standar pengobatan dm
TRANSCRIPT
-
7/25/2019 Standar Pengobatan Dm
1/69
Standards of Medical Care in Diabetes2006
AMERICAN DIABETES ASSOCIATION
CONTENTS
I. CLASSIFICATIONANDDIAGNOSIS,
p. S4A. Classification
B. DiagnosisII. SCREENING FOR DIABETES,
p. S5
III. DETECTION AND DIAGNOSIS
OF GESTATIONAL DIABETES
MELLITS, p. S!
I". #RE"ENTION$DELA% OF T%#E &
DIABETES, p. S!
". DIABETES CARE, p. S'
A. Initial ()al*ation
B. Manag(+(nt
C. Glc(+ic cont-ol
. Ass(ss+(nt of glc(+iccont-ol
a. S(lf/+onito-ing of
0loo1 gl*cos(
0. AC&. Glc(+ic goals
D. M(1ical n*t-ition t2(-ap
E. Dia0(t(s s(lf/+anag(+(nt (1*cation
F. #2sical acti)it
G. #sc2osocial ass(ss+(nt an1 ca-(
3. R(f(--al fo- 1ia0(t(s +anag(+(nt
I. Int(-c*--(nt illn(ss
. 3poglc(+ia. I++*ni6ation
"I. #RE"ENTION AND MANAGEMENT
OF DIABETES COM#LICATIONS,
p. S!
A. Ca-1io)asc*la- 1is(as(
. 3p(-t(nsion$0loo1 p-(ss*-(cont-ol
&. Dslipi1(+ia$lipi1 +anag(+(nt
7. Antiplat(l(t ag(nts
4. S+o8ing c(ssation5. Co-ona- 2(a-t 1is(as( sc-((ning
an1 t-(at+(ntB. N(p2-opat2 sc-((ning an1
t-(at+(nt
C. R(tinopat2 sc-((ning an1
t-(at+(nt
D. N(*-opat2 sc-((ning an1
t-(at+(nt
E. Foot ca-(
"II. DIABETES CARE IN S#ECIFIC
#O#LATIONS, p. S&9
A. C2il1-(n an1 a1ol(sc(nts
B. #-(conc(ption ca-(
C. Ol1(- in1i)i1*als
"III. DIABETES CARE IN S#ECIFICSETTINGS, p. S&:
A. Dia0(t(s ca-( in t2( 2ospitalB. Dia0(t(s ca-( in t2( sc2ool an1
1a ca-( s(tting
C. Dia0(t(s ca-( at 1ia0(t(s ca+ps
D. Dia0(t(s +anag(+(nt in co--(ctional
instit*tions
I;. 3%#OGL%CEMIA AND EM#LO%MENT$
LICENSRE, p. S74
;. T3IRD/#ART% REIMBRSEMENT
FOR DIABETES CARE, SELFMANAGEMENT
EDCATION,
AND S##LIES, p. S74
;I. STRATEGIES FOR IM#RO"INGDIABETES CARE, p. S74
Dia0(t(s is a c2-onic illn(ss t2at -(it2 1ia0(t(s.
A g-a1ing sst(+ Ta0l( , 1()(lop(1 0
t2( A+(-ican Dia0(t(s Association ADA
-
7/25/2019 Standar Pengobatan Dm
2/69
an1 +o1(l(1 aft(- (=isting +(t2o1s, >as
*tili6(1 to cla-if an1 co1if t2( ()i1(nc(
t2at fo-+s t2( 0asis fo- t2( -(co++(n1ations.
T2( l()(l of ()i1(nc( t2at s*ppo-ts
(ac2 -(co++(n1ation is list(1 aft(- (ac2-(co++(n1ation *sing t2( l(tt(-s A, B, C,
o- E.I. CASSI!ICATION AND
DIA"NOSIS
A. Classification
In ::!, t2( ADA iss*(1 n(> 1iagnostic
an1 classification c-it(-ia 4 in &7,
+o1ifications >(-( +a1( -(ga-1ing t2(
1iagnosis of i+pai-(1 fasting gl*cos(
IFG 5. T2( classification of 1ia0(t(s
incl*1(s fo*- clinical class(s
Tp( 1ia0(t(s -(s*lts f-o+ /c(ll 1(st-*ction,
*s*all l(a1ing to a0sol*t(
ins*lin 1(fici(nc. Tp( & 1ia0(t(s -(s*lts f-o+ a p-og-(ssi)(
ins*lin s(c-(to- 1(f(ct on t2(
0ac8g-o*n1 of ins*lin -(sistanc(.
Ot2(- sp(cific tp(s of 1ia0(t(s 1*( toot2(- ca*s(s, (.g., g(n(tic 1(f(cts in
O-iginall app-o)(1 :''. Most -(c(nt
-()i(>$-()ision, Octo0(- &5.
Abbre#iations$ ABI, an8l(/0-ac2ial in1(= AMI,
ac*t( +ocat1ial infa-ction ARB, angiot(nsin-(c(pto- 0loc8(-
CAD, co-ona- a-t(- 1is(as( CBG, capilla-
0loo1 gl*cos( C3D, co-ona- 2(a-t 1is(as( C3F,
cong(sti)(
2(a-t fail*-( CD, c2-onic 8i1n( 1is(as( C"D,
ca-1io)asc*la- 1is(as( DCCB, 1i21-op-i1in(calci*+ c2ann(l
0loc8(- DCCT, Dia0(t(s Cont-ol an1
Co+plications T-ial DA, 1ia0(tic 8(toaci1osis
DMM#, 1ia0(t(s +(1ical+anag(+(nt plan D#N, 1istal s++(t-ic
poln(*-opat2 D##, Dia0(t(s #-()(ntion#-og-a+ DRI, 1i(ta-
-(f(-(nc( inta8( DRS, Dia0(tic R(tinopat2
St*1 DSME, 1ia0(t(s s(lf/+anag(+(nt
(1*cation DSMT, 1ia0(t(s
s(lf/+anag(+(nt t-aining ECG,
(l(ct-oca-1iog-a+ ESRD, (n1/stag( -(nal 1is(as(
ETDRS, Ea-l T-(at+(nt
Dia0(tic R(tinopat2 St*1 FDA, Foo1 an1 D-*g
A1+inist-ation F#G, fasting plas+a gl*cos(
GDM, g(stational
1ia0(t(s +(llit*s GFR, glo+(-*la- filt-ation -at(
3RC, 2ig2/-is8 c2a-act(-istic IC, int(nsi)( ca-(*nit IFG,
i+pai-(1 fasting gl*cos( IGT, i+pai-(1 gl*cos(tol(-anc( MNT, +(1ical n*t-ition t2(-ap N#DR,
nonp-olif(-ati)(
1ia0(tic -(tinopat2 OGTT, o-al gl*cos( tol(-anc(
t(st #AD, p(-ip2(-al a-t(-ial 1is(as( #DR,
p-olif(-ati)(
1ia0(tic -(tinopat2 ##G, postp-an1ial plas+a
gl*cos( RDA, -(co++(n1(1 1i(ta- allo>anc(
SMBG, s(lf+onito-ing
of 0loo1 gl*cos( THD, t2ia6oli1in(1ion(
#DS, .. #-osp(cti)( Dia0(t(s St*1.
&9 0 t2( A+(-ican Dia0(t(s Association.
% O S I T I O N S T A T E M E N TS4 DIABETES CARE, "OLME &:,
S##LEMENT , ANAR% &9
/c(ll f*nction, g(n(tic 1(f(cts in ins*lin
action, 1is(as(s of t2( (=oc-in( panc-(ass*c2 as cstic fi0-osis, an1 1-*g
o- c2(+ical in1*c(1 s*c2 as in t2(
t-(at+(nt of AIDS o- aft(- o-gan t-ansplantation.
G(stational 1ia0(t(s +(llit*s GDM
1iagnos(1 1*-ing p-(gnanc.
B. Diagnosis
R(co++(n1ations
T2( F#G is t2( p-(f(--(1 t(st to 1iagnos(1ia0(t(s in c2il1-(n an1 nonp-(gnant
a1*lts. E
T2( *s( of t2( AC fo- t2( 1iagnosis of
1ia0(t(s is not -(co++(n1(1 at t2is
ti+(. E
C-it(-ia fo- t2( 1iagnosis of 1ia0(t(s innonp-(gnant a1*lts a-( s2o>n in Ta0l( &.
T2-(( >as to 1iagnos( 1ia0(t(s a-( a)aila0l(,
an1 (ac2 +*st 0( confi-+(1 on a
s*0s(
-
7/25/2019 Standar Pengobatan Dm
3/69
p(opl( >2o +((t 1iagnostic c-it(-ia fo-
1ia0(t(s 0 OGTT, 0*t not 0 F#G, >ill
2a)( an AC )al*(!.K. T2( *s( of t2(
AC fo- t2( 1iagnosis of 1ia0(t(s is not
-(co++(n1(1 at t2is ti+(.3p(-glc(+ia not s*ffici(nt to +((t
t2( 1iagnostic c-it(-ia fo- 1ia0(t(s is cat(go-i6(1as (it2(- IFG o- i+pai-(1 gl*cos(
tol(-anc( IGT, 1(p(n1ing on >2(t2(- it
is i1(ntifi(1 t2-o*g2 a F#G o- an OGTT
IFG F#G +g$1l 5.9 ++ol$l to
&5 +g$1l 9.: ++ol$l
IGT &/2 plas+a gl*cos( 4 +g$1l
!.' ++ol$l to :: +g$1l .
++ol$l
R(c(ntl, IFG an1 IGT 2a)( 0((n officiall
t(-+(1 p-(/1ia0(t(s. Bot2 cat(go-i(s,
IFG an1 IGT, a-( -is8 facto-s fo-
f*t*-( 1ia0(t(s an1 ca-1io)asc*la- 1is(as(C"D.
In t2( a0s(nc( of *n(2(n 1ia0(t(s is still s*sp(ct(1
1(spit( a no-+al F#G, as >it2 t2( postpa-t*+
()al*ation of >o+(n >it2 GDM.
II. SCREENIN" !OR
DIABETESR(co++(n1ations
Sc-((ning to 1(t(ct p-(/1ia0(t(s IFG
o- IGT an1 1ia0(t(s s2o*l1 0( consi1(-(1
in in1i)i1*als 45 (a-s of ag(,
pa-tic*la-l in t2os( >it2 a BMI &5
8g$+&. Sc-((ning s2o*l1 also 0( consi1(-(1fo- p(opl( >2o a-(45 (a-s of
ag( an1 a-( o)(->(ig2t if t2( 2a)( anot2(-
-is8 facto- fo- 1ia0(t(s Ta0l( 7.
R(p(at t(sting s2o*l1 0( ca--i(1 o*t at7/(a- int(-)als. E
Sc-((n fo- p-(/1ia0(t(s an1 1ia0(t(s in2ig2/-is8, as+pto+atic, *n1iagnos(1
a1*lts an1 c2il1-(n >it2in t2( 2(alt2
ca-( s(tting. E
To sc-((n fo- 1ia0(t(s$p-(/1ia0(t(s, (it2(-
an F#G t(st o- &/2 OGTT !5/g
gl*cos( loa1 o- 0ot2 a-( app-op-iat(.
B
An OGTT +a 0( consi1(-(1 in pati(nts
>it2 IFG to 0(tt(- 1(fin( t2( -is8
of 1ia0(t(s. E
Table &'ADA evidence grading system for
clinical practice recommendations
L()(l of()i1(nc( D(sc-iption
A Cl(a- ()i1(nc( f-o+ >(ll/con1*ct(1,g(n(-ali6a0l(, -an1o+i6(1 cont-oll(1 t-ials
t2at a-( a1((-(1 incl*1ing
E)i1(nc( f-o+ a >(ll/con1*ct(1 +*ltic(nt(-
t-ial
E)i1(nc( f-o+ a +(ta/analsis t2at inco-po-at(1
(ll/con1*ct(1
-an1o+i6(1 cont-oll(1 t-ials t2at a-(a1((-(1 incl*1ing
E)i1(nc( f-o+ a >(ll/con1*ct(1 t-ial at on( o-
+o-( instit*tions
E)i1(nc( f-o+ a +(ta/analsis t2at inco-po-at(1(ll/con1*ct(1
co2o-t st*1i(s
E)i1(nc( f-o+ a >(ll/con1*ct(1 p-osp(cti)(
co2o-t st*1 o- -(gist-
E)i1(nc( f-o+ a >(ll/con1*ct(1 +(ta/analsis
of co2o-t st*1i(sS*ppo-ti)( ()i1(nc( f-o+ a >(ll/con1*ct(1 cas(/
cont-ol st*1
C S*ppo-ti)( ()i1(nc( f-o+ poo-l cont-oll(1 o-
*ncont-oll(1 st*1i(s
E)i1(nc( f-o+ -an1o+i6(1 clinical t-ials >it2
on( o- +o-( +aJo- o- t2-((o- +o-( +ino- +(t2o1ological fla>s t2at co*l1
in)ali1at( t2( -(s*lts
E)i1(nc( f-o+ o0s(-)ational st*1i(s >it2 2ig2
pot(ntial fo- 0ias s*c2 ascas( s(-i(s >it2 co+pa-ison to 2isto-ical cont-ols
E)i1(nc( f-o+ cas( s(-i(s o- cas( -(po-tsConflicting ()i1(nc( >it2 t2( >(ig2t of ()i1(nc(
s*ppo-ting t2(
-(co++(n1ation
E E=p(-t cons(ns*s o- clinical (=p(-i(nc(
Table 2'Criteria for the diagnosis of diabetes
. S+pto+s of 1ia0(t(s an1 a cas*al plas+a
gl*cos( & +g$1l . ++ol$l.
-
7/25/2019 Standar Pengobatan Dm
4/69
Cas*al is 1(fin(1 as an ti+( of 1a >it2o*t
-(ga-1 to ti+( sinc( last +(al.
T2( classic s+pto+s of 1ia0(t(s incl*1( pol*-ia,
pol1ipsia, an1
*n(=plain(1 >(ig2t loss.OR
&. F#G &9 +g$1l !. ++ol$l. Fasting is 1(fin(1as no calo-ic inta8( fo- at l(ast
' 2.
OR
7. &/2 plas+a gl*cos( & +g$1l . ++ol$l
1*-ing an OGTT. T2( t(st s2o*l1
0( p(-fo-+(1 as 1(sc-i0(1 0 t2( ?o-l1 3(alt2
O-gani6ation, *sing a
gl*cos( loa1 containing t2( (at(-.
Position Statement
DIABETES CARE, "OLME &:,S##LEMENT , ANAR% &9 S5
T2(-( is a +aJo- 1istinction 0(t>((n 1iagnostic
t(sting an1 sc-((ning. Bot2 *tili6(
t2( sa+( clinical t(sts, >2ic2 s2o*l10( 1on( >it2in t2( cont(=t of t2( 2(alt2
ca-( s(tting. ?2(n an in1i)i1*al (=2i0its
s+pto+s o- signs of t2( 1is(as(, 1iagnostic
t(sts a-( p(-fo-+(1, an1 s*c2 t(sts
1o not -(p-(s(nt sc-((ning. T2( p*-pos(
of sc-((ning is to i1(ntif as+pto+atic
in1i)i1*als >2o a-( li8(l to 2a)( 1ia0(t(s
o- p-(/1ia0(t(s. S(pa-at( 1iagnostict(sts *sing stan1a-1 c-it(-ia a-( -(it2 tp( 1ia0(t(s
p-(s(nt >it2 ac*t( s+pto+s of 1ia0(t(san1 +a-8(1l (l()at(1 0loo1 gl*cos( l()(ls.
B(ca*s( of t2( ac*t( ons(t of s+pto+s,
+ost cas(s of tp( 1ia0(t(s a-(
1(t(ct(1 soon aft(- s+pto+s 1()(lop.?i1(sp-(a1 clinical t(sting of as+pto+atic
in1i)i1*als fo- t2( p-(s(nc( of a*toanti0o1i(s-(lat(1 to tp( 1ia0(t(s
cannot 0( -(co++(n1(1 at t2is ti+( as a
+(ans to i1(ntif in1i)i1*als at -is8. R(asons
fo- t2is incl*1( t2( follo>ing 1 c*toff
)al*(s fo- so+( of t2( i++*n( +a-8(-
assas 2a)( not 0((n co+pl(t(l (sta0lis2(1
in clinical s(ttings 2 t2(-( is no cons(ns*s
as to >2at action s2o*l1 0( ta8(n
>2(n a positi)( a*toanti0o1 t(st -(s*lt is
o0tain(1 an1 3 0(ca*s( t2( inci1(nc( of
tp( 1ia0(t(s is lo>, t(sting of 2(alt2
c2il1-(n >ill i1(ntif onl a )(- s+alln*+0(-
.5K >2o at t2at +o+(nt +a 0(p-(/1ia0(tic. Clinical st*1i(s a-( 0(ing
con1*ct(1 to t(st )a-io*s +(t2o1s of p-()(ntingtp( 1ia0(t(s in 2ig2/-is8 in1i)i1*als
(.g., si0lings of tp( 1ia0(tic
pati(nts. T2(s( st*1i(s +a *nco)(- an (ff(cti)(
+(ans of p-()(nting tp( 1ia0(t(s,
in >2ic2 cas( ta-g(t(1 sc-((ning +a 0(
app-op-iat(
in t2( f*t*-(.
