DIABETES MELLITUS

Dr. Nur Samsu, SpPD-KGH Division of Nephrology and Hypertension

DIABETES MELLITUS
Sekelompok gangguan metabolik kronik, ditandai oleh hiperglikemia yang berhubungan dengan abnormalitas metabolisme karbohidrat, lemak,

protein, disebabkan oleh defek sekresi insulin,

sensitivitas insulin atau keduanya dan mengakibatkan terjadinya komplikasi kronis termasuk mikrovaskular, makrovaskular dan neuropati
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BATASAN DIABETES MELLITUS

GDA 200 mg/dl 2. GDP 126 mg/dl 3. GD 200 mg/dl sesudah TTGO
1.

Gejala DM: poliuri, polidipsi, polifagi dan penurunan berat badan tanpa sebab yang jelas
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Klasifikasi Diabetes Mellitus

- DM tipe I : defisiensi insulin absolut - DM tipe II : resistensi insulin dan atau defek sekresi insulin - DM tipe lain : - penyakit dari pankreas eksokrin (al.pankreatitis)

- endokrinopati (al. acromegaly, cushing syndrome)

- induksi obat atau zat kimia dan lain2

- DM Gestasional
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Type I Diabetes
Low or absent endogenous insulin Dependent on exogenous insulin for life Onset generally < 30 years 5-10% of cases of diabetes Onset sudden

Symptoms: 3 Ps: polyuria, polydypsia, polyphagia

Type II Diabetes

Insulin levels may be normal, elevated or depressed

Characterized by insulin resistance, diminished tissue sensitivity to insulin, and impaired beta cell function (delayed or inadequate insulin release)

Often occurs >40 years

Type II Diabetes
Risk factors: family history, sedentary lifestyle, obesity and aging Type 2 diabetes has a stronger genetic basis than type 1 Controlled by weight loss, oral hypoglycemic agents and or insulin

Efek Fisiologik Insulin

- LIVER : ambilan glukosa sintesis glikogen lipogenesis - OTOT : ambilan glukosa

sintesis glikogen
ambilan asam amino sintesis protein

- JARINGAN : ambilan glukosa

sintesis lipid ambilan trigliserida
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Komplikasi Akut
Diabetes Mellitus

HIPOGLIKEMIA HIPERGLIKEMIAHIPEROSMOLAR

KETOASIDOSIS

HIPERTENSI

RETINOPATI

INFARK JANTUNG

GANGREEN

KOMPLIKASI KRONIK DM

STROKE

INFEKSI

NEFROPATI

NEUROPATI
OTONOM PERIFER
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DATA LABORATORIUM
-Glukosa darah -HbA1C -Peptida C -Elektrolit -Profil lipid -Complete Blood Cell -Fungsi ginjal -Urinalisis
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TERAPI DIABETES MELLITUS NON OBAT a. latihan/excersise b. diet e. restriksi alkohol/rokok

OBAT Insulin ultrashort acting short acting intermediate acting long acting pre-mixed

Oral Anti Diabet - sulfonil urea - glinid - biguanid alfa glukosidase inhibitor
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Algorithm for Type 2 Diabetes Mellitus

Nonpharmacological therapy Diet,Exercise Glycemic goals not achieved Preprandial glucose > 140 mg/dL Bedtime glucose > 160 mg/dL HbA > 8 % Monotherapy Sulfonylurea, metformin Troglitazone, or acarbose, Insulin may be considered

Glycemic goals not achieved

Combination therapy Sulfonylurea + metformin Sulfonylurea + troglitazone Glycemic goals not achieved Insulin Intermediate BID or > 3 injections or Continous insulin infusion pump

Alternative

Alternative

FPG > 250 mg/dL

Sulfonylurea + insulin (BIDS)

Postprandial hyperglycemia
Sulfonylurea+ acarbose
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Terapi - Diabetes Mellitus

Tujuan Terapi
- Pengendalian kadar glukosa darah sepanjang hari pada rentang acceptable
- Menghindarkan gejala DM -Meminimalkan dan mencegah komplikasi

-Menghindarkan hipoglikemia-

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Management of Diabetes Mellitus

Nutrition

Blood

glucose Medications Physical activity/exercise Behavior modification

Medical Nutrition Therapy

Primary
Blood

Goal improve metabolic control

glucose Lipid (cholesterol) levels

Medical Nutrition Therapy

Maintain short and long term body weight Reach and maintain normal growth and development Prevent or treat complications Improve and maintain nutritional status Provide optimal nutrition for pregnancy

Nutrition Recommendations

Carbohydrate

60-70% calories from carbohydrates and monounsaturated fats 10-20% total calories

Protein

Nutrition Recommendations

Fat
<10% calories from saturated fat 10% calories from PUFA <300 mg cholesterol

Fiber

20-35 grams/day

Alcohol
Type I limit to 2 drinks/day, with meals Type II substitute for fat calories

Nutritional Management for Type I Diabetes

Consistency

and timing of meals Timing of insulin Monitor blood glucose regularly

Nutritional Management for Type II Diabetes

Weight loss Smaller meals and snacks Physical activity Monitor blood glucose and medications

Goals Of Therapy
Parameter Preprandial plasma glucose (mg/dl) Postprandial plasma glucose (mg/dl) Hemoglobin A1C
ADA - American Diabetes Association ACE - American College of Endocrinology AACE-American Association of Endocrinologist

ADA

ACE dan AACE

90-130

110

<180

<140

<7

<6,5
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Diabetes Oral Medications

6 Classes :

Sulfonylureas Biguanides Sulfonylureas and biguanide combination drugs Thiazolidinediones Alpha-glycosidase inhibitors Meglitinides

Sulfonylureas : stimulate cells to

produce more insulin

1st generation
bind to protein

(1)Orinase

(tolbutamide) Currently > 12,000 (3)Tolinase (tolazamide) (6)Diabinese (chlorpropamide)

may become dislodged delayed activity

Rel. Potency

2nd generation
(75)Glucotrol

(glipizide) (150)Glucotrol XL (ex. rel. glipizide) (150)Micronase, Diabeta (glyburide) (250)Glynase (micronized glyburide)

3rd generation
(350)Amaryl

(glimepiride)

Types of insulin

Regular insulins Insulin analogs Pre-mixed insulin

Short peptide mimics

Regular insulins:

Human insulin: Humulin (from E.coli), Novalin (from yeast) NPH - neutral protamine Hagedorn (NPH), protamine mixed. Lente insulin / Ultralente insullinzinc added

Types of insulin

Regular insulins Insulin analogs Pre-mixed insulin

Short peptide mimics

Insulin Analogs:

Fatty Acid Acylated insulins Insulin Lispro (Humalog) (1996)

Insulin Aspart (NovoLog) (2000) Insulin Glargine (Lantus) (2002)

Insulin Detemir (Levemir) (Jun.,2005)

Insulin Glulisine (Apidra) (Jan., 2006)