dm tinjauan pustaka eng upload
TRANSCRIPT
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
1/33
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
2/33
Based on Central Bureau of Statistics Indonesia 2003, Indonesia estimated
population aged over 20 years as many as 133 million inhabitants. With the
prevalence of DM of 14.7% in urban areas and 7.2% in rural areas. Furthermore,
based on the pattern of population growth, estimated in 2030 there will be 194 million
people aged 20 years and assuming a prevalence of DM in urban (14.7%) and rural
(7.2%), it is estimated there are 12 million persons with diabetes in urban areas and
8.1 million in rural areas.
Report of Health Research Association in 2007 by the Ministry of Health,
showed that the prevalence of DM in urban Indonesia for over 15 years of age by
5.7%. The prevalence found in Papua smallest at 1.7%, and the largest in the Province
of North Maluku and West Kalimantan, which reached 11.1%. While the prevalence
of impaired glucose tolerance (IGT), ranged from 4.0% in Jambi province to 21.8% in
the Province of West Papua.
The data above show that the number of people with diabetes in Indonesia is
very large and very heavy loads to be handled by a specialist / sub spesialist or even
by all the existing health workers.
Given that the DM will have an impact on the quality of human resources andincreasing health costs are sufficiently large, then all parties, both society and
government, was supposed to participate in the response of DM, especially in
prevention.
Etiology
Insufficient production of insulin (either absolutely or relative to the body's
needs), production of defective insulin (which is uncommon), or the inability of cellsto use insulin properly and efficiently leads to hyperglycemia and diabetes. This latter
condition affects mostly the cells of muscle and fat tissues, and results in a condition
known as "insulin resistance." This is the primary problem in type 2 diabetes. The
absolute lack of insulin, usually secondary to a destructive process affecting the
insulin producing beta cells in the pancreas, is the main disorder in type 1 diabetes.
In type 2 diabetes, there also is a steady decline of beta cells that adds to the
process of elevated blood sugars. Essentially, if someone is resistant to insulin, the
http://www.medicinenet.com/script/main/art.asp?articlekey=30653http://www.medicinenet.com/script/main/art.asp?articlekey=30653 -
8/3/2019 DM Tinjauan Pustaka Eng Upload
3/33
body can, to some degree, increase production of insulin and overcome the level of
resistance. After time, if production decreases and insulin cannot be released as
vigorously, hyperglycemia develops.
Glucose is a simple sugar found in food. Glucose is an essential nutrient that
provides energy for the proper functioning of the body cells. Carbohydrates are
broken down in the small intestine and the glucose in digested food is then absorbed
by the intestinal cells into the bloodstream, and is carried by the bloodstream to all the
cells in the body where it is utilized. However, glucose cannot enter the cells alone
and needs insulin to aid in its transport into the cells. Without insulin, the cells
become starved of glucose energy despite the presence of abundant glucose in the
bloodstream. In certain types of diabetes, the cells' inability to utilize glucose gives
rise to the ironic situation of "starvation in the midst of plenty". The abundant,
unutilized glucose is wastefully excreted in the urine.
Insulin is a hormone that is produced by specialized cells (beta cells) of the
pancreas. (The pancreas is a deep-seated organ in the abdomen located behind the
stomach.) In addition to helping glucose enter the cells, insulin is also important in
tightly regulating the level of glucose in the blood. After a meal, the blood glucose
level rises. In response to the increased glucose level, the pancreas normally releases
more insulin into the bloodstream to help glucose enter the cells and lower blood
glucose levels after a meal. When the blood glucose levels are lowered, the insulin
release from the pancreas is turned down.
It is important to note that even in the fasting state there is a low steady release
of insulin than fluctuates a bit and helps to maintain a steady blood sugar level during
fasting. In normal individuals, such a regulatory system helps to keep blood glucose
levels in a tightly controlled range. As outlined above, in patients with diabetes, the
insulin is either absent, relatively insufficient for the body's needs, or not used
properly by the body. All of these factors cause elevated levels of blood glucose
(hyperglycemia).
http://www.medicinenet.com/script/main/art.asp?articlekey=15381http://www.medicinenet.com/script/main/art.asp?articlekey=5512http://www.medicinenet.com/script/main/art.asp?articlekey=5512http://www.medicinenet.com/script/main/art.asp?articlekey=15381 -
8/3/2019 DM Tinjauan Pustaka Eng Upload
4/33
Classification of Diabetes Mellitus
The three main types of diabetes are
type 1 diabetes
type 2 diabetes
gestational diabetes
Other types of diabetes
Type 1 Diabetes
Type 1 diabetes is an autoimmune disease. An autoimmune disease results
when the bodys system for fi ghting infectionthe immune systemturns against a
part of the body. In diabetes, the immune system attacks and destroys the insulin-
producing beta cells in the pancreas. The pancreas then produces little or no insulin. A
person who has type 1 diabetes must take insulin daily to live.
At present, scientists do not know exactly what causes the bodys immune
system to attack the beta cells, but they believe that autoimmune, genetic, and
environmental factors, possibly viruses, are involved. Type 1 diabetes accounts for
about 5 to 10 percent of diagnosed diabetes in the United States. It develops most
often in children and young adults but can appear at any age.
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
5/33
Symptoms of type 1 diabetes usually develop over a short period, although
beta cell destruction can begin years earlier. Symptoms may include increased thirst
and urination, constant hunger, weight loss, blurred vision, and extreme fatigue. If not
diagnosed and treated with insulin, a person with type 1 diabetes can lapse into a life-
threatening diabetic coma, also known as diabetic ketoacidosis.
Type 2 Diabetes
The most common form of diabetes is type 2 diabetes. About 90 to 95 percent
of people with diabetes have type 2. This form of diabetes is most often associated
with older age, obesity, family history of diabetes, previous history of gestational
diabetes, physical inactivity, and certain ethnicities. About 80 percent of people with
type 2 diabetes are overweight.
Type 2 diabetes is increasingly being diagnosed in children and adolescents,
especially among African American, Mexican American, and Pacific Islander youth.
When type 2 diabetes is diagnosed, the pancreas is usually producing enough insulin,
but for unknown reasons the body cannot use the insulin effectively, a condition
called insulin resistance. After several years, insulin production decreases. The result
is the same as for type 1 diabetesglucose builds up in the blood and the body cannot
make effi cient use of its main source of fuel.
