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Type 2 Diabetes
DIABETES BECOMES MORE & MORE
IMPORTANT AS A GLOBAL PROBLEM
DUE TO :
GLYCOGENOLYSIS
Insulin
G LYCOGEN
Glucose
uptake +
HGP
GLUCOSE G L UC O S E
GLUCONEO
GENESIS
MUSCLE
NORMAL
- = Suppression
+ = Stimulation
Regulasi glukosa darah
•Puasa
kebutuhan glukosa diperoleh:
produksi glukosa oleh hati (80%)
•Setelah makan
Glukosa darah ditekan oleh sel
beta pankreas : insulin
otot :meningkatkan glucose uptake
Pathophysiology of Type 2 Diabetes
Hyperglycemia
HYPERINSULINEMIA
ANGIOPATHY etc
NORMAL NGT
DECOMPENSATION - 1 IGT-DIABETES
DECOMPENSATION - 2 DIABETES
Primary defects in type 2 diabetes
Hyperglycaemia
1 Lebovitz HE. Diab Rev 1999; 7: 139-153. 2 Ward W, et al. Diab Care 1984; 7: 491-502. 3 Yki-Jarvinen H. Endocrine Revs 1992; 13: 415-431.
Normal Pancreatic Islets:
ß cells Glucagon cells
Islets in Type II Diabetes:
Loss of ß cells
Amyloid deposits
Hyalinization
Patogenesis DM tipe 2
• DM defek berupa :
1. Defisiensi insulin (hiperglikemia post prandial)
2. Resistensi insulin (hiperglikemia puasa)
• Pemahaman patogenesis
memudahkan pendekatan terapi.
DM tipe 2 Multifaktor
Sekresi insulin terganggu
Kegagalan Sel beta
Deposisi amiloid
Obat2 & hormon yang abnormal
Malnutrisi in utero and early childhood
Mutasi glukokinase
Mutasi insulin
Mutasi mitokondria DNA
Resistensi insulin
DM tipe 2 Multifaktor
Resistensi insulin
Insulin signalling
Obesitas dan diet
Penyakit Endokrin
Kehamilan
Obat-obat
Malnutrisi in utero and early childhood
Mutasi (jarang)
Reseptor insulin
Komponen Post reseptor
Defek Sekresi Insulin
Physiology of insulin secretion
Ca++
S
Voltage-dependent
ATP-sensitive U
R Depolarization Ca2+ channel
K+ channel
Ca2+
↑ ATP/ADP
Islet
transcription
Mitochondria
factors
Insulin
Pyruvate
Glucose-6-Phosphate Nucleus
Glucokinase Secretory
granules
Glucose
GlucoseGLUT2
Biphasic Insulin Response to Constant
Glucose stimulus
Stimulation by glucose
Level of insulin secretion
First(acute)
Phase on
release
Second
Phase
Baseline
Time
Diabetes Care 1984;7:491-502
Loss of Early- phase Insulin Secretion
in Type 2 Diabetes
120
Definisi :
Resistensi
Insulin
Glukosa darah
puasa
Sekresi
Insulin
-cell Failure
Insulin
Concentration
Insulin
Resistance
Euglycaemia
Normal IGT ± Obesity Diagnosis of Progression of
type 2 diabetes type 2 diabetes
DeFronzo et al. Diabetes Care 1992;15:318-68
Pada kondisi resistensi insulin, insulin tidak
mampu menggerakkan jumlah GLUT 4 yang cukup
ke permukaan sel
Environmental factors Environmental factors
•Overeating Genetic factors Genetic factors •Pregnancy
•Inactivity •Endocrine diseases
•Smoking Unknown Unknown
•Diabetogenic drugs
•Diabetogenic drugs •Malnutrition in utero
Glucose toxicity
Hyperglycaemia
NIDDM
KOMPLIKASI KRONIK DM
Complications:
• Short term Complications: (metabolic)
– Hypoglycemia
– Diabetic Ketoacidosis
– Non Ketotic hyperosmolar diabetic coma
– Lactic acidosis
• Long term Complications:(microangiopathy)
– Angiopathy, Retinopathy, Nephropathy,