Tp( & 1ia0(t(s
Tp( & 1ia0(t(s is f-(it2 1ia0(t(s +a 0( *n1iagnos(1. In1i)i1*alsat 2ig2 -is8 s2o*l1 0( sc-((n(1 fo-
1ia0(t(s an1 p-(/1ia0(t(s. C-it(-ia fo-
t(sting fo- 1ia0(t(s in as+pto+atic, *n1iagnos(1
a1*lts a-( list(1 in Ta0l( 7. T2((ff(cti)(n(ss of (a-l 1iagnosis t2-o*g2
sc-((ning of as+pto+atic in1i)i1*als
2as not 0((n 1(t(-+in(1 9.
Sc-((ning s2o*l1 0( ca--i(1 o*t
>it2in t2( 2(alt2 ca-( s(tting. Eit2(- an
F#G t(st o- &/2 OGTT !5/g gl*cos( loa1
is app-op-iat(. T2( &/2 OGTT i1(ntifi(s
p(opl( >it2 IGT, an1 t2*s, +o-( p(opl(>2o a-( at inc-(as(1 -is8 fo- t2( 1()(lop+(nt
of 1ia0(t(s an1 C"D. It s2o*l1 0(
not(1 t2at t2( t>o t(sts 1o not n(c(ssa-il
1(t(ct t2( sa+( in1i)i1*als !. It is i+po-tant
to -(cogni6( t2at alt2o*g2 t2( (fficac
of int(-)(ntions fo- p-i+a-p-()(ntion of tp( & 1ia0(t(s 2a)( 0((n
1(+onst-at(1 a+ong in1i)i1*als >it2
IGT ' @, s*c2 1ata a+ong in1i)i1*als
>it2 IFG >2o 1o not also 2a)( IGT a-(not a)aila0l(. T2( F#G t(st is +o-( con)(ni(nt
to pati(nts, +o-( -(p-o1*ci0l(,l(ss costl, an1 (asi(- to a1+inist(- t2an
t2( &/2 OGTT 4,5. T2(-(fo-(, t2( -(co++(n1(1
initial sc-((ning t(st fo- nonp-(gnant
a1*lts is t2( F#G. An OGTT
+a 0( consi1(-(1 in pati(nts >it2 IFG to
0(tt(- 1(fin( t2( -is8 of 1ia0(t(s.
T2( inci1(nc( of tp( & 1ia0(t(s in
c2il1-(n an1 a1ol(sc(nts 2as inc-(as(1
-
7/25/2019 Standar Pengobatan Dm
5/69
1-a+aticall in t2( last 1(ca1(. Consist(nt
>it2 sc-((ning -(co++(n1ations fo-
a1*lts, onl c2il1-(n an1 o*t2 at inc-(as(1
-is8 fo- t2( p-(s(nc( o- t2( 1()(lop+(nt
of tp( & 1ia0(t(s s2o*l1 0(t(st(1 Ta0l( 4.
T2( (ff(cti)(n(ss of sc-((ning +aalso 1(p(n1 on t2( s(tting in >2ic2 it is
p(-fo-+(1. In g(n(-al, co++*nit
sc-((ning o*tsi1( a 2(alt2 ca-( s(tting
+a 0( l(ss (ff(cti)( 0(ca*s( of t2( fail*-(
of p(opl( >it2 a positi)( sc-((ning t(st to
s((8 an1 o0tain app-op-iat( follo>/*p
t(sting an1 ca-( o-, con)(-s(l, to (ns*-(
app-op-iat( -(p(at t(sting fo- in1i)i1*als
>2o sc-((n n(gati)(. T2at is, sc-((ning
o*tsi1( of clinical s(ttings +a i(l1 a0no-+al
t(sts t2at a-( n()(- 1isc*ss(1 >it2
a p-i+a- ca-( p-o)i1(-, lo> co+plianc(>it2 t-(at+(nt -(co++(n1ations, an1 a
)(- *nc(-tain i+pact on long/t(-+
2(alt2. Co++*nit sc-((ning +a also 0(
poo-l ta-g(t(1, i.(., it +a fail to -(ac2t2( g-o*ps +ost at -is8 an1 inapp-op-iat(l
t(st t2os( at lo> -is8 t2( >o--i(1
>(ll o- ()(n t2os( al-(a1 1iagnos(1
&,7.
On t2( 0asis of (=p(-t opinion,
sc-((ning s2o*l1 0( consi1(-(1 0 2(alt2
ca-( p-o)i1(-s at 7/(a- int(-)als 0(ginning
at ag( 45, pa-tic*la-l in t2os( >it2Table ('Criteria for testing for diabetes in
asymptomatic adult individuals
. T(sting fo- 1ia0(t(s s2o*l1 0( consi1(-(1 in all
in1i)i1*als at ag( 45 (a-s an1 a0o)(,
pa-tic*la-l in t2os( >it2 a BMI &5 8g$+&, an1, if
no-+al, s2o*l1 0( -(p(at(1 at7/(a- int(-)als.
&. T(sting s2o*l1 0( consi1(-(1 at a o*ng(- ag(
o- 0( ca--i(1 o*t +o-( f-(2o a-( o)(->(ig2t BMI &5 8g$+&an1 2a)( a11itional -is8 facto-s
a-( 2a0it*all p2sicall inacti)( 2a)( a fi-st/1(g-(( -(lati)( >it2 1ia0(t(s
a-( +(+0(-s of a 2ig2/-is8 (t2nic pop*lation
(.g., Af-ican A+(-ican, Latino,
Nati)( A+(-ican, Asian A+(-ican, #acific
Islan1(-
2a)( 1(li)(-(1 a 0a0 >(ig2ing : l0 o- 2a)(
0((n 1iagnos(1 >it2 GDM
a-( 2p(-t(nsi)( 4$: ++3g
2a)( an 3DL c2ol(st(-ol l()(l 75 +g$1l .:
++ol$l an1$o- a t-iglc(-i1( l()(l
&5 +g$1l &.'& ++ol$l
2a)( #COS
on p-()io*s t(sting, 2a1 IGT o- IFG 2a)( ot2(- clinical con1itions associat(1 >it2
ins*lin -(sistanc( (.g. #COS o-acant2osis nig-icans
2a)( a 2isto- of )asc*la- 1is(as(
Ma not 0( co--(ct fo- all (t2nic g-o*ps. #COS,
polcstic o)a- sn1-o+(.
Table )'Testing for type 2 diabetes in children
C-it(-ia
O)(->(ig2t BMI '5t2 p(-c(ntil( fo-
ag( an1 s(=, >(ig2t fo- 2(ig2t '5t2
p(-c(ntil(, o- >(ig2t &K of i1(al fo-
2(ig2t
#l*s an t>o of t2( follo>ing -is8 facto-s
Fa+il 2isto- of tp( & 1ia0(t(s in fi-sto-s(con1/1(g-(( -(lati)(
Rac($(t2nicit Nati)( A+(-ican, Af-ican
A+(-ican, Latino, Asian A+(-ican,
#acific Islan1(- Signs of ins*lin -(sistanc( o- con1itions
associat(1 >it2 ins*lin -(sistanc(
acant2osis nig-icans, 2p(-t(nsion,
1slipi1(+ia, o- #COS
Mat(-nal 2isto- of 1ia0(t(s o- GDM
Ag( of initiation ag( (a-s o- at ons(t of
p*0(-t, if p*0(-t occ*-s at a o*ng(- ag(
F-(2o 1o not +((t t2(s(
c-it(-ia.
#COS, polcstic o)a- sn1-o+(.
Standards of Medical Care
S9 DIABETES CARE, "OLME &:,
S##LEMENT , ANAR% &9
BMI &5 8g$+&. T2( -ational( fo- t2isint(-)al is t2at fals( n(gati)(s >ill 0( -(p(at(1
0(fo-( s*0stantial ti+( (laps(s,an1 t2(-( is littl( li8(li2oo1 of an in1i)i1*al
1()(loping an of t2( co+plications
of 1ia0(t(s to a significant 1(g-(( >it2in 7
(a-s of a n(gati)( sc-((ning t(st -(s*lt.
T(sting s2o*l1 0( consi1(-(1 at a o*ng(-
ag( o- 0( ca--i(1 o*t +o-( f-(2o a-( o)(->(ig2t an1 2a)(
on( o- +o-( of t2( ot2(- -is8 facto-s fo-
-
7/25/2019 Standar Pengobatan Dm
6/69
tp( & 1ia0(t(s.
III. DETECTION AND
DIA"NOSIS O! "DM
R(co++(n1ations
Sc-((n fo- 1ia0(t(s in p-(gnanc *sing-is8 facto- analsis an1, if app-op-iat(,
*s( of an OGTT. C ?o+(n >it2 GDM s2o*l1 0( sc-((n(1
fo- 1ia0(t(s 9@& >((8s postpa-t*+
an1 s2o*l1 0( follo>(1 *p >it2 s*0s(it2 clinical c2a-act(-istics consist(nt
>it2 a 2ig2 -is8 fo- GDM t2os( >it2
+a-8(1 o0(sit, p(-sonal 2isto- of GDM,
glcos*-ia, o- a st-ong fa+il 2isto- of
1ia0(t(s s2o*l1 *n1(-go gl*cos( t(stingas soon as possi0l( 4. An F#G &9
+g$1l o- a cas*al plas+a gl*cos( &
+g$1l +((ts t2( t2-(s2ol1 fo- t2( 1iagnosis
of 1ia0(t(s an1 n((1s to 0( confi-+(1on a s*0s(o+(n s2o*l1 0( t(st(1 0(t>((n &4 an1
&' >((8s of g(station. T(sting s2o*l1 follo>
on( of t>o app-oac2(s
On(/st(p app-oac2 p(-fo-+ a 1iagnostic/g OGTT
T>o/st(p app-oac2 p(-fo-+ an initial
sc-((ning 0 +(as*-ing t2( plas+a o-
s(-*+ gl*cos( conc(nt-ation 2 aft(- a
5/g o-al gl*cos( loa1 gl*cos( c2all(ng(
t(st an1 p(-fo-+ a 1iagnostic/g OGTT on t2at s*0s(t of >o+(n
(=c((1ing t2( gl*cos( t2-(s2ol1 )al*(
on t2( gl*cos( c2all(ng( t(st. ?2(n t2(
t>o/st(p app-oac2 is *s(1, a gl*cos(t2-(s2ol1 )al*( 4 +g$1l i1(ntifi(s
'K of >o+(n >it2 GDM, an1 t2(i(l1 is f*-t2(- inc-(as(1 to :K 0 *sing
a c*toff of 7 +g$1l.
Diagnostic c-it(-ia fo- t2( /g OGTT
a-( as follo>s :5 +g$1l fasting, '
+g$1l at 2, 55 +g$1l at & 2, an1
4 +g$1l at 7 2. T>o o- +o-( of t2(
plas+a gl*cos( )al*(s +*st 0( +(t o- (=c((1(1
fo- a positi)( 1iagnosis. T2( t(st
s2o*l1 0( 1on( in t2( +o-ning aft(- an
o)(-nig2t fast of '@4 2. T2( 1iagnosis
can 0( +a1( *sing a !5/g gl*cos( loa1,
0*t t2at t(st is not as >(ll )ali1at(1 fo-
1(t(ction of at/-is8 infants o- +ot2(-s ast2( /g OGTT.
Lo>/-is8 stat*s -(o+(n +((ting all of t2( follo>ing
c2a-act(-istics
Ag( &5 (a-s.
?(ig2t no-+al 0(fo-( p-(gnanc.
M(+0(- of an (t2nic g-o*p >it2 a lo>
p-()al(nc( of GDM.
No 8no>n 1ia0(t(s in fi-st/1(g-(( -(lati)(s.
No 2isto- of a0no-+al gl*cos( tol(-anc(.
No 2isto- of poo- o0st(t-ic o*tco+(.
I*. %RE*ENTION+DEA,
O! T,%E 2 DIABETESR(co++(n1ations
In1i)i1*als at 2ig2 -is8 fo- 1()(loping
1ia0(t(s n((1 to 0(co+( a>a-( of t2(
0(n(fits of +o1(st >(ig2t loss an1 pa-ticipatingin -(g*la- p2sical acti)it.
A
#ati(nts >it2 IGT s2o*l1 0( gi)(n
co*ns(ling on >(ig2t loss as >(ll as inst-*ction
fo- inc-(asing p2sical acti)it.
A
#ati(nts >it2 IFG s2o*l1 0( gi)(n
co*ns(ling on >(ig2t loss as >(ll as inst-*ctionfo- inc-(asing p2sical acti)it.
E
Follo>/*p co*ns(ling app(a-s i+po-tant
fo- s*cc(ss. B
Monito-ing fo- t2( 1()(lop+(nt of 1ia0(t(s
in t2os( >it2 p-(/1ia0(t(s s2o*l1 0(p(-fo-+(1 ()(- @& (a-s. E
Clos( att(ntion s2o*l1 0( gi)(n to, an1
app-op-iat( t-(at+(nt gi)(n fo-, ot2(-
C"D -is8 facto-s (.g., to0acco *s(, 2p(-t(nsion,1slipi1(+ia. A
D-*g t2(-ap s2o*l1 not 0( -o*tin(l*s(1 to p-()(nt 1ia0(t(s *ntil +o-( info-+ation
is 8no>n a0o*t its cost(ff(cti)(n(ss.
E
St*1i(s 2a)( 0((n initiat(1 in t2( last 1(ca1(
to 1(t(-+in( t2( f(asi0ilit an1 0(n(fit
of )a-io*s st-at(gi(s to p-()(nt o-
1(la t2( ons(t of tp( & 1ia0(t(s. Fi)(
>(ll/1(sign(1 -an1o+i6(1 cont-oll(1 t-ials
-
7/25/2019 Standar Pengobatan Dm
7/69
2a)( 0((n -(po-t(1 ' @,5,9. T2(
st-at(gi(s s2o>n to 0( (ff(cti)( in p-()(nting
1ia0(t(s -(li(1 on lif(stl( +o1ification
o- gl*cos(/lo>(-ing 1-*gs t2at
2a)( 0((n app-o)(1 fo- t-(ating 1ia0(t(s.In t2( Finnis2 st*1 :, +i11l(/ag(1
o0(s( s*0J(cts >it2 IGT >(-( -an1o+i6(1to -(c(i)( (it2(- 0-i(f 1i(t an1 (=(-cis(
co*ns(ling cont-ol g-o*p o- int(nsi)(
in1i)i1*ali6(1 inst-*ction on >(ig2t -(1*ction,
foo1 inta8(, an1 g*i1anc( on inc-(asing
p2sical acti)it int(-)(ntion
g-o*p. Aft(- an a)(-ag( follo>/*p of 7.&
(a-s, t2(-( >as a 5'K -(lati)( -(1*ction
in t2( inci1(nc( of 1ia0(t(s in t2( int(-)(ntion
g-o*p co+pa-(1 >it2 t2( cont-ol
s*0J(cts.
In t2( Dia0(t(s #-()(ntion #-og-a+
D## ', (n-oll(1 s*0J(cts >(-( slig2tlo*ng(- an1 +o-( o0(s( 0*t 2a1 n(a-l
i1(ntical gl*cos( intol(-anc( co+pa-(1
>it2 s*0J(cts in t2( Finnis2 st*1. A0o*t
45K of t2( pa-ticipants >(-( f-o+ +ino-itg-o*ps (.g., Af-ican A+(-ican, 3ispanic,
an1 &K >(-( 9 (a-s of ag(.
S*0J(cts >(-( -an1o+i6(1 to on( of t2-((
int(-)(ntion g-o*ps, >2ic2 incl*1(1 t2(
int(nsi)( n*t-ition an1 (=(-cis( co*ns(ling
lif(stl( g-o*p o- (it2(- of t>o
+as8(1 +(1ication t-(at+(nt g-o*ps t2(
0ig*ani1( +(tfo-+in g-o*p o- t2( plac(0og-o*p. T2( latt(- int(-)(ntions >(-(
co+0in(1 >it2 stan1a-1 1i(t an1 (=(-cis(
-(co++(n1ations. Aft(- an a)(-ag( follo>/
*p of &.' (a-s, a 5'K -(lati)( -(1*ction
in t2( p-og-(ssion to 1ia0(t(s >as
o0s(-)(1 in t2( lif(stl( g-o*p an1 a 7K-(lati)( -(1*ction in t2( p-og-(ssion of
1ia0(t(s >as o0s(-)(1 in t2( +(tfo-+in
g-o*p co+pa-(1 >it2 cont-ol s*0J(cts.