The symptoms of type 2 diabetes develop gradually. Their onset is not as
sudden as in type 1 diabetes. Symptoms may include fatigue, frequent urination,
increased thirst and hunger, weight loss, blurred vision, and slow healing of wounds
or sores. Some people have no symptoms.
Gestational Diabetes
Some women develop gestational diabetes late in pregnancy. Although this
form of diabetes usually disappears after the birth of the baby, women who have had
gestational diabetes have a 40 to 60 percent chance of developing type 2 diabetes
within 5 to 10 years. Maintaining a reasonable body weight and being physically
active may help prevent development of type 2 diabetes.
About 3 to 8% of pregnant women in the United States develop gestational
diabetes. As with type 2 diabetes, gestational diabetes occurs more often in some
ethnic groups and among women with a family history of diabetes. Gestational
diabetes is caused by the hormones of pregnancy or a shortage of insulin. Women
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
6/33
with gestational diabetes may not experience any symptoms.
Other Types of Diabetes
A number of other types of diabetes exist. A person may exhibit
characteristics of more than one type. For example, in latent autoimmune diabetes in
adults (LADA), also called type 1.5 diabetes or double diabetes, people show signs of
both type 1 and type 2 diabetes.
Other types of diabetes include those caused by :
Genetic defects of the beta cellthe part of the pancreas that makes insulin
such as maturity-onset diabetes of the young (MODY) or neonatal diabetes
mellitus (NDM)
Genetic defects in insulin action, resulting in the bodys inability to control
blood glucose levels, as seen in leprechaunism and the Rabson-Mendenhall
syndrome
Diseases of the pancreas or conditions that damage the pancreas, such as
pancreatitis and cystic fibrosis
Excess amounts of certain hormones resulting from some medical
conditionssuch as cortisol in Cushings syndromethat work against the
action of insulin
Medications that reduce insulin action, such as glucocorticoids, or chemicals
that destroy beta cells
Infections, such as congenital rubella and cytomegalovirus
Rare immune-mediated disorders, such as stiff-man syndrome, an autoimmune
disease of the central nervous system
Genetic syndromes associated with diabetes, such as Down syndrome and
Prader-Willi syndrome
Latent Autoimmune Diabetes in Adults (LADA)
People who have LADA show signs of both type 1 and type 2 diabetes.
Diagnosis usually occurs after age 30. Researchers estimate that as many as 10
percent of people diagnosed with type 2 diabetes have LADA. Some experts believe
that LADA is a slowly developing kind of type 1 diabetes because patients have
antibodies against the insulin-producing beta cells of the pancreas.
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
7/33
Most people with LADA still produce their own insulin when first diagnosed, like
those with type 2 diabetes. In the early stages of the disease, people with LADA do
not require insulin injections. Instead, they control their blood glucose levels with
meal planning, physical activity, and oral diabetes medications. However, several
years after diagnosis, people with LADA must take insulin to control blood glucose
levels. As LADA progresses, the beta cells of the pancreas may no longer make
insulin because the bodys immune system has attacked and destroyed them, as in
type 1 diabetes.
Diabetes Caused by Genetic Defects of the Beta Cell
Genetic defects of the beta cell cause several forms of diabetes. For example,
monogenic forms of diabetes result from mutations, or changes, in a single gene. In
most cases of monogenic diabetes, the gene mutation is inherited. In the remaining
cases, the gene mutation develops spontaneously. Most mutations in monogenic
diabetes reduce the bodys ability to produce insulin. Genetic testing can diagnose
most forms of monogenic diabetes.
NDM and MODY are the two main forms of monogenic diabetes. NDM is a
form of diabetes that occurs in the first 6 months of life. Infants with NDM do not
produce enough insulin, leading to an increase in blood glucose. NDM can be
mistaken for the much more common type 1 diabetes, but type 1 diabetes usually
occurs after the fi rst 6 months of life.
MODY usually first occurs during adolescence or early adulthood. However,
MODY sometimes remains undiagnosed until later in life. A number of different gene
mutations have been shown to cause MODY, all of which limit the pancreas ability
to produce insulin. This process leads to the high blood glucose levels characteristic
of diabetes.
Diabetes Caused by Genetic Defects in Insulin Action
A number of types of diabetes result from genetic defects in insulin action.
Changes to the insulin receptor may cause mild hyperglycemiahigh blood
glucoseor severe diabetes. Symptoms may include acanthosis nigricans, a skin
condition characterized by darkened skin patches, and, in women, enlarged and cystic
ovaries plus virilization and the development of masculine characteristics such as
excess facial hair. Two syndromes in children, leprechaunism and the Rabson-
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
8/33
Mendenhall syndrome, cause extreme insulin resistance.
Diabetes Caused by Diseases of the Pancreas
Injuries to the pancreas from trauma or disease can cause diabetes. This
category includes pancreatitis, infection, and cancer of the pancreas. Cystic fibrosis
and hemochromatosis can also damage the pancreas enough to cause diabetes.
Diabetes Caused by Endocrinopathies
Excess amounts of certain hormones that work against the action of insulin
can cause diabetes. These hormones and their related conditions include growth
hormone in acromegaly, cortisol in Cushings syndrome, glucagon in glucagonoma,
and epinephrine in pheochromocytoma.
Diabetes Caused by Medications or Chemicals
A number of medications and chemicals can interfere with insulin secretion,
leading to diabetes in people with insulin resistance. These medications and chemicals
include pentamidine, nicotinic acid, glucocorticoids, thyroid hormone, phenytoin
(Dilantin), and Vacor, a rat poison.
Diabetes Caused by Infections
Several infections are associated with the occurrence of diabetes, including
congenital rubella, coxsackievirus B, cytomegalovirus, adenovirus, and mumps.
Rare Immune-mediated Types of Diabetes
Some immune-mediated disorders are associated with diabetes. About one-
third of people with stiff-man syndrome develop diabetes. In other autoimmune
diseases, such as systemic lupus erythematosus, patients may have anti-insulin
receptor antibodies that cause diabetes by interfering with the binding of insulin to
body tissues.
Other Genetic Syndromes Sometimes Associated with Diabetes
Many genetic syndromes are associated with diabetes. These conditions
include Down syndrome, Klinefelters syndrome, Huntingtons chorea, porphyria,
Prader-Willi syndrome, and diabetes insipidus.
