terapi insulin dan pemantauan glukosa darah...

Terapi Insulin

dan

Pemantauan Glukosa

Darah Mandiri

Hemi Sinorita

1. Diabetes Melitus Tipe 1

2. Diabetes Melitus Tipe 2

3. Diabetes Melitus Tipe Lain

4. Diabetes Mellitus Gestational

Klasifikasi Diabetes Melitus

PENYEBAB Diabetes Melitus Tipe 2

Insulin resistance and -cell dysfunctionare core defects of type 2 DM

Insulin

resistance

Genetic, obesity, Western lifestyle

IR-cell

dysfunction

Rhodes CJ & White MF. Eur J Clin Invest 2002; 32 (Suppl. 3):3–13.

INSULIN ↓

Prinsip Dasar Terapi Diabetes Mellitus

3

PENGATURAN MAKAN

2

AKTIFITAS

FISIK

OBAT ANTIDIABETES/INSULIN

4

1

PENYULUHAN

SMBG

5

Algoritme Pengelolaan DM Tipe 2 di Indonesia KONSENSUS PERKENI 2015

Modifikasi pola hidup sehat

HbA1c < 7.5%

Monoterapi* dengan salah satu obat di bawah ini

Metformin

Agonis GLP-1

DPP-IV inh

ἀ Glukosidase inh

SGLT-2inh**

Tiazolidindion

Sulfonilurea

Glinid

Jika HbAc1 > 6.4%

dalam 3 bulan tambahan obat ke

2 (kombinasi 2 obat)

HbA1c ≥ 7.5%

Kombinasi 2 obat* dengan mekanisme kerja yang berbeda

• Agonis GLP-1

• DPP-IV inh

• Tiazolidindion

• SGLT-2 inh

• Insulin Basal

• SU/Glinid

• Kolsevelam**

• Bromokriptin-QR

• Penghambat Glukosid

ase Alfa

Jika belum memenuhi sasaran dal

am 3 bulan, masuk ke kombinasi

3 obat

Met

form

in a

tau

ob

at li

ni p

erta

ma

yan

g la

in +

Kombinasi 3 obat

Agonis GLP-1

Penghambat DPP-IV

Tiazolidindion

Penghambat SGLT-2

Insulin Basal

Kolsevelam**

Bromokriptin-QR

Penghambat Glukosid

ase Alfa


am 3 bulan, mulai terapi insulin at

au intensifikasi terapi insulin

Met

form

in a

tau

ob

at li

ni p

erta

ma

yan

g la

in +

Ob

at li

ni k

edu

a +

Kombinasi 2 obat

Insulin ± obatjenis lain

Kombinasi 3 obat

HbA1c ≥ 9.0%Gejala (-) Gejala (+)

Keterangan

*Obat yang terdaftar, pemilihan dan

penggunaannya disarankan mempertimbangkan

faktor keuntungan, kerugian biaya, dan

ketersediaan sesuai tabel 11

** Kolsevelam belum tersedia di Indonesia

Bromokriptin QR umumnya digunakan pada terapi

tumor hipofisis

Mulai atau intensifikasi Insulin

Konsensus Pengelolaan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia. 2015.

SELINGAN : 150 kalori

Brownies 5x5 cm (150 kalori)

Risoles 100 gram (240 kalori)

Lemper 70 gram (240 kal)

Serabi pandan 60 gram (137 kkal).

SELINGAN : 150 kalori

Apel 250 gram

Pepaya 350 gram

Jeruk 350 gram

Salak/buah 8 kalori

100 gram jeruk

½ SDM minyak

Aktifitas Fisik

a

30 menit intensitas moderat (berjalan cepat)

Asian Food Information Centre. 2010. Calorie Expenditures Through Exercise and Other Activities. Available from

http://www.afic.org/Burner.htm. Accessed 21 June 2010.

