Penatalaksanaan Terkini Diabetes Mellitus

Penatalaksanaan Terkini Diabetes Mellitus

Dr. Nanang Miftah F, SpPD

Diabetes MellitusSuatu penyakit metabolik yang ditandai oleh hiperglikemia (Gula darah tinggi) akibat :gangguan pada sekresi insulin, kerja insulin tidak optimalatau keduanya.American Diabetes Association, 2010

Diabeinein = pancuran air, Mellitus = Rasa Manis Kencing Manis

Faktor Resiko Diabetes Mellitus Umur > 45 tahunObesityPhysical inactivity First -degree relative with diabetesWanita yang melahirkan bayi 4 kg atau terdiagnosa gestasional DMHypertensi (Tekanan Darah 140/90mmHg)Dyslipidemia ( TG> 250, HDL < 35mg/dL)IFG (impaired fasting glucose) or IGT (impaired glucose tolerance) on previous testingRiwayat coronary heart diseaseRiwayat polycystic ovarial syndrome (PCOS)

Diabetes care 32,suppl1,2009Faktor risiko DM menurut Perkeni 2006 dan ADA ,200934Indonesian Diabetes Prevalence (Guestimate for 2003 / 2005)- BPS& CIATahun20032030BPS Rural Urban of DM patients 5,548,869 8,248.601 13,797,470 8,076,613 12,006,186 20,082,799CIA facts book Rural Urban of DM patients 6,379,735 * 9,432,108 * 15,881,843 9,031,326 13,352,348 22,383,674* 2006 Total population BPS = 214 juta (est.) & Total population 20 years = 133 juta ; urban = 56 juta , rural = 77 juta Total population CIA = 245 juta (est.) & Total population 20 years = 152juta ; urban = 64 juta, rural = 88 juta

Kriteria Diagnosis DMNormalPrediabetes DMIFGIGTFPG (mg/dL)< 100100-125 1262-h PG (mg/dL)< 140< 140140-199*> 200FPG : Fasting Plasma Glucose2-h PG : 2- hour Plasma Glucose IFG : Impaired Fasting GlucoseIGT : Impaired Glucose ToleranceOGTT : Oral Glucose Tolerance Test* OGTT : post load 75 gADA Diabetes.org diabetes basics

Kriteria Diagnosis Diabetes MellitusClassification of Diabetes Type 1Type 2Other specific type of diabetes due to other causesGestational Cells destruction absolute insulin deficiencyProgressive insulin secretory defect on background of insulin resistanceGenetic defect on cell functionGenetic defects in insulin actionDisease of the exocrine pancreasDrug or chemical induced diabetesDiabetes diagnosed during pregnancyPatogenesa DM Tipe2InsulinresistanceGenetic susceptibility,obesity, Western lifestyleType 2 diabetes

IR

b-celldysfunctionRhodes CJ & White MF. Eur J Clin Invest 2002; 32 (Suppl. 3):313.8A number of factors, both genetic and environmental, influence the development of insulin resistance and -cell dysfunction. In addition to the risk posed by inherited factors, a Western lifestyle (i.e. sedentary lifestyle, high-fat diet) can contribute to obesity, a strong risk factor for insulin resistance. Insulin resistance at the tissue level contributes significantly to hyperglycemia and is due primarily to abnormalities in the way that the effects of insulin are carried from the receptor on the cells surface to intracellular proteins that regulate glucose transport. The consequences of insulin resistance include reduced glucose uptake into fat and muscle, and increased glucose production by the liver.1-cell dysfunction is characterized by a reduced ability to respond to raised glucose levels leading to reduced insulin secretion, which in turn results in chronic hyperglycemia.Together, these two factors often lead to the development of type 2 diabetes, and so are key targets for therapeutic intervention.1Rhodes CJ & White MF. Eur J Clin Invest 2002; 32 (Suppl. 3):313.

9Before the manifestation of the metabolic defects that lead to type 2 diabetes, fasting and postprandial insulin levels are similar and constant. In the majority of patients in whom type 2 diabetes develops, increasing insulin resistance leads to compensatory increases in circulating insulin, which prevents an increase in glucose levels.As time progresses, the insulin resistance reaches a peak and stabilizes, while the compensatory increase in insulin continues to prevent fasting glucose levels from becoming abnormal. However, at some point, either because of early beta-cell dysfunction or because of a natural limit of beta-cell capacity, challenge of this delicate balance with a glucose load may demonstrate that, although fasting glucose levels remain normal, postprandial glucose levels become abnormal as a limitation in insulin response is reached. Following the onset of beta-cell dysfunction, insulin levels can no longer keep up in overcoming the insulin resistance, and fasting and postprandial glucose levels increase progressively over time.

Goldstein BJ. Am J Cardiol. 2002;90(suppl):3G-10G.Bergenstal RM, et al. In: DeGroot LJ, Jameson JL, eds. Endocrinology. Vol 1, 4th ed. 2001:821-835.

10Patients with type 2 diabetes are at high risk for atherosclerosis and other cardiovascular disease (CVD). Insulin resistance is related to the elevated risk of CVD. Evidence suggests that hyperglycemia may contribute to endothelial dysfunction and ultimately lead to accelerated atherogenesis. Many individuals with type 2 diabetes are not diagnosed until they have experienced a cardiovascular event. People with impaired glucose tolerance orIGT (considered prediabetes) who do not have chronic hyperglycemia have a twofold increase in the risk of coronary artery disease (CAD) compared with normal subjects. Patients with type 2 diabetes have a threefold increased risk of CAD. In an effort to decrease the high level of morbidity and mortality associated withtype 2 diabetes and to facilitate early diagnosis, the American DiabetesAssociation (ADA) guidelines now include a lower fasting plasma glucose (FPG) level for diagnosis of diabetes: >=126 mg/dL, reduced from the previous level of 140 mg/dL. The ADA also recently reduced the cutpoint for impaired fastingglucose (IFG) to 100 mg/dL, and redefined IFG as an FPG of 100 to 125 mg/dL.

American Diabetes Association. Diabetes Care. 2003;26:3160-3167.Tsao PS, et al. Arterioscler Thromb Vasc Biol. 1998;18:947-953.Hsueh WA, et al. Am J Med. 1998;105(1A):4S-14S.American Diabetes Association. Diabetes Care. 1998;21:310-314.Management of Type 2 DM1. Life Style Modification :DiitExcercise2. Blood Glucose ControleOral Anti DiabeticInsulinBoth3. Prevent Complication4. Eliminate ComplicationAnti HypertensionAnti lipidemia agent

Terapi non Farmakologis Pada DM Tipe 2Langkah Perencanaan Untuk Diit Composition Calculate Daily Calorie IntakeCarbohydrate Counting

13Macronutrien RecommendationCategoryRecommendationCH (% of energy)4 kcal/gram45-65% total energy, simple CH