Neurophathy
Chronic Complications: Angiopathy
4 Kelainan lemak
4 Merokok
Resistensi insulin
BAGAIMANA TERJADINYA KOMPLIKASI
PADA PEMBULUH DARAH BESAR
4 Perlukaan endotel
Terjadinya plak
aterosklerosis
Diabetic
Neuropathy
• Sensory Motor (myelin)
• Peripheral Neuropathy
– Bilateral, symmetric
– Progressive, irreversible
– Paraesthesia, pain, muscle atrophy
• Visceral neuropathy
– Cranial nerve – diplopia, Bell palsy
– GIT- constipation, diarrhoea
– CVS – orthostatic hypotension
KLASIFIKASI NEUROPATI DIABETIK
1. NEUROPATI FOKAL
Mononeuropati - neuropati kranial - radikulopati/pleksopati
Entrapment syndrome - carpal tunnel syndrome
- ulnar nerve entrapment - peroneal neuropathy
2. NEUROPATI DIFUS
Neuropati motorik proksimal
Polineuropati simetrik distal
3. NEUROPATI OTONOMIK
Sistem kardiovaskuler
Sistem pencernaan
Sistem perkencingan
Sudomotor kaki tidak berkeringat
NEUROPATI DIABETIK
Chronic Polyneuropathy
Claw foot – Dermopathy & Neuropathy
Diabetic Amyotrophy
Painful muscle wasting
Neuropathic ulcer
Callus formation
Nephropathy
• Most common cause of morbidity
& mortality.
• Deposition of ‘AGE’ Advanced
Glycosylation Endproducts as
nodules.
• Nephrotic syndrome
• Pyelonephritis
• End stage renal failure
Diabetic Glomerulosclerosis
Hyaline nodules
Diabetic Glomerulosclerosis
PERKEMBANGAN NORMO-MAKROALBUMINURIA
10 30 300
Mg/hari
Proteinuria
500 mg/hari
Mikroalbuminuria 30-300 mg/h atau
rasio albumin:kreatinin urin = 2 – 25 mg/mmol pada laki-laki
3 – 30 mg/mmol pada wanita
DERAJAT NEFROPATI DIABETIK
Derajat 3 : Mikroalbuminuria
DMT2 saat diagnosis terjadi pada 18%, DMT1 6,4%
Fungsi ginjal mulai turun
FBG FBG
>126 <126 >126 110 - <126 <110
or or
2h pp >200 <200 2h pp >200
140-199
Repeat FBG or 2h pp
OGTT
FBG 2h pp
>126 <126
or
2h pp >200 <200
Diabetes Diabetes
Mellitus Mellitus
126 mg/dL 200 mg/dL
IFG IGT
110 mg/dL 140 mg/dL
Normal Normal
55
Targets for Glycemic Control
ADA1 IDF2 ACE3
58
Management Plan
• Statement of short- and long-term goals
• Medication (insulin OHA, antihypertensive,
lipid-lowering agents, aspirin therapy, and others
• Individualized nutrition recommendation
• Recommendations for appropriate lifestyle
changes
• Patient and family education
59
Laboratory Tests
• Fasting plasma glucose, 2 hPP, HbA1C
• Fasting lipid profile – total-C (total
cholesterol), HDL-C, LDL-C, TG
(triglycerides)
• Serum creatinine (if proteinuria present)
• Urinalysis – glucose, ketones, protein,
sediment
• Test for microalbuminuria
• ECG
60
ADA/EASD Consensus Algorithm
Lifestyle +
Metformin Lifestyle + Metformin
Tier 2: + Pioglitazone +
Less well validated No hypoglycaemia
therapies Oedema/CHF
Bone loss
Lifestyle +
metformin Lifestyle + metformin
+ GLP-1 agonist +
No hypoglycaemia
Weight loss
Nausea/vomiting
Nathan DM, et al. Diabetes Care 2009;32 193-203.
HbA1c reflects
FPG and mealtime glucose spikes
200 Mealtime
glucose
spikes
Fasting
100 hyperglycemia
Normal
0
6 am 12 pm 6 pm 12 pm 6 am
Time of day
Riddle MC. Diabetes Care 1990;13:676–686.