On a)(-ag(, 5K of t2( lif(stl( g-o*pac2i()(1 t2( goal of !K >(ig2t -(1*ction
an1 !4K +aintain(1 at l(ast 5+in$>((8 of +o1(-at(l int(ns( acti)it.
In t2( t-oglita6on( a-+ of t2( D## 1iscontin*(1
aft(- a +(an of .: (a-s >2(n
t2( 1-*g >as >it21-a>n f-o+ t2( +a-8(t,
t-oglita6on( +a-8(1l -(1*c(1 t2(
inci1(nc( of 1ia0(t(s 1*-ing t2( p(-io1
t2( 1-*g >as gi)(n 9a.
In t2( Da ing St*1 , +(n an1
>o+(n f-o+ 2(alt2 ca-( clinics in t2( cit
of Da ing, C2ina, >(-( sc-((n(1 >it2
OGTT, an1 t2os( >it2 IGT >(-( -an1o+i6(1
0 clinic to a cont-ol g-o*p o- to on(
of t2-(( acti)( t-(at+(nt g-o*ps 1i(tonl, (=(-cis( onl, o- 1i(t pl*s (=(-cis(.
S*0J(cts >(-( -((=a+in(1 0iann*all,an1 aft(- an a)(-ag( of 9 (a-sP follo>/*p,
t2( 1i(t, (=(-cis(, an1 1i(t pl*s (=(-cis(
Position Statement
DIABETES CARE, "OLME &:,
S##LEMENT , ANAR% &9 S!
int(-)(ntions >(-( associat(1 >it2 7,
49, an1 4&K -(1*ctions in -is8 of 1()(loping
tp( & 1ia0(t(s, -(sp(cti)(l.
T2-(( ot2(- st*1i(s, (ac2 *sing a 1iff(-(nt
class of gl*cos(/lo>(-ing ag(nt,
2a)( s2o>n a -(1*ction in p-og-(ssion to
1ia0(t(s >it2 p2a-+acological int(-)(ntion.In t2( T-oglita6on( in #-()(ntion of
Dia0(t(s TRI#OD st*1 5, 3ispanic
>o+(n >it2 p-()io*s GDM >(-( -an1o+i6(1
to -(c(i)( (it2(- plac(0o o- t-oglita6on(a 1-*g no> >it21-a>n f-o+
co++(-cial sal( in t2( .S. 0*t 0(longing
to t2( t2ia6oli1in(1ion( QTHD class. Aft(-
a +(1ian follo>/*p of 7 +ont2s, t-oglita6on(
t-(at+(nt >as associat(1 >it2 a
59K -(lati)( -(1*ction in p-og-(ssion to
1ia0(t(s. In t2( STO#/IDDM t-ial 9,
pa-ticipants >it2 IGT >(-( -an1o+i6(1in a 1o*0l(/0lin1 fas2ion to -(c(i)( (it2(-
t2( /gl*cosi1as( in2i0ito- aca-0os( o- a
plac(0o. Aft(- a +(an follo>/*p of 7.7
(a-s, a &5K -(lati)( -is8 -(1*ction in
p-og-(ssion to 1ia0(t(s, 0as(1 on on(
OGTT, >as o0s(-)(1 in t2( aca-0os(t-(at(1g-o*p co+pa-(1 >it2 t2( plac(0o
g-o*p. If t2is 1iagnosis >as confi-+(1 0
a s(con1 OGTT, a 79K -(lati)( -is8 -(1*ction
>as o0s(-)(1 in t2( aca-0os(g-o*p co+pa-(1 >it2 t2( plac(0o g-o*p.
Finall, in t2( ;ENical in t2( p-()(ntionof Dia0(t(s in O0(s( S*0J(cts
;ENDOS st*1, o-listat >as (=a+in(1
fo- its a0ilit to 1(la tp( & 1ia0(t(s
>2(n a11(1 to lif(stl( c2ang( in a g-o*p
>it2 BMI 7 8g$+& >it2 o- >it2o*t
IGT. Aft(- 4 (a-s of t-(at+(nt, t2( (ff(ct
of o-listat a11ition co--(spon1(1 to a
45K -is8 -(1*ction in t2( IGT g-o*p,
-
7/25/2019 Standar Pengobatan Dm
8/69
>it2 no (ff(ct o0s(-)(1 in t2os( >it2o*t
IGT 90.
O*- 8no>l(1g( of t2( (a-l stag(s of
2p(-glc(+ia t2at po-t(n1 t2( 1iagnosis
of 1ia0(t(s, an1 t2( -(c(nt s*cc(ss of +aJo-int(-)(ntion t-ials, cl(a-l s2o> t2at
in1i)i1*als at 2ig2 -is8 can 0( i1(ntifi(1an1 1ia0(t(s 1(la(1, if not p-()(nt(1.
T2( cost/(ff(cti)(n(ss of int(-)(ntion
st-at(gi(s is *ncl(a-, 0*t t2( 2*g( 0*-1(n
-(s*lting f-o+ t2( co+plications of 1ia0(t(s
an1 t2( pot(ntial ancilla- 0(n(fits of
so+( of t2( int(-)(ntions s*gg(st t2at an
(ffo-t to p-()(nt 1ia0(t(s is >o-t2>2il(.
Lif(stl( +o1ification
In >(ll/cont-oll(1 st*1i(s t2at incl*1(1 a
lif(stl( int(-)(ntion a-+, s*0stantial (ffo-ts
>(-( n(c(ssa- to ac2i()( onl +o1(st
c2ang(s in >(ig2t an1 (=(-cis(, 0*tt2os( c2ang(s >(-( s*ffici(nt to ac2i()(
an i+po-tant -(1*ction in t2( inci1(nc(
of 1ia0(t(s. In t2( Finnis2 Dia0(t(s #-()(ntion
St*1, >(ig2t loss a)(-ag(1 :.& l0at (a-, !.! l0 aft(- & (a-s, an1 4.9 l0
aft(- 5 (a-s : +o1(-at( (=(-cis(,
s*c2 as 0-is8 >al8ing, fo- 7 +in$1a >as
s*gg(st(1. In t2( Finnis2 st*1, t2(-( >as
a 1i-(ct -(lations2ip 0(t>((n a12(-(nc(
>it2 t2( lif(stl( int(-)(ntion an1 t2( -(1*c(1
inci1(nc( of 1ia0(t(s.
In t2( D## ', t2( lif(stl( g-o*p lost& l0 at & (a-s an1 : l0 at 7 (a-s +(an
>(ig2t loss fo- t2( st*1 1*-ation >as
& l0 o- 9K of initial 0o1 >(ig2t. In
0ot2 of t2(s( st*1i(s, +ost of t2( pa-ticipants
>(-( o0(s( BMI 7 8g$+&.
A lo>/fat &5K fat inta8( >as -(co++(n1(1if -(1*cing fat 1i1 not p-o1*c(
>(ig2t loss to goal, calo-i(
-(st-iction >as also -(co++(n1(1. #a-ticipants
>(ig2ing &@!4 l0 54@!'8g at 0as(lin( >(-( inst-*ct(1 to follo> a
,&/8cal$1a 1i(t 77 g fat, t2os( !5@&: l0 !:@:: 8g >(-( inst-*ct(1 to follo>
a ,5/8cal$1a 1i(t 4& g fat, t2os(
&& @&4: l0 @7 8g >(-( inst-*ct(1
to follo> an ,'/8cal$1a 1i(t
5 g fat, an1 t2os( &5 l0 4 8g
>(-( inst-*ct(1 to follo> a &,/8cal$
1a 1i(t 55 g fat.
#2a-+acological int(-)(ntions
T2-(( 1ia0(t(s p-()(ntion t-ials *s(1
p2a-+acological t2(-ap, an1 all 2a)( -(po-t(1
a significant lo>(-ing of t2( inci1(nc(
of 1ia0(t(s. T2( 0ig*ani1(
+(tfo-+in -(1*c(1 t2( -is8 of 1ia0(t(s 07K in t2( D## ', t2( /gl*cosi1as(
in2i0ito- aca-0os( -(1*c(1 t2( -is8 07&K in t2( STO#/IDDM t-ial 9, an1
t2( THD t-oglita6on( -(1*c(1 t2( -is8 0
59K in t2( TRI#OD st*1 5.
In t2( D##, +(tfo-+in >as a0o*t 2alf
as (ff(cti)( as 1i(t an1 (=(-cis( in 1(laing
t2( ons(t of 1ia0(t(s o)(-all, 0*t it >as
n(a-l in(ff(cti)( in ol1(- in1i)i1*als
9 (a-s of ag( o- in t2os( >2o >(-(
l(ss o)(->(ig2t BMI 7 8g$+&. Con)(-s(l,
+(tfo-+in >as as (ff(cti)( as lif(stl(
+o1ification in in1i)i1*als ag(1
&4@44 (a-s o- in t2os( >it2 a BMI 758g$+&. T2*s, t2( pop*lation of p(opl( in
>2o+ t-(at+(nt >it2 +(tfo-+in 2as
(2o a-(li8(l to 2a)( p-(/1ia0(t(s IFG o- IGT.
T2(-( a-( also 1ata to s*gg(st t2at
0loc8a1( of t2( -(nin/angiot(nsin sst(+
! +a lo>(- t2( -is8 of 1()(loping 1ia0(t(s,
0*t +o-( st*1i(s a-( n(c(ssa- 0(fo-(
t2(s( 1-*gs can 0( -(co++(n1(1 fo-
p-()(nting 1ia0(t(s.
Lif(stl( o- +(1icationT2( D## is t2( onl st*1 in >2ic2 a co+pa-ison
of t2( t>o >as +a1(, an1 lif(stl(
+o1ification >as n(a-l t>ic( as (ff(cti)(
in p-()(nting 1ia0(t(s 5' )s. 7K -(lati)(
-(1*ctions, -(sp(cti)(l. T2( g-(at(-
0(n(fit of >(ig2t loss an1 p2sical acti)itst-ongl s*gg(sts t2at lif(stl( +o1ification
s2o*l1 0( t2( fi-st c2oic( to p-()(nt
o- 1(la 1ia0(t(s. Mo1(st >(ig2t loss 5@
K of 0o1 >(ig2t an1 +o1(st p2sicalacti)it 7 +in 1ail a-( t2( -(co++(n1(1
goals. B(ca*s( t2is int(-)(ntionnot onl 2as 0((n s2o>n to p-()(nt o-
1(la 1ia0(t(s, 0*t also 2as a )a-i(t of
ot2(- 0(n(fits, 2(alt2 ca-( p-o)i1(-s
s2o*l1 *-g( all o)(->(ig2t o- s(1(nta-
in1i)i1*als to a1opt t2(s( c2ang(s, an1
s*c2 -(co++(n1ations s2o*l1 0( +a1(
at ()(- oppo-t*nit.
?2(n all facto-s a-( consi1(-(1, t2(-(
-
7/25/2019 Standar Pengobatan Dm
9/69
is ins*ffici(nt ()i1(nc( to s*ppo-t t2( *s(
of 1-*g t2(-ap as a s*0stit*t( fo-, o- -o*tin(l
*s(1 in a11ition to, lif(stl( +o1ification
to p-()(nt 1ia0(t(s. #*0lic 2(alt2
+(ssag(s, 2(alt2 ca-( p-of(ssionals, an12(alt2 ca-( sst(+s s2o*l1 all (nco*-ag(
0(2a)io- c2ang(s to ac2i()( a 2(alt2 lif(stl(.F*-t2(- -(s(a-c2 is n(c(ssa- to *n1(-stan1
0(tt(- 2o> to facilitat( (ff(cti)(
an1 (ffici(nt p-og-a+s fo- t2( p-i+a-
p-()(ntion of tp( & 1ia0(t(s.
*. DIABETES CARE
A. Initial ()al*ation
A co+pl(t( +(1ical ()al*ation s2o*l1 0(
p(-fo-+(1 to classif t2( pati(nt, 1(t(ct
t2( p-(s(nc( o- a0s(nc( of 1ia0(t(s co+plications,
assist in fo-+*lating a +anag(+(nt
plan, an1 p-o)i1( a 0asis fo-
contin*ing ca-(. If t2( 1iagnosis of 1ia0(t(s2as al-(a1 0((n +a1(, t2( ()al*ation
s2o*l1 -()i(> t2( p-()io*s t-(at+(nt an1
t2( past an1 p-(s(nt 1(g-((s of glc(+ic
cont-ol. La0o-ato- t(sts app-op-iat( tot2( ()al*ation of (ac2 pati(ntPs g(n(-al
+(1ical con1ition s2o*l1 0( p(-fo-+(1.
A foc*s on t2( co+pon(nts of co+p-(2(nsi)(
ca-( Ta0l( 5 >ill assist t2(
2(alt2 ca-( t(a+ to (ns*-( opti+al +anag(+(nt
of t2( pati(nt >it2 1ia0(t(s.
B. Manag(+(nt
#(opl( >it2 1ia0(t(s s2o*l1 -(c(i)( +(1icalca-( f-o+ a p2sician/coo-1inat(1
t(a+. S*c2 t(a+s +a incl*1(, 0*t a-(
not li+it(1 to, p2sicians, n*-s( p-actition(-s,
p2sicianPs assistants, n*-s(s, 1i(titians,
p2a-+acists, an1 +(ntal 2(alt2
p-of(ssionals >it2 (=p(-tis( an1 a sp(cial
Standards of Medical Care
S' DIABETES CARE, "OLME &:,
S##LEMENT , ANAR% &9
int(-(st in 1ia0(t(s. It is (ss(ntial in t2iscolla0o-ati)( an1 int(g-at(1 t(a+ app-oac2
t2at in1i)i1*als >it2 1ia0(t(s ass*+(an acti)( -ol( in t2(i- ca-(.
T2( +anag(+(nt plan s2o*l1 0( fo-+*lat(1
as an in1i)i1*ali6(1 t2(-ap(*tic
allianc( a+ong t2( pati(nt an1 fa+il, t2(
p2sician, an1 ot2(- +(+0(-s of t2(
2(alt2 ca-( t(a+. An plan s2o*l1 -(cogni6(
1ia0(t(s s(lf/+anag(+(nt (1*cation
DSME as an int(g-al co+pon(nt of ca-(.
