Systems Leads to
Serious Long-term Complications in T2DM
Brain and Cerebral
Eyes
Circulation
(retinopathy, glaucoma,
cataracts) (stroke, TIA)

Heart and Coronary

Circulation
Kidneys (angina, MI, CHF)
(nephropathy, ESRD)

Peripheral Nervous
System
(peripheral neuropathy) Peripheral Vascular Tree
(peripheral vascular disease,
gangrene, amputation)

CHF=congestive heart failure; ESRD=end-stage renal disease; MI=myocardial infarction; TIA=transient ischemic attack; T2DM=type 2 diabetes mellitus
Adapted from International Diabetes Federation. Complications. Available at: www.eatlas.idf.org/complications Accessed February 17, 2009.
TREATMENT
 DM - management
 Goals of therapy:
 Reduce symptoms
 Promote well-being
 Prevent acute complications
 Delay onset and progression of
long-term complications
 Decrease mortality
 Maintain a good quality of life
 DM - management

 Lines of therapy:
 Non-pharmacological treatment
 Pharmacological treatment
Non Pharmacological

Lifestyle management is a fundamental

aspect of diabetes care and includes diabetes
self-management education and support
(DSMES), medical nutrition therapy (MNT),
physical activity, smoking cessation
counseling, and psychosocial care
 DSMES Delivery

Four critical time points for DSMES delivery:

1. At diagnosis
2. Annually for assessment of education, nutrition, and
emotional needs
3. When new complicating factors (health conditions,
physical limitations, emotional factors, or basic
living needs) arise that influence self-management;
and
4. When transitions in care occur
Lifestyle Management:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S38-S50
 Nutritional Therapy
 Overall goal of nutritional therapy
o Assist people to make changes in
nutrition and exercise habits that will
lead to improved metabolic control
 Nutritional Therapy
 Type 1 DM
o Diet based on usual food intake,
balanced with insulin and exercise
patterns
o In most cases, high carbohydrate, low
fat, and low cholesterol diet taken
 Type 2 DM
o Calorie reduction
 Nutritional Therapy
 Food composition
 Meal plan developed with dietitian
 Nutritionally balanced
 Does not prohibit the consumption of
any one type of food
 The Ideal or Paleolithic Diet

 50 -65% carbohydrate, complex carbohydrates

derived mainly from whole grains and legumes, low
glycaemic index

 0.6g/kg body weight proteins (15-20%) derived from

game animals or fish, insects

 15 -25% fat derived from vegetable and nut oils.

 High fiber 25 – 30g daily

Exercise

 Essential part of diabetes management

o Increases insulin sensitivity
o Lowers blood glucose levels
o Decreases insulin resistance
 Take small carbohydrate snacks during
exercise to prevent hypoglycemia
 Exercise after meals
 Monitor blood glucose levels before,
during, and after exercise
Pharmacological treatment
 Insulin (Type 1 and Type 2 DM)
 Sulfonylurea (Type 2 DM)
 Biguanides (Type 2 DM)
 Meglitinides (Type 2 DM)
 Thiazolidinediones Glitazones (Type 2 DM)
 α-Glucosidase inhibitors (Type 2 DM)
 Incretin mimetic (Type 2 DM)
 DPP4 inhibitors (Type 2 DM)
 Amylin analogs(Type 1 and Type 2 DM)
 SGLT2 Inhibitors(Type 2 DM)
 Antihyperglycemic Therapy in Adults with
T2DM

Pharmacologic Approaches to Glycemic Treatment:

Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S73-S85

Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018

 Antihyperglycemic Therapy in Adults
with T2DM

Pharmacologic Approaches to Glycemic Treatment:

Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S73-S85
 Combination Injectable Therapy in
T2DM

Pharmacologic Approaches to Glycemic Treatment:

Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S73-S85
 Summary of Glycemic Recommendations

Glycemic Targets:
Standards of Medical Care in Diabetes - 2018. Diabetes Care 2018; 41 (Suppl. 1): S55-S64
Summary
• T2DM is a metabolic disease characterized by
hyperglycemia, resulting from a combination of
resistance to insulin action and an inadequate
insulin secretory response
• Control and monitoring of complication acute and
chronic diabetes mellitus
• All people with type 2 diabetes  diabetes self-
management education and support (DSMES)
programs
• Increased physical activity improves glycemic
control and should be encouraged in all people with
type 2 diabetes
Summary
• Patients with type 2 diabetes who have
established atherosclerotic cardiovascular
disease (ASCVD)  (SGLT2) inhibitors or
(GLP-1) receptor agonists with proven
cardiovascular benefit are recommended
• Intensification of treatment to maintain
glycemic targets requires consideration of the
impact of medication side effects on
comorbidities, as well as the burden of
treatment and cost
Terima Kasih

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