BERDASARKAN TARGETNYA TERAPI DM DAPAT
DIGOLONGKAN MENJADI
4 5
INTESTINE
a-glucosidase inhibitors
GLUCOSE
PRODUCTION PERIPHERAL GLUCOSE
UPTAKE & UTILIZATION
LIVER
Glucose
MUSCLE
Biguanides
Thiazolidinediones
ADIPOSE TISSUE
Thiazolidinediones
INSULIN SECRETION Biguanides
Sulphonylureas
Meglitinides
ref version 2.1 PANCREAS Modified: Ann Intern Med 1999;131:281
ANTI DIABETES
LAMA : BARU
1. Sulfonilurea 1. meglitinid
– klorpropamid 2. Golongan thiazolidinedione
– glibenklamid 3.GLP-1 inhibitor
– glipisid 4.DPP IV Inhibitor
– glikasid 5. Amylin analogues
– glimepirid 6. Inlacin
– glikuidon
2. Metformin
3. α glukosidase inhibitor
4. Insulin
Sulfonilurea :
1. DMTTI :
– OBEIS
– GAGAL MONOTERAPI
– DISERTAI DISLIPIDEMIA, HIPERINSULINEMIA
• Made in Indonesia
• Memperbaiki resistensi insulin
• Menginduksi ekspresi gen PPAR y pada tingkat mRNA
• Meningkatkan expresi GLUT 4
Summary of glucose-lowering interventions
Intervention dec A1C Advantages Disadvantages
Tier 1: well-validated core
Step 1: initial therapy
Lifestyle to
decrease weight Insufficient for most
1.0-2.0 Broad benefits
and increase within first year
activity
GI side effects,
Metformin 1.0-2.0 Weight neutral contraindicated with
renal insufficiency
Step 2: additional therapy
One to four injections
No dose limit, rapidly
daily, monitoring, weight
Insulin 1.5-3.5 effective,
gain, hypoglycemia,
improved lipid profile
analogues are expensive
Weight gain,
Sulfonylurea 1.0-2.0 Rapidly effective hypoglycemia ( gliben-
clamide chlorpropamide)
Tier 2: less well validated
Improved lipid profile Fluid retention, HF, weight gain,
(pioglitazone), bone fractures, expensive,
TZDs 0.5-1.4
potential decrease in potential increase in MI
MI (pioglitazone) (rosiglitazone)
Two injections daily, frequent
GLP-1 agonist 0.5-1.0 Weight loss GI side effects, long-term safety
not established, expensive
Other therapy
α-Glucosidase Frequent GI side effects, three
0.5-0.8 Weight neutral
inhibitor times/day dosing, expensive
Weight gain, three times/day
Glinide 0.5-1.5* Rapidly effective dosing, hypoglycemia,
expensive
Three injections daily, frequent
Pramlintide 0.5-1.0 Weight loss GI side effects, long-term safety
not established, expensive
TERAPI GIZI MEDIK
• Pengkajian
• Penentuan Tujuan
• Intervensi
• Evaluasi
FOKUS
• Gaya hidup
• Pengendalian
Glukosa darah
Dislipidemia
Tekanan darah
Berat Badan
REKOMENDASI GIZI DIABETES
(PERKENI 2006)
• Karbohidrat : 45-65 %
Sukrose : < 5%
Serat : 25 g (/1000 kal)
Pemanis : Sesuai ADI
• Total lemak : 20-25%
As. Lemak jenuh : < 7 %
PUFA : < 10 %
MUFA : selebihnya
Lemak trans sesedikit mungkin
• Kolesterol : < 200-300 mg
• Protein : 10 -20 %
• Alkohol : < 30 g (L), < 15 g (W) (ADA)
KARBOHIDRAT
• Mempengaruhi respon glikemik
- Jumlah KH
- Index glikemik
- Glikemik load
- Mengenyangkan / tidak
- Tipe Gula
- Sifat Tepung
- Pemasakan
- Bentuk makanan
- Bahan yang memperlambat pencernaan
- Jenis Karbohidrat : Kompleks/sederhana
- Tidak dianjurkan kurang dari 130 g per hari
FAKTOR-FAKTOR YG MENENTUKAN
KEBUTUHAN KALORI
1. Jenis Kelamin
2. Umur
3. Aktivitas fisik
4. Kehamilan / lakatasi
5. Komplikasi
6. Tinggi dan berat badan
PERHITUNGAN BERAT BADAN
RUMUS BROCCA IMT
Bb lebih 10 %
Bb gemuk 20 %
Bb kuran 30 %
• C : continuous
• R : rhytmical
• I : interval
• P : progressive
• E : endurance
Physical Activity
z Benefits: