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A. Immune mediated
B. Idiopathic
II. Type 2 diabetes* (may range from predominantly insulin resistance with
relative insulin deficiency to a predominantly secretory defect with insulin
resistance)
D. Endocrinopathies
E. Drug- or chemical-induced
F. Infections
Normal T1DM
β-Cells
(insulin)
• Autoimmune process/
α-Cells unknown origin
(glucagon) • β-cell amount is very
little/depleted
Normal T2DM
Amyloid
plaques
β-Cells
(insulin)
Fasting
10 glucose
250
Relative -cell
function (%)
MACROVASCULAR CHANGES
Clinical
features
MICROVASCULAR CHANGES
Years 10 5 0 5 10 15 20 25 30
Adapted from Rhodes CJ. Science. 2005;307:380-4.
KADAR TES LABORATORIUM DARAH UNTUK DIAGNOSIS
DIABETES DAN PREDIABETES
(Perkeni 2015)
Kriteria diagnosis DM
Muscle
Brain
Holst JJ, Ørskov C. Diabetes. 2004;53:S197-S204.
Lebovitz HE. Diabetes Rev. 1999;7:139-153.
Algoritme Pengelolaan DM Tipe 2 di Indonesia KONSENSUS PERKENI 2015
• Tiazolidindion
• Penghambat • Penghambat SGLT-2
• Penghambat SGLT-2
•
ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2012;35(suppl 1):S15.
SKRINING & Dx GDM
(ADA 2017)
PERKENI: Diabetes Prevention
Management
Periodic Blood
Pharmacology
Early Detection Lifestyle Changes Glucose & Risk Factor
Therapy
Monitoring
High-risk population at < • Medical Nutritional • Not yet • Hypertension
30-year old Therapy recommended
• Dyslipidemia
• Family history of DM • Physical activity
• Cardiovascular disorder • Physical health
• Overweight
• Weight reduction
• Sedentary life style
• Known IFG or IGT • Body weight control
• Hypertension • If overweight,
• Elevated triglyceride, low reduce body weight
HDL or both by 5-10%
• History of Gestational DM
• History of given birth • Physical exercise for
> 4000g
• PCOS
30 minutes,
5 times/week
• 2-hour OGTT is the most
sensitive method for early
detection and a
recommended screening test
procedure
Target of Treatment
Risk CVD (-) Risk CVD (+)
BMI (kg/m2) 18.5 – <23 18.5 – <23
Blood Glucose
• FPG (mg/dL) <100 <100
Lipid
Total Cholesterol (mg/dL) <200 <200
Current practice in the management of type 2 diabetes in Indonesia. Results from IDMPS. J Indon Med Assoc 2011
Percentage of Patients at LDL-C goals recommended
by the 2004 updated NCEP ATP III* guidelines
% of Patients at LDL-C goals recommended by 2004 updated NCEP ATP III* guidelines
• For patients in Hong Kong the treatment goal attainment rate was 82.9% while patients in other countries had
very low LDL-C attainment rate (31.3 – 52.7%).
• Cigarette smoking
• Hypertension (≥140/90 mm Hg or on
antihypertensive medication)
3.0
Risk of CHD
2.0
1.0
25
45
0.0 65
100 160 220 85
LDL-C (mg/dL)
Lowering Lipid Blood Level
Accounted for >70% of CV Risk Reduction in Diabetes
Risk Reduction in CVD Events
80 Steno-2 study
Percent of Total Calculated
60
Multifactorial therapy in type 2 DM , to achieve :
40 BP <130/80, HbA1c < 6.5%, total cholest < 175 mg/dL
20
0
Lipids HbA1c Blood Pressure
The most of the CV benefit was attributable to the use of lipid-lowering therapy
LDL 18-55% Myopati, peningkatan enzim Absolut : gangguan hati akut dan
HDL 5-15% hati krnois
STATIN
TG 7-30% Relatif : Penggunaan beberapa
obat tertentu
LDL 15-30% Gangguan gastrointestinal, Absolute: dysbetalipoproteinemia
BILE ACID HDL 3-5% konstipasi, penurunan TG > 400mg/dl
SEQUESTRANT TG no change absorbsi obat lain Relatif: TG > 200 mg/dl
Penurunan LDL-C ≥ 50% Penurunan LDL-C 30 – 50% Penurunan LDL-C < 30%
32
ACC/AHA Guidelines identify
4 statin benefit groups
Group 1 Group 2
Group 3 Group 4
• Documented CVD
Patients with clinical ASCVD
• DM (type 1 or 2) with one or
Very high more CV risk factors and/or
risk target organ damage
• Severe CKD
Patients with primary elevation of LDL-C of
• A calculated SCORE ≥10%. >190 mg/dL
Estimated 10-yr
Diabetes ; age 40-75
Clinical ASCVD LDL-C ≥190 mg/dL ASCVD risk ≥7.5%†;
years*
age 40-75 years*
• High-Intensity statin • High-intensity statin • Moderate-intensity • Moderate- to high-
(age ≤75 years) statin intensity statin
• Moderate-intensity
• Moderate-intensity statin if not a • High-intensity statin if
statin if >75 years or candidate for high- estimated 10 year
not a candidate for intensity statin ASCVD risk ≥7.5%
high-intensity statin
ASCVD prevention benefit of statin therapy may be less clear in other groups . Consider additional factors
influencing ASCVD risk , potential ASCVD risk benefits and adverse effects, drug-drug interactions, and patient
preferences for statin treatment.
Stone NJ, Robinson J, Lichtenstein AH et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: A report of
the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2014;129(suppl 2):S1-S45
Cardiovascular Risk Reduction:
Recommendations of ESC Guidelines
• Smoking
cessation Lifestyle modification
• Dietary
modification
• Weight Management of comorbid
management
• Physical activity
conditions
Lipid-lowering drugs
European Guidelines on cardiovascular disease prevention in clinical practice (version 2012). Eur Heart J. 2012;33:1635–1701
Summary
• Screening for risk factors for development of DM helps identify
patients early
• T1DM & T2DM can be distinguished by age onset, weight, and
progression of signs and symptoms
• Each have different underlying pathophysiology and thus require
different treatment and management strategies
• There are several different classes of anti-hyperglycemia
medications available
– Biguanides, SU, thiazolidinediones, alpha-glucosidase inhibitors,
DPP-IV inh. and GLP-1 receptor agonists, SGLT2-inh.
• Each class differs in their target site, pharmacology, efficacy and
safety profile
• Treatment algorithms aid in choosing which medication to use for
each patient
Summary: Cardiometabolic Risk