In 1()(loping t2( plan, consi1(-ation
s2o*l1 0( gi)(n to t2( pati(ntPs ag(,
sc2ool o- >o-8 sc2(1*l( an1 con1itions,
p2sical acti)it, (ating patt(-ns, social
sit*ation an1 p(-sonalit, c*lt*-al facto-s,an1 p-(s(nc( of co+plications of 1ia0(t(s
o- ot2(- +(1ical con1itions. A )a-i(t ofTable -'Components of the comprehensive
diabetes evaluation
M(1ical 2isto-
S+pto+s, -(s*lts of la0o-ato- t(sts, an1
sp(cial (=a+ination -(s*lts -(lat(1 to t2( 1iagnosis
of 1ia0(t(s
#-io- AC -(co-1s
Eating patt(-ns, n*t-itional stat*s, an1 >(ig2t
2isto- g-o>t2 an1 1()(lop+(nt in c2il1-(n an1
a1ol(sc(nts
D(tails of p-()io*s t-(at+(nt p-og-a+s,
incl*1ing n*t-ition an1 1ia0(t(s s(lf/+anag(+(nt(1*cation, attit*1(s, an1 2(alt2 0(li(fs
C*--(nt t-(at+(nt of 1ia0(t(s, incl*1ing
+(1ications, +(al plan, an1 -(s*lts of gl*cos(
+onito-ing an1 pati(ntsP *s( of 1ata E=(-cis( 2isto-
F-(it2 1ia0(t(s
Ot2(- +(1ications t2at +a aff(ct 0loo1 gl*cos(l()(ls
Ris8 facto-s fo- at2(-oscl(-osis s+o8ing,
2p(-t(nsion, o0(sit, 1slipi1(+ia, an1 fa+il
2isto- 3isto- an1 t-(at+(nt of ot2(- con1itions,
incl*1ing (n1oc-in( an1 (ating 1iso-1(-s Ass(ss+(nt fo- +oo1 1iso-1(-
Fa+il 2isto- of 1ia0(t(s an1 ot2(- (n1oc-in(
1iso-1(-s
Lif(stl(, c*lt*-al, psc2osocial, (1*cational,
an1 (cono+ic facto-s t2at +ig2t infl*(nc( t2(
+anag(+(nt of 1ia0(t(s
To0acco, alco2ol, an1$o- cont-oll(1 s*0stanc(
*s(
-
7/25/2019 Standar Pengobatan Dm
10/69
Cont-ac(ption an1 -(p-o1*cti)( an1 s(=*al
2isto-
#2sical (=a+ination
3(ig2t an1 >(ig2t +(as*-(+(nt an1
co+pa-ison to no-+s in c2il1-(n an1 a1ol(sc(nts S(=*al +at*-ation staging 1*-ing p*0(-tal
p(-io1 Bloo1 p-(ss*-( 1(t(-+ination, incl*1ing
o-t2ostatic +(as*-(+(nts >2(n in1icat(1, an1
co+pa-ison to ag(/-(lat(1 no-+s
F*n1oscopic (=a+ination
O-al (=a+ination
T2-oi1 palpation
Ca-1iac (=a+ination
A01o+inal (=a+ination (.g., fo- 2(pato+(gal
E)al*ation of p*ls(s 0 palpation an1 >it2
a*sc*ltation
3an1$fing(- (=a+ination
Foot (=a+ination S8in (=a+ination fo- acant2osis nig-icans an1
ins*lin/inJ(ction sit(s
N(*-ological (=a+ination
Signs of 1is(as(s t2at can ca*s( s(con1a-1ia0(t(s (.g., 2(+oc2-o+atosis, panc-(atic
1is(as(
La0o-ato- ()al*ation
AC
Fasting lipi1 p-ofil(, incl*1ing total c2ol(st(-ol,
3DL c2ol(st(-ol, t-iglc(-i1(s, an1 LDL
c2ol(st(-ol, li)(- f*nction t(sts >it2 f*-t2(-
()al*ation fo- fatt li)(- o- 2(patitis if a0no-+al T(st fo- +ic-oal0*+in*-ia in tp( 1ia0(tic
pati(nts >2o 2a)( 2a1 1ia0(t(s fo- at l(ast 5 (a-s
an1 in all pati(nts >it2 tp( & 1ia0(t(s
so+( a1)ocat( 0(ginning sc-((ning of p*0(-tal
c2il1-(n 0(fo-( 5 (a-s of 1ia0(t(s
S(-*+ c-(atinin( an1 calc*lat(1 GFR in a1*ltsc2(c8 c-(atinin( in c2il1-(n if p-ot(in*-ia is
p-(s(nt
T2-oi1/sti+*lating 2o-+on( TS3 in all tp(
1ia0(tic pati(nts in tp( & if clinicall in1icat(1 El(ct-oca-1iog-a+ in a1*lts, if clinicall
in1icat(1 -inalsis fo- 8(ton(s, p-ot(in, s(1i+(nt
R(f(--als
E( (=a+, if in1icat(1
Fa+il planning fo- >o+(n of -(p-o1*cti)( ag(
MNT, as in1icat(1
Dia0(t(s (1*cato-, if not p-o)i1(1 0 p2sician
o- p-actic( staff
B(2a)io-al sp(cialist, as in1icat(1
Foot sp(cialist, as in1icat(1
Ot2(- sp(cialti(s an1 s(-)ic(s as app-op-iat(
Position Statement
DIABETES CARE, "OLME &:,
S##LEMENT , ANAR% &9 S:st-at(gi(s an1 t(c2ni
-
7/25/2019 Standar Pengobatan Dm
11/69
ta-g(ts a-( 0(ing ac2i()(1. R(s*lts
of SMBG can 0( *s(f*l in p-()(nting
2poglc(+ia
an1 a1J*sting +(1ications,
MNT, an1 p2sical acti)it.T2( f-(it2 ins*lin to +onito- fo- an1 p-()(nt
as+pto+atic 2poglc(+ia an1 2p(-glc(+ia.
Fo- +ost pati(nts >it2 tp(
1ia0(t(s an1 p-(gnant >o+(n ta8ing ins*lin,
SMBG is -(co++(n1(1 t2-(( o-
+o-( ti+(s 1ail. T2( opti+al f-(it2 tp(
& 1ia0(t(s on o-al ag(nt t2(-ap is not
8no>n 0*t s2o*l1 0( s*ffici(nt to facilitat(
-(ac2ing gl*cos( goals. #ati(nts >it2tp( & 1ia0(t(s on ins*lin tpicall n((1
to p(-fo-+ SMBG +o-( f-(it2 tp( & 1ia0(t(s
is not 8no>n.
B(ca*s( t2( acc*-ac of SMBG is inst-*+(nt
an1 *s(- 1(p(n1(nt &, it is
i+po-tant fo- 2(alt2 ca-( p-o)i1(-s to
()al*at( (ac2 pati(ntPs +onito-ing t(c2nio ti+(s
a (a- in pati(nts >2o a-( +((ting t-(at+(nt
goals an1 >2o 2a)( sta0l( glc(+ic
cont-ol. E
#(-fo-+ t2( AC t(st 2os( t2(-ap 2as c2ang(1 o-
>2o a-( not +((ting glc(+ic goals. E
s( of point/of/ca-( t(sting fo- AC allo>s
fo- ti+(l 1(cisions on t2(-ap
c2ang(s, >2(n n((1(1. E
B p(-fo-+ing an AC t(st, 2(alt2 p-o)i1(-s
can +(as*-( a pati(ntPs a)(-ag( glc(+ia
o)(- t2( p-(c(1ing &@7 +ont2s &an1, t2*s, ass(ss t-(at+(nt (fficac. AC
t(sting s2o*l1 0( p(-fo-+(1 -o*tin(l inall pati(nts >it2 1ia0(t(s, fi-st to 1oc*+(nt
t2( 1(g-(( of glc(+ic cont-ol at
initial ass(ss+(nt an1 t2(n as pa-t of contin*ing
ca-(. Sinc( t2( AC t(st -(fl(cts
+(an glc(+ia o)(- t2( p-(c(1ing &@7
+ont2s, +(as*-(+(nt app-o=i+at(l ()(-
7 +ont2s is -(2(t2(- a pati(ntPs +(ta0olic cont-ol 2as
0((n -(ac2(1 an1 +aintain(1 >it2in t2(
ta-g(t -ang(. T2*s, -(g*la- p(-fo-+anc(
of t2( AC t(st p(-+its 1(t(ction of 1(pa-t*-(s
f-o+ t2( ta-g(t Ta0l( 9 in ati+(l fas2ion. Fo- an in1i)i1*al pati(nt,
t2( f-(
-
7/25/2019 Standar Pengobatan Dm
12/69
>it2 s()(-( o- f-(it2
1ia0(t(s. UC*--(nt NCE#$AT# III g*i1(lin(s
s*gg(st t2at in pati(nts >it2 t-iglc(-i1(s &
+g$1l, t2(
non/3DL c2ol(st(-ol total c2ol(st(-ol +in*s
3DL 0( *tili6(1. T2( goal is7 +g$1l 74.
VFo- >o+(n,
it 2as 0((n s*gg(st(1 t2at t2( 3DL goal 0(
inc-(as(1 0 +g$1l.
Standards of Medical Care
S DIABETES CARE, "OLME &:,S##LEMENT , ANAR% &9
itations. Con1itions t2at aff(ct (-t2-oct(
t*-no)(- 2(+olsis, 0loo1 loss an1
2(+oglo0in )a-iants +*st 0( consi1(-(1,pa-tic*la-l >2(n t2( AC -(s*lt 1o(s not
co--(lat( >it2 t2( pati(ntPs clinical sit*ation
&. T2( a)aila0ilit of t2( AC -(s*lt
at t2( ti+( t2at t2( pati(nt is s((n
point of ca-( t(sting 2as 0((n -(po-t(1
to -(s*lt in t2( f-((-ing AC 2as 0((n associat(1 >it2
a -(1*ction of +ic-o)asc*la- an1 n(*-opat2ic
co+plications of 1ia0(t(s. A
T2( AC goalfor patients in general is an
AC goal of !K. B
T2( AC goalfor the individual patient is
an AC as clos( to no-+al 9K as
possi0l( >it2o*t significant 2poglc(+ia.
E L(ss st-ing(nt t-(at+(nt goals +a 0(
app-op-iat( fo- pati(nts >it2 a 2isto-of s()(-( 2poglc(+ia, pati(nts >it2
li+it(1 lif( (=p(ctanci(s, )(- o*ng
c2il1-(n o- ol1(- a1*lts, an1 in1i)i1*als
>it2 co+o-0i1 con1itions. E
Agg-(ssi)( glc(+ic +anag(+(nt >it2
ins*lin +a -(1*c( +o-0i1it in pati(nts
>it2 s()(-( ac*t( illn(ss, p(-iop(-ati)(l,
follo>ing +oca-1ial
infa-ction, an1 in p-(gnanc. B
Glc(+ic cont-ol is f*n1a+(ntal to t2(
+anag(+(nt of 1ia0(t(s. T2( goal of t2(-ap
is to ac2(i)( an AC as clos( to no-+alas possi0l( -(p-(s(nting no-+al
fasting an1 postp-an1ial gl*cos( conc(nt-ations
in t2( a0s(nc( of 2poglc(+ia.
3o>()(-, t2is goal is 1iffic*lt to ac2i()(>it2 p-(s(nt t2(-api(s &4. #-osp(cti)(
-an1o+i6(1 clinical t-ials s*c2 as t2(
DCCT &5 an1 t2( .. #-osp(cti)( Dia0(t(s
St*1 #DS &9,&! 2a)(
s2o>n t2at i+p-o)(1 glc(+ic cont-ol is
associat(1 >it2 s*stain(1 1(c-(as(1 -at(s
of -(tinopat2, n(p2-opat2, an1 n(*-opat2
&'. In t2(s( t-ials, t-(at+(nt-(gi+(ns t2at -(1*c(1 a)(-ag( AC to
!K K a0o)( t2( *pp(- li+its of
no-+al >(-( associat(1 >it2 f(>(- longt(-+
+ic-o)asc*la- co+plications 2o>()(-,
int(nsi)( cont-ol >as fo*n1 to
inc-(as( t2( -is8 of s()(-( 2poglc(+iaan1 >(ig2t gain &:,7. T2( pot(ntial of
int(nsi)( glc(+ic cont-ol to -(1*c( C"D
is s*ppo-t(1 0 (pi1(+iological st*1i(s
&5@7 an1 a -(c(nt +(ta/analsis 7,0*t t2is pot(ntial 0(n(fit on C"D ()(nts
2as not (t 0((n 1(+onst-at(1 in a -an1o+i6(1clinical t-ial.
R(co++(n1(1 glc(+ic goals fo-
nonp-(gnant in1i)i1*als a-( s2o>n in Ta0l(
9. A +aJo- li+itation to t2( a)aila0l(
1ata is t2at t2( 1o not i1(ntif t2( opti+*+
l()(l of cont-ol fo- pa-tic*la- pati(nts,
as t2(-( a-( in1i)i1*al 1iff(-(nc(s
in t2( -is8s of 2poglc(+ia, >(ig2t gain,
-
7/25/2019 Standar Pengobatan Dm
13/69
an1 ot2(- a1)(-s( (ff(cts. F*-t2(-+o-(,
>it2 +*ltifacto-ial int(-)(ntions, it is *ncl(a-
2o> 1iff(-(nt co+pon(nts (.g., (1*cational
int(-)(ntions, glc(+ic ta-g(ts,
lif(stl( c2ang(s, p2a-+acologicalag(nts cont-i0*t( to t2( -(1*ction of
co+plications. T2(-( a-( no clinical t-ial1ata a)aila0l( fo- t2( (ff(cts of glc(+ic
cont-ol in pati(nts >it2 a1)anc(1 co+plications,
t2( (l1(-l 95 (a-s of ag(, o-
o*ng c2il1-(n 7 (a-s of ag(. L(ss
st-ing(nt t-(at+(nt goals +a 0( app-op-iat(
fo- pati(nts >it2 li+it(1 lif( (=p(ctanci(s,
in t2( )(- o*ng o- ol1(- a1*lts,
an1 in in1i)i1*als >it2 co+o-0i1 con1itions.
S()(-( o- f-((- li+it of AC at >2ic2 f*-t2(- lo>(-ing
1o(s not -(1*c( t2( -is8 of co+plications,
at t2( -is8 of inc-(as(1
2poglc(+ia pa-tic*la-l in t2os( >it2
tp( 1ia0(t(s. 3o>()(-, t2( a0sol*t(
-is8s an1 0(n(fits of lo>(- ta-g(ts a-( *n8no>n.
T2( -is8s an1 0(n(fits of an AC
goal of 9K a-( c*--(ntl 0(ing t(st(1 inan ongoing st*1 ACCORD QAction to
Cont-ol Ca-1io)asc*la- Ris8 in Dia0(t(s
in tp( & 1ia0(t(s.
El()at(1 postc2all(ng( &/2 OGTT
gl*cos( )al*(s 2a)( 0((n associat(1 >it2
inc-(as(1 ca-1io)asc*la- -is8 in1(p(n1(ntof F#G in so+( (pi1(+iological
st*1i(s. #ostp-an1ial plas+a gl*cos(
##G l()(ls 4 +g$1l a-( *n*s*al in
non1ia0(tic in1i)i1*als, alt2o*g2 la-g(()(ning +(als can 0( follo>(1 0 plas+a
gl*cos( )al*(s *p to ' +g$1l. T2(-( a-(no> p2a-+acological ag(nts t2at p-i+a-il
+o1if ##G an1 t2(-(0 -(1*c( AC
in pa-all(l. T2*s, in in1i)i1*als >2o 2a)(
p-(+(al gl*cos( )al*(s >it2in ta-g(t 0*t
>2o a-( not +((ting AC ta-g(ts, consi1(-ation
of +onito-ing ##G @& 2 aft(- t2(
sta-t of t2( +(al an1 t-(at+(nt ai+(1 at
-(1*cing ##G )al*(s ' +g$1l +a
lo>(- AC. 3o>()(-, it s2o*l1 0( not(1
t2at t2( (ff(ct of t2(s( app-oac2(s on +ic-o/
o- +ac-o)asc*la- co+plications 2as
not 0((n st*1i(1 7&.
As -(ga-1s goals fo- glc(+ic cont-olfo- >o+(n >it2 GDM, -(co++(n1ations
f-o+ t2( Fo*-t2 Int(-national ?o-8s2op/Conf(-(nc( on G(stational Dia0(t(s s*gg(st
lo>(-ing +at(-nal capilla- 0loo1
gl*cos( conc(nt-ations to:5 +g$1l 5.7
++ol$l fasting, 4 +g$1l !.'
++ol$l at 2, an1$o- & +g$1l 9.!
++ol$l at & 2 aft(- t2( +(al 7&a. Fo-
f*-t2(- info-+ation on GDM, -(f(- to t2(
ADA position stat(+(nt 4. Fo- info-+ation
on glc(+ic cont-ol 1*-ing p-(gnanc
in >o+(n >it2 p-((=isting
1ia0(t(s, -(f(- to -(f. 77.
D. MNTR(co++(n1ations
#(opl( >it2 1ia0(t(s s2o*l1 -(c(i)(
in1i)i1*ali6(1
MNT as n((1(1 to ac2i()(t-(at+(nt goals, p-(f(-a0l p-o)i1(1 0
a -(gist(-(1 1i(titian fa+ilia- >it2 t2(
co+pon(nts of 1ia0(t(s MNT. B
Bot2 t2( a+o*nt g-a+s of ca-0o21-at(
as >(ll as t2( tp( of ca-0o21-at(
in a foo1 infl*(nc( 0loo1 gl*cos( l()(l.
Monito-ing total g-a+s of ca-0o21-at(,
>2(t2(- 0 *s( of (=c2ang(s o-ca-0o21-at( co*nting, -(+ains a 8(
Table1'Correlation between A1C level and
mean plasma glucose levels on multiple testing
over 2! months "2!#
AC K
M(an plas+a gl*cos(+g$1l ++ol$l
9 75 !.5
! ! :.5
' &5 .5: &4 7.5
&!5 5.5 7 !.5
& 745 :.5
Position Statement
DIABETES CARE, "OLME &:,
S##LEMENT , ANAR% &9 S
st-at(g in ac2i()ing glc(+ic cont-ol.
A
T2( *s( of t2( glc(+ic in1(=$glc(+ic
-
7/25/2019 Standar Pengobatan Dm
14/69
loa1 +a p-o)i1( an a11itional 0(n(fit
o)(- t2at o0s(-)(1 >2(n total ca-0o21-at(
is consi1(-(1 alon(. B
Lo>/ca-0o21-at( 1i(ts -(st-icting total
ca-0o21-at( to7 g$1a a-( not-(co++(n1(1 in t2( +anag(+(nt of
1ia0(t(s. E To -(1*c( t2( -is8 of n(p2-opat2, p-ot(in
inta8( s2o*l1 0( li+it(1 to t2( -(co++(n1(1
1i(ta- allo>anc( RDA
.' g$8g in t2os( >it2 an 1(g-(( of
CD. B
Sat*-at(1 fat inta8( s2o*l1 0( !K of
total calo-i(s. A
Inta8( of trans fat s2o*l1 0( +ini+i6(1.