http://www.afic.org/Burner.htm

Insulin

resistance

-cell failure

FPG

2hPG

PENGENDALIAN

GLUKOSA DARAH

Kriteria pengendalian



HbA1c < 7.5%


Metformin

Agonis GLP-1

DPP-IV inh

ἀ Glukosidase inh

SGLT-2inh**

Tiazolidindion

Sulfonilurea

Glinid

Jika HbAc1 > 6.4%



HbA1c ≥ 7.5%


• Agonis GLP-1

• DPP-IV inh

• Tiazolidindion

• SGLT-2 inh

• Insulin Basal

• SU/Glinid

• Kolsevelam**

• Bromokriptin-QR


ase Alfa



3 obat

Met

form

in a

tau

ob

at li

ni p

erta

ma

yan

g la

in +

Kombinasi 3 obat

Agonis GLP-1

Penghambat DPP-IV

Tiazolidindion

Penghambat SGLT-2

Insulin Basal

Kolsevelam**

Bromokriptin-QR

Penghambat Glukosid

ase Alfa




Met

form

in a

tau

ob

at li

ni p

erta

ma

yan

g la

in +

Ob

at li

ni k

edu

a +

Kombinasi 2 obat


Kombinasi 3 obat


Keterangan







tumor hipofisis



IR – a reduced response of target tissues to circulating insulin

Glucose

Defective insulin

secretion

Excessive

fatty acid

release

Reduced

glucose

uptakeExcessive

glucose

production

Carbohydrate

Resistance to the action of insulin

Insulin

Hyperglycemia

IR – a reduced response of target tissues to circulating insulin

Glucose

Defective insulin

secretion Excessive

fatty acid

release

Reduced

glucose

uptakeExcessive

glucose

production

Carbohydrate

Resistance to the action of insulin

Insulin

Hyperglycemia

a-glucosidase inhibitors

Sulfonylurea,

meglitinides,

DPP IV inhibitor

Biguanides

TZD

Oral Anti Diabetes

Insulin

resistance

-cell failure

FPG

2hPG

DPP IV inh, Glinid, Acarbosa,

SGLT2 inhibitor

Metformin, TZD,

DPP IV inh, SGLT2 inhibitor

Islet

transcription

factors

SUR

↑ ATP/ADP

Pyruvate

Glucose-6-

Phosphate

Glucose

Glucokinase NucleusSecretory

granules

Ca2+

Ca++

Voltage-

dependent Ca2+

channelDepolarization

ATP-sensitive

K+ channel

Mitochondria

Glucose

GLUT2

Insulin

Sulphonylurea: glibenklamid, glimeperide

INCRETIN

Efficacy* Safety, Tolerability and Adherence

• HbA1c reduction of 1-2%

• FPG reduction of 40-70 mg/dl

• Associated with hypoglycaemiaand weight gain.

• Precaution : long acting SU (elderly, hepar-renal insuffisient, cardiovascular, malnutrisi)

Krentz AJ, Bailey CJ. Drugs 2005;65:385–411. Nathan DM, et al. Diabetologia. 2009;52:17–30. Rosenstock J, et al. Diabetes Care. 2004;27:1265–70.

* Efficacy depends on existing blood glucose levels

Sulphonylurea

Oral Anti Diabetes

FPG

InsulinSulphonylurea



HbA1c < 7.5%


Metformin

Agonis GLP-1

DPP-IV inh

ἀ Glukosidase inh

SGLT-2inh**

Tiazolidindion

Sulfonilurea

Glinid

Jika HbAc1 > 6.4%



HbA1c ≥ 7.5%


• Agonis GLP-1

• DPP-IV inh

• Tiazolidindion

• SGLT-2 inh

• Insulin Basal

• SU/Glinid

• Kolsevelam**

• Bromokriptin-QR


ase Alfa



3 obat

Met

form

in a

tau

ob

at li

ni p

erta

ma

yan

g la

in +

Kombinasi 3 obat

Agonis GLP-1

Penghambat DPP-IV

Tiazolidindion

Penghambat SGLT-2

Insulin Basal

Kolsevelam**

Bromokriptin-QR

Penghambat Glukosid

ase Alfa




Met

form

in a

tau

ob

at li

ni p

erta

ma

yan

g la

in +

Ob

at li

ni k

edu

a +

Kombinasi 2 obat


Kombinasi 3 obat


Keterangan







tumor hipofisis



Three Types of InsulinG

IR (

mg

/kg

/min

)

Time (h)

0 4 8 12 16 20 24

BASAL INSULIN

PRE-MIX INSULIN

FAST-ACTING INSULIN

FPG

2hPG

Types of Insulin

Insulin

resistance

-cell failure

FPG

2hPG

1. Type 1 DM

2. Uncontrolled type 2 DM

3. Under weight DM

4. Gestasional DM

5. Liver/renal insufficiency.

6. Acute infection (selulitis, gangren), TBC, stroke/AMI.

7. KAD/HHS

8. Major surgery

9. Grave’s disease

10. Cancer

11. Corticosteroid treatment

terima kasih

KASUS

Seorang wanita berusia 59 tahun datang ke klinik untuk

kontrol setelah opname karena penyakit jantung koroner.