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
9/33
Type 1 Beta cell destruction, usually leads to absolute insulin deficiency
Autoimmune
Idiopathic
Type 2 Various cause, start from dominant insulin resistant with relativeinsulin deficiency until dominant defect insulin secretion with
insulin resistant
Other types of
Diabetes
Genetic defect beta cell function
Genetic defect in insulin action
Diseases of the pancreas
Diabetes caused by endocrinopathies
Caused by medications or chemicals Infection
Rare immune-mediated types of diabetes
Other genetic syndromes associated with diabetes
Gestational
Diabetes
Sign and Symptoms- The early symptoms of untreated diabetes are related to elevated blood sugar levels,
and loss of glucose in the urine. High amounts of glucose in the urine can cause
increased urine output and lead to dehydration. Dehydration causes increased thirst
and water consumption.- The inability of insulin to perform normally has effects on protein, fat and
carbohydrate metabolism. Insulin is an anabolic hormone, that is, one that encourages
storage of fat and protein.
- A relative or absolute insulin deficiency eventually leads to weight loss despite an
increase in appetite.- Some untreated diabetes patients also complain of fatigue, nausea and vomiting.- Patients with diabetes are prone to developing infections of the bladder, skin, and
vaginal areas.- Fluctuations in blood glucose levels can lead to blurred vision. Extremely elevated
http://www.medicinenet.com/script/main/art.asp?articlekey=339http://www.medicinenet.com/script/main/art.asp?articlekey=24749http://www.medicinenet.com/script/main/art.asp?articlekey=24732http://www.medicinenet.com/script/main/art.asp?articlekey=41943http://www.medicinenet.com/script/main/art.asp?articlekey=513http://www.medicinenet.com/script/main/art.asp?articlekey=26099http://www.medicinenet.com/script/main/art.asp?articlekey=26099http://www.medicinenet.com/script/main/art.asp?articlekey=513http://www.medicinenet.com/script/main/art.asp?articlekey=41943http://www.medicinenet.com/script/main/art.asp?articlekey=24732http://www.medicinenet.com/script/main/art.asp?articlekey=24749http://www.medicinenet.com/script/main/art.asp?articlekey=339 -
8/3/2019 DM Tinjauan Pustaka Eng Upload
10/33
glucose levels can lead to lethargy and coma.
Diagnosis
The fasting blood glucose (sugar) test is the preferred way to diagnose diabetes. It
is easy to perform and convenient. After the person has fasted overnight (at least 8
hours), a single sample of blood is drawn and sent to the laboratory for analysis. This
can also be done accurately in a doctor's office using a glucose meter.
Normal fasting plasma glucose levels are less than 100 milligrams per deciliter
(mg/dl). Fasting plasma glucose levels of more than 126 mg/dl on two or more tests on
different days indicate diabetes. A random blood glucose test can also be used to diagnose diabetes. A blood
glucose level of 200 mg/dl or higher indicates diabetes.
When fasting blood glucose stays above 100mg/dl, but in the range of 100-126mg/dl,
this is known as impaired fasting glucose (IFG). While patients with IFG do not have
the diagnosis of diabetes, this condition carries with it its own risks and concerns, and
is addressed elsewhere.
The oral glucose tolerance test
Though not routinely used anymore, the oral glucose tolerance test (OGTT) is
a gold standard for making the diagnosis of type 2 diabetes. It is still commonly used
for diagnosing gestational diabetes and in conditions of pre-diabetes, such as
polycystic ovary syndrome. With an oral glucose tolerance test, the person fasts
overnight (at least eight but not more than 16 hours). Then first, the fasting plasma
glucose is tested. After this test, the person receives 75 grams of glucose (100 grams
for pregnant women). There are several methods employed by obstetricians to do this
test, but the one described here is standard. Usually, the glucose is in a sweet-tasting
liquid that the person drinks. Blood samples are taken at specific intervals to measure
the blood glucose.
For the test to give reliable results:
The person must be in good health (not have any other illnesses, not even a
cold)
http://www.medicinenet.com/script/main/art.asp?articlekey=4138http://www.medicinenet.com/script/main/art.asp?articlekey=85386http://www.medicinenet.com/script/main/art.asp?articlekey=3393http://www.medicinenet.com/script/main/art.asp?articlekey=46359http://www.medicinenet.com/script/main/art.asp?articlekey=453http://www.medicinenet.com/script/main/art.asp?articlekey=453http://www.medicinenet.com/script/main/art.asp?articlekey=46359http://www.medicinenet.com/script/main/art.asp?articlekey=3393http://www.medicinenet.com/script/main/art.asp?articlekey=85386http://www.medicinenet.com/script/main/art.asp?articlekey=4138 -
8/3/2019 DM Tinjauan Pustaka Eng Upload
11/33
The person should be normally active (not lying down, for example, as an
inpatient in a hospital)
The person should not be taking medicines that could affect the blood
glucose
For three days before the test, the person should have eaten a diet high in
carbohydrates (200-300 grams per day) In the morning of the test, the person should not smoke or drink coffee
The classic oral glucose tolerance test measures blood glucose levels five times over a
period of three hours. Some physicians simply get a baseline blood sample followed
by a sample two hours after drinking the glucose solution. In a person without
diabetes, the glucose levels rise and then fall quickly. In someone with diabetes,
glucose levels rise higher than normal and fail to come back down as fast.
People with glucose levels between normal and diabetic have impaired
glucose tolerance (IGT). People with impaired glucose tolerance do not have diabetes,
but are at high risk for progressing to diabetes. Each year, 1%-5% of people whose
test results show impaired glucose tolerance actually eventually develop diabetes.
Weight loss and exercise may help people with impaired glucose tolerance return
their glucose levels to normal. In addition, some physicians advocate the use of
medications, such as metformin (Glucophage), to help prevent/delay the onset of
overt diabetes.
Recent studies have shown that impaired glucose tolerance itself may be a risk
factor for the development of heart disease. In the medical community, most
physicians are now understanding that impaired glucose tolerance is nor simply a
precursor of diabetes, but is its own clinical disease entity that requires treatment and
monitoring.