E
?(ig2t loss is -(co++(n1(1 fo- all
o)(->(ig2t BMI &5. @&:.: 8g$+& o-
o0(s( BMI 7. 8g$+& a1*lts >2o2a)(, o- a-( at -is8 fo- 1()(loping, tp(
& 1ia0(t(s. E
T2( p-i+a- app-oac2 fo- ac2i()ing
>(ig2t loss is t2(-ap(*tic lif(stl(c2ang(, >2ic2 incl*1(s a -(1*ction in
(n(-g inta8( an1 an inc-(as( in p2sical
acti)it. A +o1(-at( 1(c-(as( in calo-ic
0alanc( 5 @, 8cal$1a >ill
-(s*lt in a slo> 0*t p-og-(ssi)( >(ig2t
loss @& l0$>((8. Fo- +ost pati(nts,
>(ig2t loss 1i(ts s2o*l1 s*ppl at l(ast
, @,& 8cal$1a fo- >o+(n an1,& @,9 8cal$1a fo- +(n. E
Initial p2sical acti)it -(co++(n1ations
s2o*l1 0( +o1(st an1 0as(1 on
t2( pati(ntPs >illingn(ss an1 a0ilit,
g-a1*all inc-(asing t2( 1*-ation an1
f-(((8 goal at
l(ast 5 +in$>((8. G-(at(- acti)it
l()(ls of at l(ast 2$1a of +o1(-at(
>al8ing o- 7 +in$1a of )igo-o*sJogging acti)it +a 0( n((1(1 to
ac2i()( s*cc(ssf*l long/t(-+ >(ig2tloss. E
D-*g t2(-ap fo- o0(sit an1 s*-g(- to
in1*c( >(ig2t loss +a 0( app-op-iat(
in s(l(ct(1 pati(nts. E
Nonn*t-iti)( s>((t(n(-s a-( saf( >2(n
cons*+(1 >it2in t2( acc(pta0l( 1ail
inta8( l()(ls (sta0lis2(1 0 t2( Foo1
an1 D-*g A1+inist-ation FDA. A
If a1*lts >it2 1ia0(t(s c2oos( to *s(
alco2ol, 1ail inta8( s2o*l1 0( li+it(1
to a +o1(-at( a+o*nt on( 1-in8 p(-
1a o- l(ss fo- a1*lt >o+(n an1 t>o
1-in8s p(- 1a o- l(ss fo- a1*lt +(non( 1-in8 is 1(fin(1 as & o6 0((-, 5 o6
>in(, o- .5 o6 1istill(1 spi-its. A Ro*tin( s*ppl(+(ntation >it2 antio=i1ants,
s*c2 as )ita+ins E an1 C an1
/ca-ot(n(, is not a1)is(1 0(ca*s( of
lac8 of ()i1(nc( of (fficac an1 conc(-n
-(lat(1 to long/t(-+ saf(t. A
B(n(fit f-o+ c2-o+i*+ s*ppl(+(ntation
in p(opl( >it2 1ia0(t(s o- o0(sit
2as not 0((n concl*si)(l 1(+onst-at(1
an1, t2(-(fo-(, cannot 0( -(co++(n1(1.
E
MNT is an int(g-al co+pon(nt of 1ia0(t(s
p-()(ntion, +anag(+(nt, an1 s(lf+anag(+(nt(1*cation. In a11ition to its
-ol( in p-()(nting an1 cont-olling 1ia0(t(s,
t2( ADA -(cogni6(s t2( i+po-tanc( of
n*t-ition as an (ss(ntial co+pon(nt of ano)(-all 2(alt2 lif(stl( . T2(s( g*i1(lin(s
a-( 0as(1 on p-incipl(s of goo1 n*t-ition
fo- t2( o)(-all pop*lation f-o+ t2( &5
Di(ta- G*i1(lin(s an1 t2( RDAs f-o+ t2(
Instit*t( of M(1icin( of t2( National
Aca1(+i(s of Sci(nc(s. A -()i(> of t2(
()i1(nc( an1 1(tail(1 info-+ation can 0(
fo*n1 in t2( && ADA t(c2nical -()i(>on t2is topic 75 an1 t2( &4 ADA
Stat(+(nts -(ga-1ing 1i(ta- ca-0o21-at(
79 an1 >(ig2t +anag(+(nt. 7!.
Goal of MNT t2at appli(s to in1i)i1*als
>it2 p-(/1ia0(t(s
D(c-(as( t2( -is8 of 1ia0(t(s an1 C"D0 p-o+oting p2sical acti)it an1
2(alt2 foo1 c2oic(s t2at -(s*lt in +o1(-at(
>(ig2t loss t2at is +aintain(1 o-,
at a +ini+*+, p-()(nts >(ig2t gain.Goal of MNT t2at appli(s to all in1i)i1*als
>it2 1ia0(t(s #-()(nt an1 t-(at t2( c2-onic co+plications
of 1ia0(t(s 0 attaining an1 +aintaining
opti+al +(ta0olic o*tco+(s,
incl*1ing 0loo1 gl*cos( an1 AC l()(l,
LDL an1 3DL c2ol(st(-ol an1 t-iglc(-i1(
l()(ls, 0loo1 p-(ss*-(, an1 0o1
>(ig2t Ta0l( 9.
Ac2i()ing n*t-ition/-(lat(1 goals -(
-
7/25/2019 Standar Pengobatan Dm
15/69
a coo-1inat(1 t(a+ (ffo-t t2at incl*1(s
t2( acti)( in)ol)(+(nt of t2( p(-son >it2
p-(/1ia0(t(s o- 1ia0(t(s. B(ca*s( of t2(
co+pl(=it of n*t-ition iss*(s, it is -(co++(n1(1
t2at a -(gist(-(1 1i(titian >2o is8no>l(1g(a0l( an1 s8ill(1 in i+pl(+(nting
n*t-ition t2(-ap into 1ia0(t(s +anag(+(ntan1 (1*cation 0( t2( t(a+
+(+0(- >2o p-o)i1(s MNT. 3o>()(-, it
is (ss(ntial t2at all t(a+ +(+0(-s a-(
8no>l(1g(a0l( a0o*t n*t-ition t2(-ap
an1 a-( s*ppo-ti)( of t2( p(-son >it2 1ia0(t(s
>2o n((1s to +a8( lif(stl(
c2ang(s.
MNT in)ol)(s a n*t-ition ass(ss+(nt
to ()al*at( t2( pati(ntPs foo1 inta8(, +(ta0olic
stat*s, lif(stl(, -(a1in(ss to +a8(
c2ang(s, goal s(tting, 1i(ta- inst-*ction,
an1 ()al*ation. To facilitat( a12(-(nc(,t2( plan s2o*l1 0( in1i)i1*ali6(1 an1
ta8( into acco*nt in1i)i1*al c*lt*-al, lif(stl(,
an1 financial consi1(-ations. Monito-ing
of gl*cos( an1 AC, lipi1s, 0loo1p-(ss*-(, an1 -(nal stat*s is (ss(ntial to
()al*at( n*t-ition/-(lat(1 o*tco+(s. If
goals a-( not +(t Ta0l( 9, c2ang(s +*st
0( +a1( in t2( o)(-all 1ia0(t(s ca-( an1
+anag(+(nt plan.
?(ig2t +anag(+(nt 7!
O)(->(ig2t an1 o0(sit a-( st-ongl
lin8(1 to t2( 1()(lop+(nt of tp( & 1ia0(t(san1 can co+plicat( its +anag(+(nt.
O0(sit is also an in1(p(n1(nt -is8 facto-
fo- 2p(-t(nsion an1 1slipi1(+ia as >(ll
as C"D, >2ic2 is t2( +aJo- ca*s( of 1(at2
in t2os( >it2 1ia0(t(s. Mo1(-at( >(ig2t
loss i+p-o)(s glc(+ic cont-ol, -(1*c(sC"D -is8, an1 can p-()(nt t2( 1()(lop+(nt
of tp( & 1ia0(t(s in t2os( >it2 p-(1ia0(t(s.
T2(-(fo-(, >(ig2t loss is an
i+po-tant t2(-ap(*tic st-at(g in all o)(->(ig2to- o0(s( in1i)i1*als >2o 2a)(
tp( & 1ia0(t(s o- a-( at -is8 fo- 1()(loping1ia0(t(s. T2( p-i+a- app-oac2 fo-
ac2i()ing >(ig2t loss, in t2( )ast +aJo-it
of cas(s, is t2(-ap(*tic lif(stl( c2ang(,
>2ic2 incl*1(s a -(1*ction in (n(-g inta8(
an1 an inc-(as( in p2sical acti)it. A
+o1(-at( 1(c-(as( in calo-ic 0alanc(
5 @, 8cal$1a >ill -(s*lt in a slo>
0*t p-og-(ssi)( >(ig2t loss @& l0$
>((8. Fo- +ost pati(nts, >(ig2t loss 1i(ts
s2o*l1 s*ppl at l(ast , @,&
8cal$1a fo- >o+(n an1 ,& @,9
8cal$1a fo- +(n.
In s(l(ct(1 pati(nts, 1-*g t2(-ap toac2i()( >(ig2t loss as an a1J*nct to lif(stl(
c2ang( +a 0( app-op-iat( 7'.3o>()(-, it is i+po-tant to not( t2at -(gain
of >(ig2t co++onl occ*-s on 1iscontin*ation
of +(1ication. In pati(nts
>it2 s()(-($+o-0i1 o0(sit, s*-gical options,
s*c2 as gast-ic 0pass an1 gast-oplast,
+a 0( app-op-iat( an1 allo>
significant i+p-o)(+(nt in glc(+ic cont-ol
>it2 -(1*ction o- 1iscontin*ation of
+(1ications 7:. It is i+po-tant to f*ll
()al*at( t2( pati(nt fo- (=isting o- -is8 fo-
C"D an1 i+p-o)( glc(+ic cont-ol p-(op(-ati)(l
in o-1(- to 1(c-(as( t2( -is8 ofco+plications. It is i+po-tant to co*ns(l
pati(nts on t2( -is8s of s*-g(-, incl*1ing
+o-talit, 1(p-(ssion, 2poglc(+ia, n*t-itional
1(fici(nci(s, ost(opo-osis, an1>(ig2t -(gain o)(- t2( long t(-+. "(-
Standards of Medical Care
S& DIABETES CARE, "OLME &:,
S##LEMENT , ANAR% &9
littl( 1ata a-( c*--(ntl a)aila0l( on t2(
long/t(-+ cons((ig2t loss in p(opl( >it2 1ia0(t(s. T2(
pot(ntial 0(n(fits s2o*l1 0( >(ig2(1against s2o-t/ an1 long/t(-+ -is8s 4.
#2sical acti)it is an i+po-tant co+pon(nt
of a co+p-(2(nsi)( >(ig2t+anag(+(nt
p-og-a+. R(g*la-
+o1(-at(/int(nsit p2sical acti)it (n2anc(s
long/t(-+ >(ig2t +aint(nanc(.R(g*la- acti)it also i+p-o)(s ins*lin
s(nsiti)it, glc(+ic cont-ol, an1 s(l(ct(1
-is8 facto-s fo- C"D i.(., 2p(-t(nsion
an1 1slipi1(+ia, an1 inc-(as(1 a(-o0icfitn(ss 1(c-(as(s t2( -is8 of co-ona- 2(a-t
1is(as( C3D. Initial p2sical acti)it-(co++(n1ations s2o*l1 0( +o1(st,
0as(1 on t2( pati(ntPs >illingn(ss an1
a0ilit, g-a1*all inc-(asing t2( 1*-ation
an1 f-(((8, >2(n
possi0l(. G-(at(- acti)it l()(ls of at l(ast
2$1a of +o1(-at( >al8ing o- 7 +in$
1a of )igo-o*s Jogging acti)it +a 0(
-
7/25/2019 Standar Pengobatan Dm
16/69
n((1(1 to ac2i()( s*cc(ssf*l long/t(-+
>(ig2t loss.
Di(ta- ca-0o21-at( 79
R(g*lation of 0loo1 gl*cos( to ac2i()(
n(a-/no-+al l()(ls is a p-i+a- goal in t2(+anag(+(nt of 1ia0(t(s, an1 t2*s, 1i(ta-
t(c2niing a +(al a-( i+po-tant in li+iting
t2( co+plications of 1ia0(t(s. Bot2 t2(
a+o*nt g-a+s an1 tp( of ca-0o21-at(
in a foo1 infl*(nc( 0loo1 gl*cos( l()(l.
T2( total a+o*nt of ca-0o21-at( cons*+(1
is a st-ong p-(1icto- of glc(+ic
-(spons(, an1 t2*s, +onito-ing total
g-a+s of ca-0o21-at(, >2(t2(- 0 *s( of
(=c2ang(s o- ca-0o21-at( co*nting, -(+ains
a 8( st-at(g in ac2i()ing glc(+ic
cont-ol. A -(c(nt analsis of t2( -an1o+i6(1
cont-oll(1 t-ials t2at 2a)( (=a+in(1t2( (fficac of t2( glc(+ic in1(= a +(as*-(
of t2( (ff(ct of tp( of ca-0o21-at(
on o)(-all 0loo1 gl*cos( cont-ol in1icat(s
t2at t2( *s( of t2is t(c2ni2(n total ca-0o21-at( is consi1(-(1
alon(.
Lo>/ca-0o21-at( 1i(ts a-( not -(co++(n1(1
in t2( +anag(+(nt of 1ia0(t(s.
Alt2o*g2 1i(ta- ca-0o21-at( is t2(
+aJo- cont-i0*to- to postp-an1ial gl*cos(
conc(nt-ation, it is an i+po-tant so*-c( of(n(-g, >at(-/sol*0l( )ita+ins an1 +in(-als,
an1 fi0(-. T2*s, in ag-((+(nt >it2
t2( National Aca1(+ of Sci(nc(s@Foo1
an1 N*t-ition Boa-1 4, a -(co++(n1(1
-ang( of ca-0o21-at( inta8( is
45@95K of total calo-i(s. In a11ition, 0(ca*s(t2( 0-ain an1 c(nt-al n(-)o*s sst(+
2a)( an a0sol*t( -(it2 1ia0(t(s.
T2( 1i(ta- -(f(-(nc( inta8( DRI/
acc(pta0l( +ac-on*t-i(nt 1ist-i0*tion
-ang( fo- p-ot(in is @75K of (n(-g inta8(
an1 t2( RDA is .' g 2ig2/t 1a 4.
Di(ta- inta8( of p-ot(in is si+ila- to
t2at of t2( g(n(-al p*0lic in in1i)i1*als>it2 1ia0(t(s an1 *s*all 1o(s not (=c((1
&K of (n(-g inta8(. Inta8( of p-ot(in int2is -ang( +a 0( a -is8 facto- fo- t2( 1()(lop+(nt
of 1ia0(tic n(p2-opat2 4&.
Bas(1 on st*1i(s in pati(nts >it2 )a-ing
stag(s of n(p2-opat2 4&@ 44, it s((+s
p-*1(nt to li+it p-ot(in inta8( in t2os(
>it2 1ia0(t(s to t2( RDA .' g$8g,
>2ic2 >o*l1 0( K of total calo-i(s.
Di(ta- fat
Sat*-at(1 an1 trans fatt aci1s a-( t2(
p-incipal 1i(ta- 1(t(-+inant of plas+a
LDL c2ol(st(-ol, t2( +aJo- -is8 facto- fo-
C"D. In non1ia0(tic in1i)i1*als, -(1*cingsat*-at(1 an1 trans fatt aci1s an1
c2ol(st(-ol inta8( 1(c-(as(s plas+a total
an1 LDL c2ol(st(-ol 0*t +a also -(1*c(
3DL c2ol(st(-ol. I+po-tantl, t2( -atio ofLDL to 3DL c2ol(st(-ol is not a1)(-s(l
aff(ct(1. St*1i(s in in1i)i1*als >it2 1ia0(t(s
1(+onst-ating t2( (ff(cts of sp(cific
p(-c(ntag(s of 1i(ta- sat*-at(1 an1 trans
fatt aci1s an1 sp(cific a+o*nts of 1i(ta-
c2ol(st(-ol on C"D -is8 a-( not a)aila0l(.
