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Skrining pada individu berisiko dengan nilai-nilai glukosa dalam batas normal setiap
3 tahun
Pertimbangkan skrining tahunan untuk pasien dengan 2 atau lebih faktor risiko
3
How is diabetes screened and diagnosed?
Diagnostic Criteria for Prediabetes
and Diabetes in Nonpregnant Adults
prediabetes, which may manifest as either IFG or IGT, should be confirmed with
glucose testing.
Glucose criteria are preferred for the diagnosis of DM. In all cases, the diagnosis
should be confirmed on a separate day by repeating the glucose or A1C testing.
FPG,When A1C glucose;
fasting plasma is usedIFG,for diagnosis,
impaired follow-up
fasting glucose; glucose
IGT, impaired glucose testing should
tolerance; PG, plasma be done when
glucose.
possible to help manage DM.
4
Pilar penatalaksanaan DM
1. Edukasi
2. Terapi gizi medis
3. Latihan jasmani
4. Intervensi farmakologis
EDUKASI
Terapi Nutrisi Medis
Karbohidrat yang dianjurkan sebesar 45-65% total asupan
energi.
Sukrosa tidak boleh lebih dari 5% total asupan energi.
Asupan lemak dianjurkan sekitar 20-25% kebutuhan kalori.
Protein dibutuhkan sebesar 10 20% total asupan energi.
Pada pasien dengan nefropati perlu penurunan asupan
protein menjadi 0,8 g/Kg BB perhari atau 10% dari
kebutuhan energi
Anjuran asupan natrium untuk penyandang diabetes sama
dengan anjuran untuk masyarakat umum yaitu tidak lebih
dari 3000 mg atau sama dengan 6-7 gram (1 sendok teh)
garam dapur. Penderita hipertensi, pembatasan natrium
sampai 2400 mg garam dapur.
Anjuran konsumsi serat adalah 25 g/hari
kebutuhan kalori basal yang besarnya 25-30
kalori/kgBB ideal
Klasifikasi IMT*
BB Kurang < 18,5
BB Normal 18,5-22,9
BB Lebih 23,0
o Obes I 25,0-29,9
o Obes II > 30
Latihan Jasmani
How are glycemic targets achieved for T2D?
15
Rekomendasi Makan Sehat
Carbohydrat Tentukan karbohidrat sehat (buah-buahan segar dan sayuran, kacang-
e kacangan, biji-bijian); menargetkan 7-10 porsi per hari
Istimewa mengkonsumsi makanan rendah glikemik indeks (indeks
glikemik skor <55 dari 100: roti multigrain, pumpernickel roti, gandum
utuh, kacang-kacangan, apel, kacang, buncis, mangga, ubi jalar, beras
merah)
Fat Tentukan lemak sehat (merkuri rendah / kontaminan yang mengandung
kacang-kacangan, alpukat, minyak tumbuhan tertentu, ikan)
lemak jenuh batas (mentega, daging merah berlemak, minyak tumbuhan
tropis, makanan cepat) dan lemak trans; memilih produk susu bebas
lemak atau rendah lemak
Protein Mengkonsumsi protein dalam makanan dengan lemak rendah jenuh
(ikan, putih telur, kacang-kacangan); tidak ada kebutuhan untuk
menghindari protein hewani
Hindari atau membatasi daging olahan
Micronutrien suplementasi rutin tidak diperlukan; a menyehatkan rencana makan
ts makanan umumnya dapat memberikan mikronutrien yang cukup
Chromium; vanadium; magnesium; vitamin A, C, dan E; dan CoQ10 tidak
dianjurkan untuk kontrol glikemik
suplemen vitamin harus dianjurkan untuk pasien berisiko kekurangan
atau defisiensi
16
Algoritma pengelolaan DM tipe 2 tanpa disertai
dekompensasi
Algoritma pengelolaan DM tipe 2 tanpa disertai
dekompensasi (alternatif terutama untuk internist)
Noninsulin Agents Available for
T2D
Class Primary Mechanism of Action Agent(s)
-Glucosidase Menunda penyerapan Acarbose
inhibitors karbohidrat dari usus Miglitol
Decrease glucagon secretion
Amylin analogue Slow gastric emptying Pramlintide
Increase satiety
Decrease HGP
Biguanide Increase glucose uptake in Metformin
muscle
Bile acid Decrease HGP?
Colesevelam
sequestrant Increase incretin levels?
Increase glucose-dependent Alogliptin
Linagliptin
DPP-4 inhibitors insulin secretion
Saxagliptin
Decrease glucagon secretion Sitagliptin
Dopamine-2 Activates dopaminergic Bromocriptin
agonist receptors e
Nateglinide
Glinides Increase insulin secretion
Repaglinide
Canagliflozin
Increase urinary excretion of
SGLT2 inhibitors Dapagliflozin
glucose Empagliflozin
Glimepiride
Glipizide
Sulfonylureas Increase insulin secretion
Glyburide
GLP-1 = glucagon-like peptide; HGP = hepatic glucose production; SGLT2 = sodium glucose cotransporter 2.
Garber AJ, et al. Endocr Pract. 2013;19(suppl 2):1-48. Inzucchi SE, et al. Diabetes Care. 2012;35:1364-1379.
Continued from previous slide
23
Q4. How are glycemic targets achieved for T2D?