Evaluating the results of the oral glucose tolerance test
Glucose tolerance tests may lead to one of the following diagnoses:
Normal response: A person is said to have a normal response when the 2-hour
glucose level is less than 140 mg/dl, and all values between 0 and 2 hours are
less than 200 mg/dl. Impaired glucose tolerance: A person is said to have impaired glucose
http://www.medicinenet.com/script/main/art.asp?articlekey=42930http://www.medicinenet.com/script/main/art.asp?articlekey=18262http://www.medicinenet.com/script/main/art.asp?articlekey=56640http://www.medicinenet.com/script/main/art.asp?articlekey=904http://www.medicinenet.com/script/main/art.asp?articlekey=5377http://www.medicinenet.com/script/main/art.asp?articlekey=5377http://www.medicinenet.com/script/main/art.asp?articlekey=14105http://www.medicinenet.com/script/main/art.asp?articlekey=2750http://www.medicinenet.com/script/main/art.asp?articlekey=2750http://www.medicinenet.com/script/main/art.asp?articlekey=14105http://www.medicinenet.com/script/main/art.asp?articlekey=5377http://www.medicinenet.com/script/main/art.asp?articlekey=5377http://www.medicinenet.com/script/main/art.asp?articlekey=904http://www.medicinenet.com/script/main/art.asp?articlekey=56640http://www.medicinenet.com/script/main/art.asp?articlekey=18262http://www.medicinenet.com/script/main/art.asp?articlekey=42930 -
8/3/2019 DM Tinjauan Pustaka Eng Upload
12/33
tolerance when the fasting plasma glucose is less than 126 mg/dl and the 2-
hour glucose level is between 140 and 199 mg/dl. Diabetes: A person has diabetes when two diagnostic tests done on different
days show that the blood glucose level is high.Gestational diabetes : A woman has gestational diabetes when she has any two of
the following: a 100g OGTT, a fasting plasma glucose of more than 95 mg/dl, a 1-
hour glucose level of more than 180 mg/dl, a 2-hour glucose level of more than
155 mg/dl, or a 3-hour glucose level of more than 140 mg/dl.
Not DM Not sure DM DM
Randomized
blood glucose
Vena plasma < 100 100-199 200
Capillary blood < 90 90-199 200
Fasting blood
glucose
Vena plasma < 100 100-125 126
Capillary blood < 90 90-99 100
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
13/33
Hemoglobin A1c (A1c)
To explain what an hemoglobin A1c is, think in simple terms. Sugar sticks,
and when it's around for a long time, it's harder to get it off. In the body, sugar sticks
too, particularly to proteins. The red blood cells that circulate in the body live for
about three months before they die off. When sugar sticks to these cells, it gives us an
idea of how much sugar is around for the preceding three months. In most labs, the
normal range is 4%-5.9 %. In poorly controlled diabetes, its 8.0% or above, and in
well controlled patients it's less than 7.0% (optimal is
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
14/33
A1c(%) Mean blood sugar (mg/dl)
6 135
7 170
8 205
9 240
10 275
11 310
12 345
The American Diabetes Association currently recommends an A1c goal of
less than 7.0%. Other Groups such as the American Association of Clinical
Endocrinologists feel that an A1c of
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
15/33
therapy also aims to achieve blood pressure
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
16/33
- Activity mild = +10%
- Medium activity = +20%
- Strenuous o = +30%
- Weight loss fat = -20%
- Weight loss more = -10%
- Weight loss skinny = +20%
- Metabolic Stress = +10-30%
- Pregnancy trimesters I and II = +300 calories
- The third trimester Pregnancy and lactation = +500calories
The results of the total calorie requirement per day is then divided into 3 major
portions for breakfast (20%), lunch (30%), dinner (25%), and 2-3 servings of mild
(10-15%) among a large meal. Changes in eating patterns is done in stages in
accordance with the conditions and habits of the patient.
Physical exercise in people with diabetes can lower HbA1c concentrations,
gives a good effect on body fat, vasodilatation of blood vessels that endothelium-
dependent, thereby reducing cardiovascular events. But in its implementation should
be supervised physical exercise frequency, intensity, duration, and type. Frequency of
physical exercise is good is 3-5 times per week with mild-moderate intensity (60-70%
maximum pulse), a duration of 30-60 minutes with the type of aerobic physical
exercise. Physical exercise in diabetics with uncontrolled blood sugar can lead to
elevated levels of blood glucose and ketone bodies which can lead to fatal effect, so
people with diabetes who perform physical exercise, blood glucose levels should have
no more than 250 mg / dL.
Therapeutic targets in DM
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
17/33
Pharmacological treatment of people with diabetes can vary. There are three
kinds of insulin sensitizing drugs anti hyperglycemic (biguanid and glitazone), insulin
secretagoue (sulfonylureas and glinid), and inhibiting the absorption of glucose
(alpha-glucosidase inhibitors). Biguanid class that is often used is metformin, serves
to lower blood glucose by improving insulin action at the cellular level, improving
insulin action on the distal insulin receptor, increasing the use of glucose by the
intestinal cells, reduce hepatic glucose production, and lower absorption in the
intestine after a meal glucose .
Metformin have side effects lactic acidosis and digestive disturbances that are
not given in diabetics with serum creatinine over 1.3 mg / dL, liver failure, heart
failure, and the elderly. To avoid the side effects of digestive disorders, metformin
administered with a low initial dose and concurrent with food. Achieved the highest
levels in the blood after 2 hours, 2.5 hours half-life of metformin is then removed
through the kidneys so it is given 2-3 times per day except in the form of extended
release. Metformin does not cause hypoglycemia or weight gain such as the
sulfonylurea class. Metformin can be combined with sulfonylureas or insulin.
Metformin is the first choice for overweight people with dyslipidemia and insulin
resistance because it can reduce insulin resistance, preventing weight gain, and
improve lipid profiles.
Class of Glitazone works by increasing insulin sensitivity. Glitazone an
agonist Peroxisome proliferator-activated receptor (PPAR) selectively in adipose
tissue, skeletal muscle, and liver so that it can stimulate protein for improved insulin
sensitivity and glycemic improvement as well as affect the expression and release of
mediators of insulin resistance such as TNF-alpha and leptin. Achieved the highest
levels in the blood after 1-2 hours. The half-life for rosiglitazone glitazone 3-4 hours,
3-7 hours for pioglitazone. Giving glitazone can be combined with insulin or
metformin secretagoue. Class of sulfonylureas can increase and maintain insulin
secretion. This group is often used as initial treatment of diabetics with impaired
insulin secretion.
Sulfonylureas work by stimulating the pancreatic beta cells to release insulin
is stored so it is not suitable for people with type 1 diabetes. Sulfonylurea have anincreased risk of hypoglycemia, then the gift must be considered in patients with DM
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
18/33
who are elderly, with renal failure, severe liver dysfunction, or lack of food inputs.