3o>()(-, t2os( >it2 1ia0(t(s a-( consi1(-(1
to 0( at si+ila- -is8 to t2os( >it2 apast 2isto- of C"D. T2(-(fo-(, 0(ca*s( of
a lac8 of sp(cific info-+ation, t2( goal fo-
1i(ta- fat inta8( a+o*nt an1 tp( fo-
in1i)i1*als >it2 1ia0(t(s is t2( sa+( as
fo- t2os( >it2o*t 1ia0(t(s >it2 a 2isto-
of C"D. T2( +ost -(c(nt g*i1(lin(s f-o+t2( National C2ol(st(-ol E1*cation #-og-a+
-(co++(n1 t2at total fat 0( &5@
75K of total calo-i(s an1 sat*-at(1 fat
!K 74. G*i1(lin(s f-o+ t2( A+(-ican3(a-t Association also -(co++(n1 t2at
sat*-at(1 fat 0(!K in t2os( >it2 1ia0(t(s,gi)(n t2(i- inc-(as(1 -is8 of C"D
45,49. Inta8( of trans fat s2o*l1 0(
+ini+i6(1.
Opti+al +ac-on*t-i(nt +i=
Fo- t2os( in1i)i1*als s((8ing g*i1anc(
-(ga-1ing +ac-on*t-i(nt 1ist-i0*tion, t2(
DRIs +a 0( 2(lpf*l T2( DRI -(po-t -(co++(n1s
t2at to +((t t2( 0o1Ps 1ail
-
7/25/2019 Standar Pengobatan Dm
17/69
n*t-itional n((1s >2il( +ini+i6ing -is8
fo- c2-onic 1is(as(s, a1*lts in g(n(-al,
not sp(cificall t2os( >it2 1ia0(t(s
s2o*l1 cons*+( 45@95K of total (n(-g
f-o+ ca-0o21-at(, &@75K f-o+ fat,an1 @75K f-o+ p-ot(in 4. Alt2o*g2
n*+(-o*s st*1i(s 2a)( att(+pt(1 toi1(ntif t2( opti+al co+0ination of +ac-on*t-i(nts
fo- t2os( >it2 1ia0(t(s, it is *nli8(l
t2at an on( s*c2 co+0ination of
+ac-on*t-i(nts (=ists. T2( 0(st +i= of
ca-0o21-at(,
p-ot(in, an1 fat app(a-s to )a-
1(p(n1ing on in1i)i1*al ci-c*+stanc(s.
Fi0(-
Si+ila- to t2( g(n(-al pop*lation, p(opl(
>it2 1ia0(t(s a-( (nco*-ag(1 to c2oos( a
)a-i(t of fi0(-/containing foo1s, s*c2 as
l(g*+(s, fi0(-/-ic2 c(-(als 5 g fi0(-$s(-)ing, as >(ll as f-*its, )(g(ta0l(s, an1
>2ol(/g-ain p-o1*cts 0(ca*s( t2( p-o)i1(
)ita+ins, +in(-als, fi0(-, an1 ot2(-
s*0stanc(s i+po-tant fo- goo1 2(alt2.R(1*c(1 calo-i( s>((tn(-s
R(1*c(1 calo-i( s>((t(n(-s app-o)(1 0
t2( FDA incl*1( s*ga- alco2ols (-t2-itol,
21-og(nat(1 sta-c2 21-olsat(s,
iso+alt, lactitol, +altitol, +annitol, so-0itol,
an1 =litol an1 tagatos(. St*1i(s *sing
s*0J(cts >it2 an1 >it2o*t 1ia0(t(s
2a)( s2o>n t2at s*ga- alco2ols p-o1*c( alo>(- postp-an1ial gl*cos( -(spons( t2an
s*c-os( o- gl*cos( an1 2a)( lo>(- a)aila0l(
(n(-g. S*ga- alco2ols contain, on
a)(-ag(, & calo-i(s$g-a+ on(/2alf t2(
calo-i(s of ot2(- s>((t(n(-s s*c2 as s*c-os(.
?it2 foo1s containing s*ga- alco2ols,s*0t-action of on(/2alf of s*ga-
alco2ol g-a+s f-o+ total ca-0o21-at(
g-a+s is app-op-iat(, pa-tic*la-l >2(n
*sing t2( ca-0o21-at( co*nting +(t2o1fo- +(al planning. T2(-( is no ()i1(nc(
t2at t2( a+o*nts of s*ga- alco2ol li8(l to0( cons*+(1 >ill -(s*lt in significant -(1*ction
in (n(-g inta8( o- long/t(-+ i+p-o)(+(nt
in glc(+ia. T2( *s( of s*ga-
alco2ols app(a-s to 0( saf(.
T2( FDA 2as app-o)(1 fi)( nonn*t-iti)(
s>((t(n(-s fo- *s( in t2( .S. ac(s*lfa+(
potassi*+, aspa-ta+(, n(ota+(,
sacc2a-in, an1 s*c-alos(. All 2a)( *n1(-gon(
-igo-o*s sc-*tin an1 2a)( 0((n
s2o>n to 0( saf( >2(n cons*+(1 0 t2(
p*0lic, incl*1ing p(opl( >it2 1ia0(t(s
an1 >o+(n >2o a-( p-(gnant.
Position Statement
DIABETES CARE, "OLME &:,
S##LEMENT , ANAR% &9 S7Antio=i1ants
Sinc( 1ia0(t(s +a 0( a stat( of inc-(as(1
o=i1ati)( st-(ss, t2(-( 2as 0((n int(-(st in
p-(sc-i0ing antio=i1ant )ita+ins to in1i)i1*als
>it2 1ia0(t(s. ?2il( o0s(-)ational
st*1i(s 2a)( s2o>n a co--(lation
0(t>((n 1i(ta- o- s*ppl(+(ntal cons*+ption
of antio=i1ants an1 a )a-i(t of
clinical o*tco+(s s*c2 as p-()(ntion of
1is(as( stat(s 75,4!, la-g( plac(0ocont-oll(1
clinical t-ials 2a)( fail(1 to
s2o> a 0(n(fit an1, in so+( instanc(s,2a)( s*gg(st(1 a1)(-s( (ff(cts 75,4!.
C2-o+i*+
S()(-al s+all st*1i(s 2a)( s*gg(st(1 a
-ol( fo- c2-o+i*+ s*ppl(+(ntation int2( +anag(+(nt of gl*cos( intol(-anc(,
0o1 >(ig2t, GDM, an1 co-ticost(-oi1in1*c(1
1ia0(t(s 4' @5. Also, plac(0ocont-oll(1
st*1i(s con1*ct(1 in C2ina
fo*n1 t2at c2-o+i*+ s*ppl(+(ntation
2a1 0(n(ficial (ff(cts on glc(+ia, alt2o*g2
it is i+po-tant to not( t2at t2(
st*1 pop*lation in C2ina +a 2a)( 2a1+a-ginal 0as(lin( c2-o+i*+ stat*s. A -(c(nt
FDA stat(+(nt in1icat(1 t2at t2(-( is
ins*ffici(nt ()i1(nc( to s*ppo-t an of t2(
p-opos(1 2(alt2 clai+s fo- c2-o+i*+
s*ppl(+(ntation. T2( FDA concl*1(1
t2at alt2o*g2 a s+all st*1 s*gg(st(1 t2atc2-o+i*+ picolinat( +a -(1*c( t2( -is8
of ins*lin -(sistanc(, t2( (=ist(nc( of a -(lations2ip
0(t>((n c2-o+i*+ picolinat(
an1 (it2(- ins*lin -(sistanc( o- tp( & 1ia0(t(s>as 2ig2l *nc(-tain s(( c2-o+i*+
picolinat( an1 ins*lin -(sistanc( at>>>.cfsan.f1a.go)$1+s$(ig2t 5.
Alco2ol
Fo- in1i)i1*als >it2 1ia0(t(s, t2( sa+(
p-(ca*tions appl -(ga-1ing t2( *s( of alco2ol
-
7/25/2019 Standar Pengobatan Dm
18/69
t2at appl to t2( g(n(-al pop*lation.
If in1i)i1*als c2oos( to *s( alco2ol,
alco2ol/containing 0()(-ag(s s2o*l1 0(
li+it(1 to a +o1(-at( a+o*nt l(ss t2an
on( 1-in8 p(- 1a fo- a1*lt >o+(n an1l(ss t2an t>o 1-in8s p(- 1a fo- a1*lt +(n.
On( alco2ol containing 0()(-ag( is 1(fin(1as & o6 0((-, 5 o6 >in(, o- .5 o6 1istill(1
spi-its. Eac2 contains 5 g alco2ol.
E. DSME
R(co++(n1ations
#(opl( >it2 1ia0(t(s s2o*l1 -(c(i)(
DSME acco-1ing to national stan1a-1s
>2(n t2(i- 1ia0(t(s is 1iagnos(1 an1 as
n((1(1 t2(-(aft(-. B
DSME s2o*l1 0( p-o)i1(1 0 2(alt2
ca-( p-o)i1(-s >2o a-( (ll/0(ing is
st-ongl associat(1 >it2 positi)( 1ia0(t(so*tco+(s. C
DSME s2o*l1 0( -(i+0*-s(1 0 t2i-1pa-t
pao-s. E
DSME is an (ss(ntial (l(+(nt of 1ia0(t(s
ca-( 5&@5', an1 National Stan1a-1s fo-
DSME a-( 0as(1 on ()i1(nc( fo- its 0(n(fits.
E1*cation 2(lps p(opl( >it2 1ia0(t(s
initiat( (ff(cti)( s(lf/ca-( >2(n t2(a-( fi-st 1iagnos(1. Ongoing DSME also
2(lps p(opl( >it2 1ia0(t(s +aintain (ff(cti)(
s(lf/+anag(+(nt as t2(i- 1ia0(t(s
p-(s(nts n(> c2all(ng(s an1 t-(at+(nt
a1)anc(s 0(co+( a)aila0l(. DSME 2(lps
pati(nts opti+i6( +(ta0olic cont-ol, p-()(ntan1 +anag( co+plications, an1
+a=i+i6( it2 DSME foc*singon p-o)i1ing info-+ation to a
s8ill/0as(1 app-oac2 t2at foc*s(s on
2(lping t2os( >it2 1ia0(t(s +a8( info-+(1
s(lf/+anag(+(nt c2oic(s. S()(-al
st*1i(s 2a)( fo*n1 t2at DSME is associat(1
>it2 i+p-o)(1 1ia0(t(s 8no>l(1g(
57, i+p-o)(1 s(lf/ca-( 0(2a)io- 57,
i+p-o)(1 clinical o*tco+(s s*c2 as lo>(-
AC 54,55,5!,5', lo>(- s(lf/-(po-t(1
>(ig2t 57, an1 i+p-o)(1 (-( -(po-t(1 fo-
DSME t2at >(-( long(- an1 incl*1(1 follo>/
*p s*ppo-t 57, >(-( tailo-(1 to in1i)i1*aln((1s an1 p-(f(-(nc(s 5&, an1
a11-(ss(1 psc2osocial iss*(s 5&,57,5!.
T2( national stan1a-1s fo- DSME
ADA/-(cogni6(1 DSME p-og-a+s 2a)(
staff t2at incl*1(s at l(ast a -(gist(-(1
n*-s( an1 a -(gist(-(1 1i(titian t2(s( staff
+*st 0( c(-tifi(1 1ia0(t(s (1*cato-s o-
2a)( -(c(nt (=p(-i(nc( in 1ia0(t(s (1*cation
an1 +anag(+(nt. T2( c*--ic*l*+ of
ADA/-(cogni6(1 DSME p-og-a+s +*st
co)(- all a-(as of 1ia0(t(s +anag(+(nt,
>it2 t2( ass(ss(1 n((1s of t2( in1i)i1*al
1(t(-+ining >2ic2 a-(as a-( a11-(ss(1.All ADA/-(cogni6(1 DSME p-og-a+s *tili6(
a p-oc(ss of contin*o*s >>.2cfa.go)$co)(-ag(.
F. #2sical acti)it
R(co++(n1ations To i+p-o)( glc(+ic cont-ol, assist
>it2 >(ig2t +aint(nanc(, an1 -(1*c(
-is8 of C"D, at l(ast 5 +in$>((8 of
+o1(-at(/int(nsit a(-o0ic p2sical acti)it
5@!K of +a=i+*+ 2(a-t -at(
is -(co++(n1(1 an1$o- at l(ast : +in$>((8 of )igo-o*s a(-o0ic (=(-cis(
!K of +a=i+*+ 2(a-t -at(. T2(
p2sical acti)it s2o*l1 0( 1ist-i0*t(1
o)(- at l(ast 7 1as$>((8 an1 >it2 no+o-( t2an & cons(c*ti)( 1as >it2o*t
p2sical acti)it. A In t2( a0s(nc( of cont-ain1ications,
p(opl( >it2 tp( & 1ia0(t(s s2o*l1 0(
(nco*-ag(1 to p(-fo-+ -(sistanc( (=(-cis(
t2-(( ti+(s a >((8, ta-g(ting all
+aJo- +*scl( g-o*ps, p-og-(ssing to
t2-(( s(ts of ' @ -(p(titions at a
>(ig2t t2at cannot 0( lift(1 +o-( t2an
'@ ti+(s. A
-
7/25/2019 Standar Pengobatan Dm
19/69
In1ications fo- g-a1(1 (=(-cis( t(st
>it2 (l(ct-oca-1iog-a+ +onito-ing
A g-a1(1 (=(-cis( t(st >it2 (l(ct-oca-1iog-a+
ECG +onito-ing s2o*l1 0(
s(-io*sl consi1(-(1 0(fo-( *n1(-ta8inga(-o0ic p2sical acti)it >it2 int(nsit
(=c((1ing t2( 1(+an1s of ()(-1ali)ing +o-( int(ns( t2an 0-is8 >al8ing
in p-()io*sl s(1(nta- 1ia0(tic in1i)i1*als
>2os( /(a- -is8 of a
co-ona- ()(nt is li8(l to 0( K.
ADA t(c2nical -()i(>s on (=(-cis( in pati(nts
>it2 1ia0(t(s 2a)( s*++a-i6(1 t2(
)al*( of (=(-cis( in t2( 1ia0(t(s +anag(+(nt
plan 5:,9. R(g*la- (=(-cis( 2as
0((n s2o>n to i+p-o)( 0loo1 gl*cos(
cont-ol, -(1*c( ca-1io)asc*la- -is8 facto-s,
cont-i0*t( to >(ig2t loss, an1 i+p-o)(
>(ll/0(ing. F*-t2(-+o-(, -(g*la-(=(-cis( +a p-()(nt tp( & 1ia0(t(s in
2ig2/-is8 in1i)i1*als ' @.
D(finitions
T2( follo>ing 1(finitions a-( 0as(1 ont2os( o*tlin(1 in #2sical Acti)it an1
3(alt2, t2( ::9 -(po-t of t2( S*-g(on
G(n(-al 9. #2sical acti)it is 1(fin(1
Standards of Medical Care
S4 DIABETES CARE, "OLME &:,
S##LEMENT , ANAR% &9
as 0o1il +o)(+(nt p-o1*c(1 0 t2(
cont-action of s8(l(tal +*scl( t2at -(al8ing,0iccling, Jogging, s>i++ing, >at(- a(-o0ics,
an1 +an spo-ts. R(sistanc( (=(-cis(consists of acti)iti(s t2at *s(
+*sc*la- st-(ngt2 to +o)( a >(ig2t o-
>o-8 against a -(sisti)( loa1. E=a+pl(s
incl*1( >(ig2t lifting an1 (=(-cis(s *sing
>(ig2t +ac2in(s.
Eff(cts of st-*ct*-(1 (=(-cis(
int(-)(ntions on glc(+ic cont-ol
an1 0o1 >(ig2t in tp( & 1ia0(t(s
Bo*l(W (t al. 9& *n1(-too8 a sst(+atic
-()i(> an1 +(ta/analsis on t2( (ff(cts of
st-*ct*-(1 (=(-cis( int(-)(ntions in clinical
t-ials of 1*-ation ' >((8s on 30Ac
an1 0o1 +ass in p(opl( >it2 tp( & 1ia0(t(s.T>(l)( a(-o0ic t-aining st*1i(s
an1 t>o -(sistanc( t-aining st*1i(s >(-(incl*1(1 totaling 54 s*0J(cts, an1 t2(
-(s*lts >(-( pool(1 *sing stan1a-1 +(taanaltic
statistical +(t2o1s. #ostint(-)(ntion
30Ac >as significantl lo>(- in
(=(-cis( t2an cont-ol g-o*ps. M(ta-(g-(ssion
confi-+(1 t2at t2( 0(n(ficial (ff(ct of
(=(-cis( on 30Ac >as in1(p(n1(nt of
an (ff(ct on 0o1 >(ig2t. T2(-(fo-(,
st-*ct*-(1 (=(-cis( p-og-a+s 2a1 a statisticall
an1 clinicall significant 0(n(ficial
(ff(ct on glc(+ic cont-ol, an1 t2is (ff(ct
>as not +(1iat(1 p-i+a-il 0 >(ig2tloss.