Effects of Agents Available
for T2D
SU/
Met GLP1RA SGLT2I DPP4I TZD AGI Coles BCR-QR Insulin Pram
Glinide
Mod to
marked
FPG SU: mod (basal
Mild to
lowerin Mod Mod Mild Mod Neutral Mild Neutral Glinide: insulin Mild
mod*
g mild or
premixe
d)
Mod to
marked
(short/
PPG rapid-
Mod to Mod to
lowerin Mild Mild Mod Mild Mod Mild Mild Mod acting
marked marked
g insulin
or
premixe
d)
AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibitors;
FPG = fasting plasma glucose; GLP1RA = glucagon-like peptide 1 receptor agonists; Met = metformin; Mod = moderate; PPG =
postprandial glucose; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU = sulfonylureas; TZD = thiazolidinediones.
*Mild: albiglutide and exenatide; moderate: dulaglutide, exenatide extended release, and liraglutide.
Continued on next slide
24
Q4. How are glycemic targets achieved for T2D?
Effects of Agents Available
for T2D
GLP1R SU/
Met SGLT2I DPP4I TZD AGI Coles BCR-QR Insulin Pram
A Glinide
NAFLD
Mild Mild Neutral Neutral Mod Neutral Neutral Neutral Neutral Neutral Neutral
benefit
SU: mod
to
Hypo- severe Mod to
Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral
glycemia Glinide: severe*
mild to
mod
Slight
Weight Loss Loss Neutral Gain Neutral Neutral Neutral Gain Gain Loss
loss
AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; DPP4I = dipeptidyl peptidase 4 inhibitors;
GLP1RA = glucagon-like peptide 1 receptor agonists; Met = metformin; Mod = moderate; NAFLD, nonalcoholic fatty liver disease; SGLT2I
= sodium-glucose cotransporter 2 inhibitors; SU = sulfonylureas; TZD = thiazolidinediones.
*Especially with short/ rapid-acting or premixed.
Continued from previous slide
25
Q4. How are glycemic targets achieved for T2D?
Effects of Agents Available
for T2D
GLP1R SU/
Met SGLT2I DPP4I TZD AGI Coles BCR-QR
Insulin Pram
A Glinide
Increase
Exenatid
Contra- Dose d risks
e May
indicate adjust- Increase of hypo-
Renal contra- GU worsen
d in ment d hypo- glycemi
impair- indicate infection fluid Neutral Neutral Neutral Neutral
stage (except glycemi a and
ment/ GU d CrCl risk retentio
3B, 4, 5 lina- a risk fluid
<30 n
CKD gliptin) retentio
mg/mL
n
GI adverse
Mod Mod* Neutral Neutral* Neutral Mod Mild Mod Neutral Neutral Mod
effects
CHF Neutral Neutral Neutral Neutral Mod Neutral Neutral Neutral Neutral Neutral Neutral
Possible
CVD Neutral Neutral Neutral Neutral Neutral Neutral Safe ? Neutral Neutral
benefit
Mod
Bone
Bone Neutral Neutral Neutral bone Neutral Neutral Neutral Neutral Neutral Neutral
loss
loss
AGI = -glucosidase inhibitors; BCR-QR = bromocriptine quick release; Coles = colesevelam; CHF = congestive heart failure; CVD =
cardiovascular disease; DPP4I = dipeptidyl peptidase 4 inhibitors; GI = gastrointestinal; GLP1RA = glucagon-like peptide 1 receptor
agonists; GU = genitourinary; Met = metformin; Mod = moderate; SGLT2I = sodium-glucose cotransporter 2 inhibitors; SU =
sulfonylureas; TZD = thiazolidinediones.
*Caution in labeling about pancreatitis.
<150 <150
> 50 >40
PENILAIAN HASIL TERAPI
ANAMNESIS
PEMERIKSAAN PENUNJANG, SEPERTI :
1. KADAR GLUKOSA DARAH
2. A1C (3 BULAN SEKALI)
How should glycemia in T1D be managed?
Insulin Regimens
Insulin is required for survival in T1D
Physiologic regimens using insulin
analogs should be used for most patients
33
How is diabetes managed in the hospital?
Glucose Screening and
Monitoring
Laboratory blood glucose testing on admission,
regardless of DM history
Known DM: assess A1C if not measured in past 3
months
No history of DM: assess A1C to identify undiagnosed
cases
Bedside glucose monitoring for duration of
hospital stay
Diagnosed DM
No DM but receiving therapy associated with
hyperglycemia
Corticosteroids
Enteral or parenteral nutrition
DM = diabetes mellitus.
34
How is diabetes managed in the hospital?
Inpatient Glucose Targets for
Nonpregnant Adults
Hospital Unit Treatment Goal
Intensive/critical care
Glucose range, mg/dL 140-180*
General medicine and surgery, non-ICU
Premeal glucose, mg/dL <140*
Random glucose, mg/dL <180*
*Provided target can be safely achieved.
9.5
9.0
13-26 years
8.5
1-13 years
8.0
7.5 26-50 years
50+ years
7.0
6.5
0-2 3-4 5-6 7-8 9- 11- 13
SMBG per day10 12
Endocrin-
Endocrin-
ologist
Mental ologist
health
Mental
care
health PCP
profes-
care PCP
sional
profes-
sional
Physician
Exercise Patien assistant
Physician
specialist
Exercise Patien
t
/ assistant
Nurse
practi-
/ Nurse
specialist
t tioner
practi-
tioner
Registere
Dietitian
dRegistere
nurse
Dietitian
d nurse
CDE
CDE
38
TERIMA KASIH