Beak long period depending on usage, chronic users have a half-life is longer than
acute users. Sulfonylureas administered hour before meals and can be combined
with insulin at night.
Glinid group has a structure similar to sulfonylurea and works on sulfonylurea
receptors, but the effect from hypoglycemia is more minimal than the sulfonylureas.
The last class is the alpha-glucosidase inhibitor that works by inhibiting the enzyme
alpha-glucosidase in the proximal small intestine thereby inhibiting the formation of
intraluminal monosaccharides, affecting the plasma insulin response, and inhibits the
increase in blood sugar regulation.
Drug commonly used is acarbose. Acarbose works locally in the
gastrointestinal tract and not in absorption. Acarbose does not stimulate insulin
secretion thus does not cause hypoglycemia. Acarbose 2-hour half-life and is excreted
through the feces. Provision of acarbose on the main meal because as a barrier
competitor when carbohydrate reached the small intestine. Side effects of this class is
the result of maldigestion carbohydrate, meteorismus, flatulance, and diarrhea.
Acarbose can be combined with metformin, glitazone, sulfonylurea, and insulin, but
the administration is in conjunction with metformin may reduce the bioavailability of
metformin.
In addition to anti hyperglicemic oral medication as well, diabetes can be
controlled using insulin. Insulin is needed on rapid weight loss, severe hyperglycemia
with ketosis, diabetic ketoacidosis, hyperglycemic hyperosmolar non ketotic,
hyperglycemia with lactic acidosis, failure by a combination of maximal doses of oral
medications anti hyperglicemic, severe stress (systemic infection, stroke, surgery),
pregnancy with diabetes, impaired renal function or severe liver, contraindications or
allergy to the drug oral anti hyperglicemic. There are four types of insulin based on its
long-acting insulin that is fast, short-acting insulin, intermediate acting insulin and
long acting insulin. Rapid and short-acting insulin is included in the prandial insulin
so it is more useful to decrease glucose after a meal because the peak onset of action
and it works fast. Medium and long-acting insulin, including the basal insulin that
serves to regulate blood glucose levels daily as well as the peak onset of action is
slow work. Long-acting insulin glargine and detemir is a basal insulin without a top
job, this is very beneficial in controlling blood glucose levels daily because it can
reduce the risk of hypoglycemia due to insulin.
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
19/33
Complication
1. Diabetic Ketoacidosis
Insulin is vital to patients with type 1 diabetes - they cannot live with out a
source of exogenous insulin. Without insulin, patients with type 1 diabetes develop
severely elevated blood sugar levels. This leads to increased urine glucose, which in
turn leads to excessive loss of fluid and electrolytes in the urine. Lack of insulin also
causes the inability to store fat and protein along with breakdown of existing fat and
protein stores. This dysregulation, results in the process of ketosis and the release of
ketones into the blood. Ketones turn the blood acidic, a condition called diabetic
ketoacidosis (DKA). Symptoms of diabetic ketoacidosis include nausea, vomiting,
and abdominal pain. Without prompt medical treatment, patients with diabetic
ketoacidosis can rapidly go into shock, coma, and even death.
Diabetic ketoacidosis can be caused by infections, stress, or trauma all which
may increase insulin requirements. In addition, missing doses of insulin is also an
obvious risk factor for developing diabetic ketoacidosis. Urgent treatment of diabetic
ketoacidosis involves the intravenous administration of fluid, electrolytes, and insulin,
usually in a hospital intensive care unit. Dehydration can be very severe, and it is not
unusual to need to replace 6-7 liters of fluid when a person presents in diabetic
ketoacidosis. Antibiotics are given for infections. With treatment, abnormal blood
sugar levels, ketone production, acidosis, and dehydration can be reversed rapidly,
and patients can recover remarkably well.
2. Hyperglicemia and hyperosmolar state
In patients with type 2 diabetes, stress, infection, and medications (such as
corticosteroids) can also lead to severely elevated blood sugar levels. Accompanied
by dehydration, severe blood sugar elevation in patients with type 2 diabetes can lead
to an increase in blood osmolality (hyperosmolar state). This condition can lead to
coma (hyperosmolar coma). A hyperosmolar coma usually occurs in elderly patients
with type 2 diabetes. Like diabetic ketoacidosis, a hyperosmolar coma is a medical
emergency. Immediate treatment with intravenous fluid and insulin is important in
reversing the hyperosmolar state. Unlike patients with type 1 diabetes, patients with
http://www.medicinenet.com/script/main/art.asp?articlekey=16387http://www.medicinenet.com/script/main/art.asp?articlekey=39573http://www.medicinenet.com/script/main/art.asp?articlekey=39573http://www.medicinenet.com/script/main/art.asp?articlekey=1908http://www.medicinenet.com/script/main/art.asp?articlekey=85053http://www.medicinenet.com/script/main/art.asp?articlekey=85386http://www.medicinenet.com/script/main/art.asp?articlekey=488http://www.medicinenet.com/script/main/art.asp?articlekey=39574http://www.medicinenet.com/script/main/art.asp?articlekey=6846http://www.medicinenet.com/script/main/art.asp?articlekey=24593http://www.medicinenet.com/script/main/art.asp?articlekey=24593http://www.medicinenet.com/script/main/art.asp?articlekey=24593http://www.medicinenet.com/script/main/art.asp?articlekey=24593http://www.medicinenet.com/script/main/art.asp?articlekey=6846http://www.medicinenet.com/script/main/art.asp?articlekey=39574http://www.medicinenet.com/script/main/art.asp?articlekey=488http://www.medicinenet.com/script/main/art.asp?articlekey=85386http://www.medicinenet.com/script/main/art.asp?articlekey=85053http://www.medicinenet.com/script/main/art.asp?articlekey=1908http://www.medicinenet.com/script/main/art.asp?articlekey=39573http://www.medicinenet.com/script/main/art.asp?articlekey=39573http://www.medicinenet.com/script/main/art.asp?articlekey=16387 -
8/3/2019 DM Tinjauan Pustaka Eng Upload
20/33
type 2 diabetes do not generally develop ketoacidosis solely on the basis of their
diabetes. Since in general, type 2 diabetes occurs in an older population, concomitant
medical conditions are more likely to exist, and these patients may actually be sicker
overall. The complication and death rates from hyperosmolar coma is thus higher than
in DKA.