Pasien ini penyandang DM tipe 2 selama 10 tahun.

BB 50kg, TB 158cm, tekanan darah 130/85 mmHg.

Selama ini pasien setiap hari mengkonsumsi Glibenklamid

2x5 mg, kadar glukosa sekitar 200 mg/dL.

1. Type 1 DM

2. Uncontrolled type 2 DM

3. Under weight DM4. Gestasional DM

5. Liver/renal insufficiency.

6. Acute infection (celulitis, gangren), TBC, stroke/AMI.

7. KAD/HHS

8. Major surgery

9. Grave’s disease

10. Cancer

11. Corticosteroid treatment



HbA1c < 7.5%


Metformin

Agonis GLP-1

DPP-IV inh

ἀ Glukosidase inh

SGLT-2inh**

Tiazolidindion

Sulfonilurea

Glinid

Jika HbAc1 > 6.4%



HbA1c ≥ 7.5%


• Agonis GLP-1

• DPP-IV inh

• Tiazolidindion

• SGLT-2 inh

• Insulin Basal

• SU/Glinid

• Kolsevelam**

• Bromokriptin-QR


ase Alfa



3 obat

Met

form

in a

tau

ob

at li

ni p

erta

ma

yan

g la

in +

Kombinasi 3 obat

Agonis GLP-1

Penghambat DPP-IV

Tiazolidindion

Penghambat SGLT-2

Insulin Basal

Kolsevelam**

Bromokriptin-QR

Penghambat Glukosid

ase Alfa




Met

form

in a

tau

ob

at li

ni p

erta

ma

yan

g la

in +

Ob

at li

ni k

edu

a +

Kombinasi 2 obat


Kombinasi 3 obat


Keterangan







tumor hipofisis



• Pasien menggunakan insulin basal dosis 10 unit setiap pagi.

• Setelah 3 bulan menggunakan insulin basal, berat badan naik 2 kg, kadar glukosa darahsebelum makan pagi - siang - malam sekitar100 sd 125 mg/dl.

Types of Insulin

FPG

100 – 125 mg/dl

Insulin basal

• Namun bulan selanjutnya, kadar glukosadarah 2 jam setelah makan pagi – siang –malam berkisar 250 sd 300 mg/dl.

• Kadar glukosa darah puasa tetap baik.

Types of Insulin

FPG

2HPG250 – 300mg/dl



HbA1c < 7.5%


Metformin

Agonis GLP-1

DPP-IV inh

ἀ Glukosidase inh

SGLT-2inh**

Tiazolidindion

Sulfonilurea

Glinid

Jika HbAc1 > 6.4%



HbA1c ≥ 7.5%


• Agonis GLP-1

• DPP-IV inh

• Tiazolidindion

• SGLT-2 inh

• Insulin Basal

• SU/Glinid

• Kolsevelam**

• Bromokriptin-QR


ase Alfa



3 obat

Met

form

in a

tau

ob

at li

ni p

erta

ma

yan

g la

in +

Kombinasi 3 obat

Agonis GLP-1

Penghambat DPP-IV

Tiazolidindion

Penghambat SGLT-2

Insulin Basal

Kolsevelam**

Bromokriptin-QR

Penghambat Glukosid

ase Alfa




Met

form

in a

tau

ob

at li

ni p

erta

ma

yan

g la

in +

Ob

at li

ni k

edu

a +

Kombinasi 2 obat


Kombinasi 3 obat


Keterangan







tumor hipofisis



Types of Insulin

FPG

2HPG250 – 300mg/dl

Insulin basal +

insulin aksi cepat/prandial

Types of Insulin

FPG

2HPG

Insulin premix

Types of Insulin

FPG

2HPG

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