Bo*l(W (t al. 97 lat(- *n1(-too8 a
+(ta/analsis of t2( int(--(lations2ips
a+ong (=(-cis( int(nsit, (=(-cis( )ol*+(,c2ang( in ca-1io-(spi-ato- fitn(ss,
an1 c2ang( in 30Ac. T2is +(ta/analsis
p-o)i1(s s*ppo-t fo- 2ig2(-/int(nsit a(-o0ic
(=(-cis( in p(opl( >it2 tp( & 1ia0(t(s
as a +(ans of i+p-o)ing 30Ac. T2(s(
-(s*lts >o*l1 p-o)i1( s*ppo-t fo- (nco*-aging
tp( & 1ia0(tic in1i)i1*als >2o
a-( al-(a1 (=(-cising at +o1(-at( int(nsitto consi1(- inc-(asing t2( int(nsit of
t2(i- (=(-cis( in o-1(- to o0tain a11itional
0(n(fits in 0ot2 a(-o0ic fitn(ss an1 glc(+ic
cont-ol.
F-(((8.
T2( A+(-ican Coll(g( of Spo-ts M(1icin(no> -(co++(n1s -(sistanc( t-aining 0(
incl*1(1 in fitn(ss p-og-a+s fo- a1*lts>it2 tp( & 1ia0(t(s 94. R(sistanc( (=(-cis(
i+p-o)(s ins*lin s(nsiti)it to
a0o*t t2( sa+( (=t(nt as a(-o0ic (=(-cis(
95. T>o clinical t-ials p*0lis2(1 in &&
p-o)i1(1 st-ong ()i1(nc( fo- t2( )al*( of
-(sistanc( t-aining in tp( & 1ia0(t(s
99,9!.
E)al*ation of t2( 1ia0(tic pati(nt
-
7/25/2019 Standar Pengobatan Dm
20/69
0(fo-( -(co++(n1ing an (=(-cis(
p-og-a+
B(fo-( 0(ginning a p-og-a+ of p2sical
acti)it +o-( )igo-o*s t2an 0-is8 >al8ing,
p(opl( >it2 1ia0(t(s s2o*l1 0( ass(ss(1fo- con1itions t2at +ig2t 0(
associat(1 >it2 inc-(as(1 li8(li2oo1 ofC"D o- t2at +ig2t cont-ain1icat( c(-tain
tp(s of (=(-cis( o- p-(1ispos( to inJ*-,
s*c2 as *ncont-oll(1 2p(-t(nsion, s()(-(
a*tono+ic n(*-opat2, s()(-( p(-ip2(-al
n(*-opat2, an1 p-(p-olif(-ati)(
o- p-olif(-ati)( -(tinopat2 o- +ac*la-
(1(+a. T2( pati(ntPs ag( an1 p-()io*s
p2sical acti)it l()(l s2o*l1 0( consi1(-(1.
A -(c(nt sst(+atic -()i(> fo- t2(
.S. #-()(nti)( S(-)ic(s Tas8 Fo-c( ca+(
to t2( concl*sion t2at st-(ss t(sts s2o*l1
*s*all not 0( -(co++(n1(1 to 1(t(ctisc2(+ia in as+pto+atic in1i)i1*als at
lo> CAD -is8 K -is8 of a ca-1iac
()(nt o)(- (a-s 0(ca*s( t2( -is8s of
s*0s((ig2(1 t2( (=p(ct(1
0(n(fits f-o+ 1(t(ction of p-()io*sl
*ns*sp(ct(1 isc2(+ia 9',9:
E=(-cis( in t2( p-(s(nc( of
nonopti+al glc(+ic cont-ol
3er/lceia. ?2(n p(opl( >it2 tp(
1ia0(t(s a-( 1(p-i)(1 of ins*lin fo-
&@4' 2 an1 8(totic, (=(-cis( can >o-s(n2p(-glc(+ia an1 8(tosis !. "igo-o*s
acti)it s2o*l1 p-o0a0l 0( a)oi1(1 in t2(
p-(s(nc( of 8(tosis. T2(-(fo-(, p-o)i1(1
t2( pati(nt f((ls >(ll an1 *-in( an1$o-
0loo1 8(ton(s a-( n(gati)(, it is not n(c(ssa-
to postpon( (=(-cis( 0as(1 si+plon 2p(-glc(+ia.
3o/lceia. In in1i)i1*als ta8ing ins*lin
an1$o- ins*lin s(c-(tagog*(s, p2sical
acti)it can ca*s( 2poglc(+ia if+(1ication 1os( o- ca-0o21-at( cons*+ption
is not alt(-(1. 3poglc(+ia>o*l1 0( -a-( in 1ia0(tic in1i)i1*als >2o
a-( not t-(at(1 >it2 ins*lin o- ins*lin
s(c-(tagog*(s. A11(1 ca-0o21-at(
s2o*l1 0( ing(st(1 if p-(/(=(-cis( gl*cos(
l()(ls a-( +g$1l 5.9 ++ol$l !.
?( ag-(( >it2 t2is -(co++(n1ation fo-
in1i)i1*als on ins*lin an1$o- an ins*lin
s(c-(tagog*(. 3o>()(-, t2( -()is(1
g*i1(lin(s cla-if t2at s*ppl(+(nta- ca-0o21-at(
is g(n(-all not n(c(ssa- fo-
in1i)i1*als t-(at(1 onl >it2 1i(t, +(tfo-+in,
/gl*cosi1as( in2i0ito-s an1$o-
THDs >it2o*t ins*lin o- a s(c-(tagog*(!&.
E=(-cis( in t2( p-(s(nc( of sp(cificlong/t(-+ co+plications of 1ia0(t(s
Retino3at4. In t2( p-(s(nc( of p-olif(-ati)(
1ia0(tic -(tinopat2 #DR o- s()(-(
nonp-olif(-ati)( 1ia0(tic -(tinopat2
N#DR, )igo-o*s a(-o0ic o- -(sistanc(
(=(-cis( +a 0( cont-ain1icat(1 0(ca*s(
of t2( -is8 of t-igg(-ing )it-(o*s 2(+o--2ag(
o- -(tinal 1(tac2+(nt !7.
%eri34eral ne5ro3at4. D(c-(as(1 pain
s(nsation in t2( (=t-(+iti(s >o*l1 -(s*lt
in inc-(as(1 -is8 of s8in 0-(a81o>n an1
inf(ction an1 of C2a-cot Joint 1(st-*ction.T2(-(fo-(, in t2( p-(s(nc( of s()(-(
p(-ip2(-al n(*-opat2, it +a 0( 0(st to
(nco*-ag( non@>(ig2t/0(a-ing acti)iti(s
s*c2 as s>i++ing, 0iccling, o- a-+ (=(-cis(s!4,!5.
A5tonoic ne5ro3at4. A*tono+ic
n(*-opat2 can inc-(as( t2( -is8 of (=(-cis(/
in1*c(1 inJ*- 0 1(c-(asing ca-1iac
-(sponsi)(n(ss to (=(-cis(, post*-al 2pot(nsion,
i+pai-(1 t2(-+o-(g*lation
1*( to i+pai-(1 s8in 0loo1 flo> an1
s>(ating, i+pai-(1 nig2t )ision 1*( toi+pai-(1 papilla- -(action, i+pai-(1
t2i-st inc-(asing -is8 of 1(21-ation, an1
gast-opa-(sis >it2 *np-(1icta0l( foo1 1(li)(-
!4. A*tono+ic n(*-opat2 is also
st-ongl associat(1 >it2 C"D in p(opl(
>it2 1ia0(t(s !9,!!. #(opl( >it2 1ia0(tica*tono+ic n(*-opat2 s2o*l1 1(finit(l
*n1(-go ca-1iac in)(stigation
0(fo-( 0(ginning p2sical acti)it +o-(
int(ns( t2an t2( a-( acc*sto+(1 to.
Microalb5in5ria and ne34ro3at4.
#2sical acti)it can ac*t(l inc-(as( *-ina-p-ot(in (=c-(tion. T2(-( is no ()i1(nc(
f-o+ clinical t-ials o- co2o-t st*1i(s
1(+onst-ating t2at )igo-o*s (=(-cis( inc-(as(s
t2( -at( of p-og-(ssion of 1ia0(tic
8i1n( 1is(as(. T2(-( +a 0( no n((1 fo-
an sp(cific (=(-cis( -(st-ictions fo- p(opl(
>it2 1ia0(tic 8i1n( 1is(as( !'.
G. #sc2osocial ass(ss+(nt an1 ca-(
-
7/25/2019 Standar Pengobatan Dm
21/69
R(co++(n1ations
#-(li+ina- ass(ss+(nt of psc2ological
an1 social stat*s s2o*l1 0( incl*1(1
Position Statement
DIABETES CARE, "OLME &:,S##LEMENT , ANAR% &9 S5
as pa-t of t2( +(1ical +anag(+(nt of1ia0(t(s. E
#sc2osocial sc-((ning s2o*l1 incl*1(
0*t is not li+it(1 to attit*1(s a0o*t t2(
illn(ss, (=p(ctations fo- +(1ical +anag(+(nt
an1 o*tco+(s, aff(ct$+oo1,
g(n(-al an1 1ia0(t(s/-(lat(1 2(n a12(-(nc( to t2( +(1ical -(gi+(nis poo-. E
It is p-(f(-a0l( to inco-po-at( psc2ological
t-(at+(nt into -o*tin( ca-(
-at2(- t2an >ait fo- i1(ntification of asp(cific p-o0l(+ o- 1(t(-io-ation in
psc2ological stat*s. E
#sc2ological an1 social stat( can i+pact
t2( pati(ntPs a0ilit to ca-- o*t 1ia0(t(s
ca-( tas8s !:@'4. As a -(s*lt, 2(alt2 stat*s
+a 0( co+p-o+is(1. Fa+il conflict
a-o*n1 1ia0(t(s ca-( tas8s is also co++on
an1 +a int(-f(-( >it2 t-(at+(nto*tco+(s '5. T2(-( a-( oppo-t*niti(s
fo- t2( clinician to ass(ss psc2osocial stat*s
in a ti+(l an1 (ffici(nt +ann(- so
t2at -(f(--al fo- app-op-iat( s(-)ic(s can
0( acco+plis2(1 '9.
( oppo-t*niti(s fo- sc-((ning ofpsc2osocial stat*s occ*- at 1iagnosis,
1*-ing -(g*la-l sc2(1*l(1 +anag(+(nt
)isits, 1*-ing 2ospitali6ations, at 1isco)(-
of co+plications, o- at t2( 1isc-(tionof t2( clinician >2(n p-o0l(+s in gl*cos(
cont-ol, it2
+(1ical -(gi+(n 1*( to s(lf o- ot2(-s
!:,'', 1(p-(ssion >it2 t2( possi0ilit of
s(lf/2a-+ ',', in1ications of an (ating
1iso-1(- ': o- a p-o0l(+ t2at app(a-s
to 0( o-ganic in o-igin, an1
cogniti)( f*nctioning t2at significantl
i+pai-s J*1g+(nt '. In t2(s( cas(s, i++(1iat(
-(f(--al fo- f*-t2(- ()al*ation 0
a +(ntal 2(alt2 sp(cialist fa+ilia- >it2 1ia0(t(s
+anag(+(nt s2o*l1 occ*-. B(2a)io-al
ass(ss+(nt of +anag(+(nt s8ills isalso -(co++(n1(1.
It is p-(f(-a0l( to inco-po-at( psc2ological
t-(at+(nt into -o*tin( ca-( -at2(-
t2an >aiting fo- i1(ntification of a sp(cificp-o0l(+ o- 1(t(-io-ation in psc2ological
stat*s '9. Sc-((ning tools can facilitat(
t2is goal, an1 alt2o*g2 t2( clinician +a
not f((l ill acc(pt -(f(--al fo- ot2(-s(-)ic(s. It is i+po-tant to (sta0lis2 t2at
(+otional >(ll/0(ing is pa-t of 1ia0(t(s
+anag(+(nt '!.
3. R(f(--al fo- 1ia0(t(s +anag(+(nt
Fo- a )a-i(t of -(asons, so+( p(opl( >it2
1ia0(t(s an1 t2(i- 2(alt2 ca-( p-o)i1(-s1o not ac2i()( t2( 1(si-(1 goals of t-(at+(nt
Ta0l( 9. Int(nsification of t2(
t-(at+(nt -(gi+(n is s*gg(st(1 an1 incl*1(s
i1(ntification o- ass(ss+(nt of0a--i(-s to a12(-(nc(, c*lt*-all app-op-iat(
an1 (n2anc(1 DSME, co+anag(+(nt>it2 a 1ia0(t(s t(a+, c2ang( in
p2a-+acological t2(-ap, initiation of o-
inc-(as( in SMBG, +o-( f-(it2 t2( pati(nt, an1 -(f(--al to an (n1oc-inologist.
I. Int(-c*--(nt illn(ss
T2( st-(ss of illn(ss, t-a*+a, an1$o- s*-g(-
f-(
-
7/25/2019 Standar Pengobatan Dm
22/69
8(toaci1osis DA o- non8(totic 2p(-os+ola-
stat(. An con1ition l(a1ing to
1(t(-io-ation in glc(+ic cont-ol n(c(ssitat(s
+o-( f-((-ing ag(nts o-
MNT alon( +a t(+po-a-il -(it2o*t 1ia0(t(s. T2( 2ospitali6(1
pati(nt s2o*l1 0( t-(at(1 0 a p2sician>it2 (=p(-tis( in t2( +anag(+(nt of 1ia0(t(s,
an1 -(c(nt st*1i(s s*gg(st t2at
ac2i()ing )(- st-ing(nt glc(+ic cont-ol
+a -(1*c( +o-talit in t2( i++(1iat(
post+oca-1ial infa-ction p(-io1 :.
Agg-(ssi)( glc(+ic +anag(+(nt >it2
ins*lin +a -(1*c( +o-0i1it in pati(nts
>it2 s()(-( ac*t( illn(ss :&.Fo- f*-t2(- info-+ation on +anag(+(nt
of pati(nts in t2( 2ospital >it2 DA
o- non8(totic 2p(-os+ola- stat(, -(f(- to
t2( ADA position stat(+(nt :.
. 3poglc(+ia
R(co++(n1ations Gl*cos( 5@& g is t2( p-(f(--(1
t-(at+(nt fo- 2poglc(+ia, alt2o*g2
an fo-+ of ca-0o21-at( t2at contains
gl*cos( +a 0( *s(1, an1 t-(at+(nt (ff(ctss2o*l1 0( appa-(nt in 5 +in. E
T-(at+(nt (ff(cts on 2poglc(+ia+a onl 0( t(+po-a-il co--(ct(1.
T2(-(fo-(, plas+a gl*cos( s2o*l1 0(
t(st(1 again in 5 +in as a11itional
t-(at+(nt +a 0( n(c(ssa-. B
Gl*cagon s2o*l1 0( p-(sc-i0(1 fo- all
pati(nts at significant -is8 of s()(-( 2poglc(+ia
an1 1o(s not -(it2 t2(
ca-0o21-at( cont(nt of t2( foo1. Alt2o*g2
p*-( gl*cos( +a 0( t2( p-(f(--(1
t-(at+(nt, an fo-+ of ca-0o21-at( t2at
contains gl*cos( >ill -ais( 0loo1 gl*cos(.
A11ing p-ot(in to ca-0o21-at( 1o(s not
aff(ct t2( glc(+ic -(spons( an1 1o(s not
p-()(nt s*0s(()(-, +a -(ta-1 an1 t2(n
p-olong t2( ac*t( glc(+ic -(spons( :4.Ra-( sit*ations of s()(-( 2poglc(+ia
>2(-( t2( in1i)i1*al -(it2 o-al ca-0o21-at( s2o*l1 0(t-(at(1 *sing (+(-g(nc gl*cagon 8its,
>2ic2 -(it2, o- 2a)ing c*sto1ial
ca-( of, p(opl( >it2 1ia0(t(s, s*c2 as fa+il
+(+0(-s, -oo++at(s, sc2ool p(-sonn(l,
c2il1 ca-( p-o)i1(-s, co--(ctional
instit*tion staff, an1 co>o-8(-s, s2o*l1
0( inst-*ct(1 in *s( of s*c2 8its. An in1i)i1*al1o(s not n((1 to 0( a 2(alt2 ca-(
Standards of Medical Care
S9 DIABETES CARE, "OLME &:,
S##LEMENT , ANAR% &9
p-of(ssional to saf(l a1+inist(- gl*cagon.