3. Hypoglycemia
Hypoglycemia means abnormally low blood sugar (glucose). In patients with
diabetes, the most common cause of low blood sugar is excessive use of insulin or
other glucose-lowering medications, to lower the blood sugar level in diabetic patients
in the presence of a delayed or absent meal. When low blood sugar levels occur
because of too much insulin, it is called an insulin reaction. Sometimes, low blood
sugar can be the result of an insufficient caloric intake or sudden excessive physical
exertion.
Blood glucose is essential for the proper functioning of brain cells. Therefore, low
blood sugar can lead to central nervous system symptoms such as:
dizziness, confusion, weakness, and tremors.
The actual level of blood sugar at which these symptoms occur varies with
each person, but usually it occurs when blood sugars are less than 65 mg/dl. Untreated,
severely low blood sugar levels can lead to coma, seizures, and, in the worse case
scenario, irreversible brain death. At this point, the brain is suffering from a lack of
sugar, and this usually occurs somewhere around levels of
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
21/33
Glucagon causes the release of glucose from the liver (for example, it
promotes gluconeogenesis). Glucagon can be lifesaving and every patient with
diabetes who has a history of hypoglycemia (particularly those on insulin) should
have a glucagon kit. Families and friends of those with diabetes need to be taught how
to administer glucagon, since obviously the patients will not be able to do it
themselves in an emergency situation. Another lifesaving device that should be
mentioned is very simple; a medic alert bracelet should be worn by all patients with
diabetes.
Chronic Complications
These diabetes complications are related to blood vessel diseases and are
generally classified into small vessel disease, such as those involving the eyes,
kidneys and nerves (microvascular disease), and large vessel disease involving the
heart and blood vessels (macrovascular disease). Diabetes accelerates hardening of
the arteries (atherosclerosis) of the larger blood vessels, leading to coronary heart
disease (angina or heart attack), strokes, and pain in the lower extremities because of
lack of blood supply (claudication).
Eye Complications
The major eye complication of diabetes is called diabetic retinopathy. Diabetic
retinopathy occurs in patients who have had diabetes for at least five years. Diseased
small blood vessels in the back of the eye cause the leakage of protein and blood in
the retina. Disease in these blood vessels also causes the formation of small
aneurysms (microaneurysms), and new but brittle blood vessels (neovascularization).
Spontaneous bleeding from the new and brittle blood vessels can lead to retinal
scarring and retinal detachment, thus impairing vision.
To treat diabetic retinopathy a laser is used to destroy and prevent the
recurrence of the development of these small aneurysms and brittle blood vessels.
Approximately 50% of patients with diabetes will develop some degree of diabetic
retinopathy after 10 years of diabetes, and 80% of diabetics have retinopathy after 15
years of the disease. Poor control of blood sugar and blood pressure further
aggravates eye disease in diabetes.
Cataracts and glaucoma are also more common among diabetics. It is also
http://www.medicinenet.com/script/main/art.asp?articlekey=262http://www.medicinenet.com/script/main/art.asp?articlekey=379http://www.medicinenet.com/script/main/art.asp?articlekey=489http://www.medicinenet.com/script/main/art.asp?articlekey=9297http://www.medicinenet.com/script/main/art.asp?articlekey=39550http://www.medicinenet.com/script/main/art.asp?articlekey=24655http://www.medicinenet.com/script/main/art.asp?articlekey=12740http://www.medicinenet.com/script/main/art.asp?articlekey=314http://www.medicinenet.com/script/main/art.asp?articlekey=373http://www.medicinenet.com/script/main/art.asp?articlekey=373http://www.medicinenet.com/script/main/art.asp?articlekey=314http://www.medicinenet.com/script/main/art.asp?articlekey=12740http://www.medicinenet.com/script/main/art.asp?articlekey=24655http://www.medicinenet.com/script/main/art.asp?articlekey=39550http://www.medicinenet.com/script/main/art.asp?articlekey=9297http://www.medicinenet.com/script/main/art.asp?articlekey=489http://www.medicinenet.com/script/main/art.asp?articlekey=379http://www.medicinenet.com/script/main/art.asp?articlekey=262 -
8/3/2019 DM Tinjauan Pustaka Eng Upload
22/33
important to note that since the lens of the eye lets water through, if blood sugar
concentrations vary a lot, the lens of the eye will shrink and swell with fluid
accordingly. As a result, blurry vision is very common in poorly controlled diabetes.
Patients are usually discouraged from getting a new eyeglass prescription until their
blood sugar is controlled. This allows for a more accurate assessment of what kind of
glasses prescription is required.
Kidney damage
Kidney damage from diabetes is called diabetic nephropathy. The onset of
kidney disease and its progression is extremely variable. Initially, diseased small
blood vessels in the kidneys cause the leakage of protein in the urine. Later on, the
kidneys lose their ability to cleanse and filter blood. The accumulation of toxic waste
products in the blood leads to the need for dialysis. Dialysis involves using a machine
that serves the function of the kidney by filtering and cleaning the blood. In patients
who do not want to undergo chronic dialysis, kidney transplantation can be
considered.
The progression ofnephropathy in patients can be significantly slowed by controlling
high blood pressure, and by aggressively treating high blood sugar levels. Angiotensinconverting enzyme inhibitors (ACE inhibitors) or angiotensin receptor blockers
(ARBs) used in treating high blood pressure may also benefit kidney disease in
diabetic patients.
Nerve damage
Nerve damage from diabetes is called diabetic neuropathy and is also caused
by disease of small blood vessels. In essence, the blood flow to the nerves is limited,
leaving the nerves without blood flow, and they get damaged or die as a result (a term
known as ischemia). Symptoms of diabetic nerve damage include numbness, burning,
and aching of the feet and lower extremities. When the nerve disease causes a
complete loss of sensation in the feet, patients may not be aware of injuries to the feet,
and fail to properly protect them. Shoes or other protection should be worn as much
as possible. Seemingly minor skin injuries should be attended to promptly to avoid
serious infections. Because of poor blood circulation, diabetic foot injuries may not
http://www.medicinenet.com/script/main/art.asp?articlekey=7225http://www.medicinenet.com/script/main/art.asp?articlekey=42000http://www.medicinenet.com/script/main/art.asp?articlekey=344http://www.medicinenet.com/script/main/art.asp?articlekey=7872http://www.medicinenet.com/script/main/art.asp?articlekey=378http://www.medicinenet.com/script/main/art.asp?articlekey=16978http://www.medicinenet.com/script/main/art.asp?articlekey=16979http://www.medicinenet.com/script/main/art.asp?articlekey=43339http://www.medicinenet.com/script/main/art.asp?articlekey=4052http://www.medicinenet.com/script/main/art.asp?articlekey=4052http://www.medicinenet.com/script/main/art.asp?articlekey=43339http://www.medicinenet.com/script/main/art.asp?articlekey=16979http://www.medicinenet.com/script/main/art.asp?articlekey=16978http://www.medicinenet.com/script/main/art.asp?articlekey=378http://www.medicinenet.com/script/main/art.asp?articlekey=7872http://www.medicinenet.com/script/main/art.asp?articlekey=344http://www.medicinenet.com/script/main/art.asp?articlekey=42000http://www.medicinenet.com/script/main/art.asp?articlekey=7225 -
8/3/2019 DM Tinjauan Pustaka Eng Upload
23/33
heal. Sometimes, minor foot injuries can lead to serious infection, ulcers, and even
gangrene, necessitating surgical amputation of toes, feet, and other infected parts.
Diabetic nerve damage can affect the nerves that are important for penile erection,
causing erectile dysfunction (ED, impotence). Erectile dysfunction can also be caused
by poor blood flow to the penis from diabetic blood vessel disease.
Diabetic neuropathy can also affect nerves to the stomach and intestines, causing
nausea, weight loss, diarrhea, and other symptoms ofgastroparesis (delayed emptying
of food contents from the stomach into the intestines, due to ineffective contraction of
the stomach muscles).
Prevention for DM type 2
Primary Prevention
Aim from primary prevention :
Primary prevention efforts are aimed at groups who have risk factors, those who have
not been affected by diabetes, but has the potential to get DM and glucose intolerance
groups
Risk factor for DM that cant be modified :
- Ethnic
- Family history with DM
- Age. risk of developing glucose intolerance increases with increasing
age. age> 45 years should be screening for DM
-
a history of having a baby with birth weight > 4000 gr or a history of
suffered from gestational diabetes mellitus (DMG)
- A history of having a baby with low birth weight, < 2,5 kg. Baby with
low birth weight have higher risk compare with baby with normal birth
weight.
Risk factor that can be modified :
- Overweight (BMI > 23 kg/m2)
-
Lack of physical activity
http://www.medicinenet.com/script/main/art.asp?articlekey=97999http://www.medicinenet.com/script/main/art.asp?articlekey=12537http://www.medicinenet.com/script/main/art.asp?articlekey=395http://www.medicinenet.com/script/main/art.asp?articlekey=4827http://www.medicinenet.com/script/main/art.asp?articlekey=41943http://www.medicinenet.com/script/main/art.asp?articlekey=1900http://www.medicinenet.com/script/main/art.asp?articlekey=8385http://www.medicinenet.com/script/main/art.asp?articlekey=8385http://www.medicinenet.com/script/main/art.asp?articlekey=1900http://www.medicinenet.com/script/main/art.asp?articlekey=41943http://www.medicinenet.com/script/main/art.asp?articlekey=4827http://www.medicinenet.com/script/main/art.asp?articlekey=395http://www.medicinenet.com/script/main/art.asp?articlekey=12537http://www.medicinenet.com/script/main/art.asp?articlekey=97999 -
8/3/2019 DM Tinjauan Pustaka Eng Upload
24/33
- Hypertension (>140/90 mmHg)
- Dyslipidemia (HDL < 35 mg/dL and trigliserid > 250 mg/dL)
- Unhealthy diet. Diet with high glucose dan low fibers will increase risk
to suffer prediabetes / glucose intolerance and type II DM
Other risk factors associated with diabetes :
- patients with polycystic ovary syndrome (PCOS) or other clinical
conditions associated with insulin resistance
- patients with metabolic syndrome have a history of impaired glucose
tolerance (IGT) or impaired fasting blood glucose (IFBG) before. have
a history of cardiovascular disease such as stroke, coronary heart
disease or PAD (Peripheral Arterial Disease)
Glucose Intolerance
glucose intolerance is a condition that precedes the onset of diabetes. the
incidence of glucose intolerance reported continues to increase
This term was first introduced in 2002 by the Department of Health and
Human Services (DHHS) and the American Diabetes Associated (ADA).
Previously the term to describe the state of glucose intolerance is the impaired
glucose tolerance (IGT) and impaired fasting blood glucose (IFBG)
glucose intolerance have a greater risk for the onset of cardiovascular
disorders a half times higher than normal people
glucose intolerance diagnosis is made by TTGO account after fasting 8 hours.
established diagnosis of glucose intolerance when blood glucose test results
show that there is one of the following:
- fasting blood glucose between 100125 mg/dl
- blood glucose 2 hours after some liquid glucose between 140 199
mg/dl
in patients with glucose intolerance, anamnesis and physical examination
considered aimed to look for risk factors that can be modified
Primary Prevention Materials
Material consists of primary prevention counseling and management actions aimed at
community groups who have a high risk and glucose intolerance.
Counseling addressed to:
A. group of people with high risk and glucose intolerance
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
25/33
Outreach materials include:
1. Weight counseling program. In someone with diabetes risk and have overweight,
weight loss is the main way to reduce the risk of type 2 diabetes or glucose
intolerance. Several studies have shown weight loss 50-10% can prevent or slow the
emergence of type 2 diabetes.
2. A healthy diet
It is recommended given to every person who has a risk.
The amount of calorie intake is intended to achieve the ideal body weight.
Complex carbohydrates are a choice and given divided and balanced so it
does not cause high blood glucose peaks after meals.
Contain less saturated fat and high in soluble fiber.
3. Physical exercise
Regular physical exercise can improve blood glucose control, maintain or lose
weight, and can increase HDL cholesterol levels.
Physical exercise is recommended:
Exercise for at least 150 minutes / week with moderate aerobic exercise (up to
50-70% maximum heart rate), or 0 minutes / week with heavy aerobic exercise
(heart rate reached> 70% maximum). Exercise Physical activity was divided
into 3-4 times / week.
4. Stop smoking
Smoking is one of the risk to get cardiovascular disease. Although snoking is
not correlate directly with glucose intolerance, but smoking can make
complication cardiovascular heavier from glucose intolerance and DM type II.