Ca-( s2o*l1 0( ta8(n to (ns*-( t2at*n(=pi-(1 gl*cagon 8its a-( a)aila0l(.
. I++*ni6ation
R(co++(n1ations
Ann*all p-o)i1( an infl*(n6a )accin(to all 1ia0(tic pati(nts 9 +ont2s of
ag(. C #-o)i1( at l(ast on( lif(ti+( pn(*+ococcal
)accin( fo- a1*lts >it2 1ia0(t(s.
A on(/ti+( -()accination is -(co++(n1(1
fo- in1i)i1*als 94 (a-s of
ag( p-()io*sl i++*ni6(1 >2(n t2(
>(-(95 (a-s of ag( if t2( )accin( >as
a1+inist(-(15 (a-s ago. Ot2(- in1ications
fo- -(p(at )accination incl*1(
-
7/25/2019 Standar Pengobatan Dm
23/69
n(p2-otic sn1-o+(, c2-onic -(nal 1is(as(,
an1 ot2(- i++*noco+p-o+is(1
stat(s, s*c2 as aft(- t-ansplantation. C
Infl*(n6a an1 pn(*+onia a-( co++on,
p-()(nta0l( inf(ctio*s 1is(as(s associat(1>it2 2ig2 +o-talit an1 +o-0i1it in t2(
(l1(-l an1 in p(opl( >it2 c2-onic 1is(as(s.T2(-( a-( li+it(1 st*1i(s -(po-ting
t2( +o-0i1it an1 +o-talit of infl*(n6a
an1 pn(*+ococcal pn(*+onia sp(cificall
in p(opl( >it2 1ia0(t(s. O0s(-)ational
st*1i(s of pati(nts >it2 a )a-i(t of
c2-onic illn(ss(s, incl*1ing 1ia0(t(s,
s2o> t2at t2(s( con1itions a-( associat(1
>it2 an inc-(as( in 2ospitali6ations fo- infl*(n6a
an1 its co+plications. Bas(1 on a
cas(/cont-ol s(-i(s, infl*(n6a )accin( 2as
0((n s2o>n to -(1*c( 1ia0(t(s/-(lat(1
2ospital a1+ission 0 as +*c2 as !:K1*-ing fl* (pi1(+ics :5. #(opl( >it2 1ia0(t(s
+a 0( at inc-(as(1 -is8 of t2( 0act(-(+ic
fo-+ of pn(*+ococcal inf(ction
an1 2a)( 0((n -(po-t(1 to 2a)( a 2ig2 -is8of nosoco+ial 0act(-(+ia, >2ic2 2as a
+o-talit -at( as 2ig2 as 5K.
Saf( an1 (ff(cti)( )accin(s a-( a)aila0l(
t2at can g-(atl -(1*c( t2( -is8 of
s(-io*s co+plications f-o+ t2(s( 1is(as(s
:9,:!. T2(-( is s*ffici(nt ()i1(nc( to
s*ppo-t t2at p(opl( >it2 1ia0(t(s 2a)(
app-op-iat( s(-ologic an1 clinical -(spons(sto t2(s( )accinations. T2( C(nt(-s
fo- Dis(as( Cont-olPs A1)iso-
Co++itt(( on I++*ni6ation #-actic(s
-(co++(n1s infl*(n6a an1 pn(*+ococcal
)accin(s fo- all in1i)i1*als 95 (a-s
of ag(, as >(ll as fo- all in1i)i1*als of anag( >it2 1ia0(t(s.
Fo- a co+pl(t( 1isc*ssion on t2( p-()(ntion
of infl*(n6a an1 pn(*+ococcal
1is(as( in p(opl( >it2 1ia0(t(s, cons*ltt2( t(c2nical -()i(> an1 position stat(+(nt
on t2is s*0J(ct :',::.*I. %RE*ENTION AND
MANA"EMENT O!
DIABETES COM%ICATIONS
A. C"D
C"D is t2( +aJo- ca*s( of +o-talit fo-
in1i)i1*als >it2 1ia0(t(s. It is also a +aJo-
cont-i0*to- to +o-0i1it an1 1i-(ct
an1 in1i-(ct costs of 1ia0(t(s. Tp( & 1ia0(t(s
is an in1(p(n1(nt -is8 facto- fo-
+ac-o)asc*la- 1is(as(, an1 its co++on
co(=isting con1itions (.g., 2p(-t(nsion
an1 1slipi1(+ia a-( also -is8 facto-s.
St*1i(s 2a)( s2o>n t2( (fficac of -(1*cingca-1io)asc*la- -is8 facto-s in p-()(nting
o- slo>ing C"D. E)i1(nc( iss*++a-i6(1 in t2( follo>ing s(ctions an1
-()i(>(1 in 1(tail in t2( ADA t(c2nical
-()i(>s on 2p(-t(nsion , 1slipi1(+ia
, aspi-in t2(-ap &, an1
s+o8ing c(ssation 7 an1 t2( cons(ns*s
stat(+(nt on C3D in p(opl( >it2 1ia0(t(s
4. E+p2asis s2o*l1 0( plac(1
on -(1*cing ca-1io)asc*la- -is8 facto-s,
>2(n possi0l(, an1 clinicians s2o*l1 0(
al(-t fo- signs an1 s+pto+s of at2(-oscl(-osis.
. 3p(-t(nsion$0loo1 p-(ss*-(
cont-olR(co++(n1ations
Sc-((ning an1 1iagnosis
Bloo1 p-(ss*-( s2o*l1 0( +(as*-(1 at
()(- -o*tin( 1ia0(t(s )isit. #ati(ntsfo*n1 to 2a)( sstolic 0loo1 p-(ss*-(
7 ++3g o- 1iastolic 0loo1 p-(ss*-(
' ++3g s2o*l1 2a)( 0loo1
p-(ss*-( confi-+(1 on a s(pa-at( 1a.
C
Goals
#ati(nts >it2 1ia0(t(s s2o*l1 0( t-(at(1
to a sstolic 0loo1 p-(ss*-( 7++3g. C
#ati(nts >it2 1ia0(t(s s2o*l1 0( t-(at(1
to a 1iastolic 0loo1 p-(ss*-( '
++3g. B
T-(at+(nt
#ati(nts >it2 2p(-t(nsion sstolic0loo1 p-(ss*-(4 o- 1iastolic 0loo1
p-(ss*-( : ++3g s2o*l1 -(c(i)(
1-*g t2(-ap in a11ition to lif(stl( an1
0(2a)io-al t2(-ap. A M*ltipl( 1-*g t2(-ap t>o o- +o-(
ag(nts at p-op(- 1os(s is g(n(-all -(it2 a sstolic 0loo1 p-(ss*-(
of 7@7: ++3g o- a 1iastolic 0loo1
p-(ss*-( of '@': ++3g s2o*l1 0(
gi)(n lif(stl( an1 0(2a)io-al t2(-ap
alon( fo- a +a=i+*+ of 7 +ont2s an1
t2(n, if ta-g(ts a-( not ac2i()(1, in a11ition,
-
7/25/2019 Standar Pengobatan Dm
24/69
0( t-(at(1 >it2 p2a-+acological
ag(nts t2at 0loc8 t2( -(nin/angiot(nsin
sst(+. E
Initial 1-*g t2(-ap fo- t2os( >it2 a
0loo1 p-(ss*-( 4$: ++3gs2o*l1 0( >it2 a 1-*g class 1(+onst-at(1
to -(1*c( C"D ()(nts in pati(nts>it2 1ia0(t(s ACE in2i0ito-s,
ARBs, /0loc8(-s, 1i*-(tics, an1 calci*+
c2ann(l 0loc8(-s. A
All pati(nts >it2 1ia0(t(s an1 2p(-t(nsion
s2o*l1 0( t-(at(1 >it2 a -(gi+(n
t2at incl*1(s (it2(- an ACE
in2i0ito- o- an ARB. If on( class is not
tol(-at(1, t2( ot2(- s2o*l1 0( s*0stit*t(1.
If n((1(1 to ac2i()( 0loo1 p-(ss*-(
ta-g(ts, a t2ia6i1( 1i*-(tic s2o*l1
0( a11(1. E
If ACE in2i0ito-s, ARBs, o- 1i*-(tics a-(*s(1, +onito- -(nal f*nction an1 s(-*+
potassi*+ l()(ls. E
In pati(nts >it2 tp( 1ia0(t(s, >it2
2p(-t(nsion an1 an 1(g-(( of al0*+in*-ia,ACE in2i0ito-s 2a)( 0((n
s2o>n to 1(la t2( p-og-(ssion of n(p2-opat2.
A
In pati(nts >it2 tp( & 1ia0(t(s, 2p(-t(nsion,
an1 +ic-oal0*+in*-ia,
ACE in2i0ito-s an1 ARBs 2a)( 0((n
s2o>n to 1(la t2( p-og-(ssion to
+ac-oal0*+in*-ia. A In t2os( >it2 tp( & 1ia0(t(s, 2p(-t(nsion,
+ac-oal0*+in*-ia, an1 -(nal
ins*ffici(nc, ARBs 2a)( 0((n
s2o>n to 1(la t2( p-og-(ssion of n(p2-opat2.
A
In p-(gnant pati(nts >it2 1ia0(t(s an1c2-onic 2p(-t(nsion, 0loo1 p-(ss*-(
ta-g(t goals of @&:$95@!: ++3g
a-( s*gg(st(1 in t2( int(-(st of longt(-+
+at(-nal 2(alt2 an1 +ini+i6ingi+pai-(1 f(tal g-o>t2. ACE in2i0ito-s
an1 ARBs a-( cont-ain1icat(1 1*-ingp-(gnanc. E
In (l1(-l 2p(-t(nsi)( pati(nts, 0loo1
p-(ss*-( s2o*l1 0( lo>(-(1 g-a1*all
to a)oi1 co+plications. E
#ati(nts not ac2i()ing ta-g(t 0loo1
p-(ss*-( 1(spit( +*ltipl( 1-*g t2(-ap
s2o*l1 0( -(f(--(1 to a p2sician (=p(-i(nc(1
in t2( ca-( of pati(nts >it2 2p(-t(nsion.
E
O-t2ostatic +(as*-(+(nt of 0loo1
p-(ss*-( s2o*l1 0( p(-fo-+(1 in p(opl(
>it2 1ia0(t(s an1 2p(-t(nsion
>2(n clinicall in1icat(1. E
Position Statement
DIABETES CARE, "OLME &:,S##LEMENT , ANAR% &9 S!
3p(-t(nsion 0loo1 p-(ss*-( 4$:
++3g is a co++on co+o-0i1it of 1ia0(t(s,
aff(cting t2( +aJo-it of p(opl(
>it2 1ia0(t(s, 1(p(n1ing on tp( of 1ia0(t(s,
ag(, o0(sit, an1 (t2nicit. 3p(-t(nsion
is also a +aJo- -is8 facto- fo- C"D
an1 +ic-o)asc*la- co+plications s*c2 as
-(tinopat2 an1 n(p2-opat2. In tp(
1ia0(t(s, 2p(-t(nsion is oft(n t2( -(s*lt
of *n1(-ling n(p2-opat2. In tp( & 1ia0(t(s,
2p(-t(nsion +a 0( p-(s(nt aspa-t of t2( +(ta0olic sn1-o+( i.(., o0(sit,
2p(-glc(+ia an1 1slipi1(+ia
t2at is acco+pani(1 0 2ig2 -at(s of C"D.
Ran1o+i6(1 clinical t-ials 2a)( 1(+onst-at(1t2( 0(n(fit -(1*ction of C3D
()(nts, st-o8(, an1 n(p2-opat2 of lo>(-ing
0loo1 p-(ss*-( to4 ++3g sstolic
an1 ' ++3g 1iastolic in
in1i)i1*als >it2 1ia0(t(s 5@'.
Epi1(+iologic
anals(s s2o> t2at 0loo1
p-(ss*-(s 5$!5 ++3g a-( associat(1>it2 inc-(as(1 ca-1io)asc*la- ()(nt -at(s
an1 +o-talit in in1i)i1*als >it2 1ia0(t(s
5,:,. T2(-(fo-(, a ta-g(t 0loo1
p-(ss*-( goal of 7$' ++3g is -(asona0l(
if it can 0( saf(l ac2i()(1.
Alt2o*g2 t2(-( a-( no >(ll/cont-oll(1st*1i(s of 1i(t an1 (=(-cis( in t2( t-(at+(nt
of 2p(-t(nsion in in1i)i1*als >it2
1ia0(t(s, -(1*cing so1i*+ inta8( an1
0o1 >(ig2t >2(n in1icat(1, inc-(asingcons*+ption of f-*its, )(g(ta0l(s, an1
lo>/fat 1ai- p-o1*cts, a)oi1ing (=c(ssi)(alco2ol cons*+ption, an1 inc-(asing acti)it
l()(ls 2a)( 0((n s2o>n to 0( (ff(cti)(
in -(1*cing 0loo1 p-(ss*-( in
non1ia0(tic in1i)i1*als . T2(s(
nonp2a-+acological st-at(gi(s +a also
positi)(l aff(ct glc(+ia an1 lipi1 cont-ol.
T2(i- (ff(cts on ca-1io)asc*la-
()(nts 2a)( not 0((n >(ll +(as*-(1.
-
7/25/2019 Standar Pengobatan Dm
25/69
Lo>(-ing of 0loo1 p-(ss*-( >it2 -(gi+(ns
0as(1 on anti2p(-t(nsi)( 1-*gs,
incl*1ing ACE in2i0ito-s, angiot(nsin -(c(pto-
0loc8(-s ARBs, /0loc8(-s, 1i*-(tics,
an1 calci*+ c2ann(l 0loc8(-s,2as 0((n s2o>n to 0( (ff(cti)( in lo>(-ing
ca-1io)asc*la- ()(nts. S()(-al st*1i(ss*gg(st t2at ACE in2i0ito-s +a 0( s*p(-io-
to 1i21-op-i1in( calci*+ c2ann(l
0loc8(-s DCCBs in -(1*cing ca-1io)asc*la-
()(nts &,7. A11itionall, in
p(opl( >it2 1ia0(tic n(p2-opat2 in1icat(
t2at ARBs +a 0( s*p(-io- to DCCBs
fo- -(1*cing 2(a-t fail*-( 0*t not o)(-all
ca-1io)asc*la- ()(nts 4. Con)(-s(l,
in t2( -(c(ntl co+pl(t(1 Int(-national
"(-apa+il St*1 IN"EST of &&,
p(opl( >it2 CAD an1 2p(-t(nsion, t2(
non/DCCB )(-apa+il 1(+onst-at(1 asi+ila- -(1*ction in ca-1io)asc*la- +o-talit
to a /0loc8(-. Mo-(o)(-, t2is -(lations2ip
2(l1 t-*( in t2( 1ia0(tic
s*0g-o*p 5.ACE in2i0ito-s 2a)( 0((n s2o>n to
i+p-o)( ca-1io)asc*la- o*tco+(s in
2ig2@ ca-1io)asc*la- -is8 pati(nts >it2 o-
>it2o*t 2p(-t(nsion 9,!. In pati(nts
>it2 cong(sti)( 2(a-t fail*-( C3F,
t2( a11ition of ARBs to (it2(- ACE in2i0ito-s
o- ot2(- t2(-api(s -(1*c(s t2( -is8 of
ca-1io)asc*la- 1(at2 o- 2ospitali6ationfo- 2(a-t fail*-( ' @&. In on( st*1,
an ARB >as s*p(-io- to a /0loc8(- as a
t2(-ap to i+p-o)( ca-1io)asc*la- o*tco+(s
in a s*0s(t of 1ia0(tic pati(nts >it2
2p(-t(nsion an1 l(ft )(nt-ic*la- 2p(-t-op2
&. T2( co+p(lling (ff(ct ofACE in2i0ito-s o- ARBs in pati(nts >it2
al0*+in*-ia o- -(nal ins*ffici(nc p-o)i1(
a11itional -ational( fo- *s( of t2(s(
ag(nts s(( s(ction "I, B 0(lo>.T2( Anti2p(-t(nsi)( an1 Lipi1/
Lo>(-ing T-(at+(nt to #-()(nt 3(a-t Attac8T-ial ALL3AT, a la-g( -an1o+i6(1
t-ial of 1iff(-(nt initial 0loo1 p-(ss*-(
p2a-+acological t2(-api(s, fo*n1 no
la-g( 1iff(-(nc(s 0(t>((n initial t2(-ap
>it2 a c2lo-t2ali1on(, a+lo1ipin( an1 lisinop-il.
Di*-(tics app(a-(1 slig2tl +o-(
(ff(cti)( t2an ot2(- ag(nts, pa-tic*la-l
fo- -(1*cing