B. Health policy planning in order to understand the socio-economic impact of this
disease and the importance of providing adequate facilities in primary prevention
efforts
Management aimed to:
- Groups of glucose intolerance
- Risk group (obesity, hypertension, dyslipidemia, etc)
1. Management of glucose intolerance
Glucose intolerance is often associated with metabolic syndrome,
characterized by central obesity, dyslipidemia (high triglycerides or low HDL
cholesterol) and hypertension.
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
26/33
Most people with glucose intolerance can be improved by lifestyle changes,
losing weight, eating a healthy diet and adequate physical exercise and regular
Diabetes Prevention Program study showed that lifestyle changes more
effectively to prevent the emergence of type 2 diabetes compared with the useof drugs.
Weight loss of 5-10% accompanied by regular physical exercise can reduce
the risk of type 2 diabetes by 58%. While the use of drugs (such as metformin,
tiazolidindion, acarbose) is only able to reduce their risk by 31% and the use
of various drugs for the treatment of glucose intolerance is still a controversy
When accompanied by obesity, hypertension, and dyslipidemia, carried weight
control, blood pressure and lipid profiles in order to reach the target set.
2. Management of various risk factors
a. obesity
b. hypertension
c. dyslipidemia
Secondary Prevention
Secondary prevention is an attempt to prevent or inhibit the onset of
complications in patients who already suffer from DM. Done by providing adequate
treatment and early detection measures since the early management of disease
complications of DM. In secondary prevention outreach programs play an important
role to improve patient compliance in carrying out the program and in towards healthy
behaviors.
For secondary prevention is aimed primarily at new patient. Extension made
since the first meeting and the need to always be repeated at every opportunity and the
next meeting.
One of the most common complications of DM is cardiovascular disease,
which is the leading cause of death in persons with diabetes. In addition to the
treatment of high blood glucose levels, weight control, blood pressure, lipid profile in
blood and antiplatelet administration can reduce the risk of cardiovascular disorders in
people with diabetes.
Tertiary Prevention
Tertiary prevention is aimed at groups of people with diabetes who have
experienced complications in an effort to prevent further disability.
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
27/33
Efforts to rehabilitate the patient as early as possible, before permanent
disability. As an example of low-dose aspirin (80-325 mg / day) can be given
routinely for persons with diabetes who already have microangiopathic
complications.
In tertiary prevention efforts remain to be done on the patient and family
counseling. Materials including rehabilitation counseling can be done to
achieve optimal quality of life.
Tertiary prevention requires a holistic and integrated health service interrelated
disciplines, particularly at a referral hospital. A good collaboration between experts in
various disciplines (heart and kidney, eye, orthopedic surgery, vascular surgery,
radiology, medical rehabilitation, nutrition, pediatric, etc.) is indispensable in the
success of tertiary prevention.
Others Problems
I. Diabetes with Infection
The presence of infection in patients is very influential on the control of blood
glucose. Infection can worsen blood glucose control, and high blood glucose levels
increase the ease or worsen the infection.
Infection is the case, among others:
- Urinary tract infections
- Respiratory tract infections: pneumonia, pulmonary tuberculosis
- Skin infections: furuncles, abscesses
- Infection of the oral cavity: infection of the teeth and gums
- Ear infections: otitis external malignant
- UTI is an infection that often occurs and is more difficult to control. May result in
pyelonephritis and septicemia. Germs are often leading causes were: Escherichia coli
and Klebsiella. Fungal infections candida species can cause cystitis and renal abscess.
Vaginal pruritus is a manifestation that often occurs due to vaginal yeast infections.
- Pneumonia in diabetes is usually caused by streptococcus, stafilococcus, and gram-
negative bacterial rods. Fungal infection of the respiratory by aspergilossis, and
mucormycosis are also common.
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
28/33
- People with diabetes are more vulnerable to suffer pulmonary tuberculosis. Chest X-
ray examination, showed at 70% people with diabetes have lower lung lesions and
cavitation. People with diabetes is also often accompanied by tuberculosis drugs
resistance.
- The skin on the lower extremities is a frequent site of infection. Staphylococcus is
the main cause of the infection. Usually infected foot ulcers involves many
microorganisms, which often involved is staphylococcus, streptococcus, gram-
negative rods and anaerobic bacteria.
- The incidence of periodontitis is increased in persons with diabetes and often lead to
tooth loss. Maintaining good oral hygiene is essential to prevent complications of the
oral cavity.
- There are people with diabetes, malignant otitis externa is often not detected as a
cause of infection.
The principles of treatment of diabetic foot ulcers can be seen in Table 9
Metabolic control: a state of metabolic control as possible such as control of blood
glucose, lipids and so on
Vascular control: improvement of vascular supply (with surgery or angioplasty),
usually takes on the state of ischemic ulcers
Infection control: an aggressive treatment of infections, if visible clinical signs of
infection (an indication of colonization of the growth of organisms on the swab is not
an infection, if there are no clinical signs)
Wound control: the disposal of infected and necrotic tissue on a regular basis
Pressure control: reducing the pressure. Repeated pressure can cause ulcers, so it
should be avoided. It is very important to do on neuropathic ulcers, and required
removal of callus and put on shoes that fit that serves to reduce the pressure
Education control: A good advices
II. Diabetes with Diabetic Nephropathy
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
29/33
- Around 20 - 40% of persons with diabetes will have diabetic nephropathy
- Acquisition of persistent albuminuria in the range of 30 -229 mg/24 h (micro
albuminuria) is an early sign of diabetic nephropathy
- Patients who are accompanied with micro albuminuria and turned into a macro
albuminuria (> 300 mg/24 hours), in the end often progress to end-stage chronic renal
failure. Classification of albuminuria can be seen in Table 10.
Diagnosis
- The diagnosis of diabetic nephropathy is suspected when obtained albumin levels>
30 mg in the urine 24 hours on 2 of 3 times the examination within a period of 3-6
months, without other causes of albuminuria.
Table 10. Classification of albuminuria
Category Urine 24 hours
(mg/24hours)
Urine within a
certain time
Randomized urine
(g/mg creatinine)
Normal = 300
Filtering
In type 2 diabetes mellitus at the time of initial diagnosis. If microalbuminuria is
negative, re-evaluation carried out every year.
Method of Inspection
- The ratio of albumin / creatinine in urine during
- Levels of albumin in the urine 24 hours
- Micral test for microalbuminuria
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
30/33
- Dipstick / tablet reagent for macroalbuminuria
- Urine in a certain time (4 hours or overnight urine)
Management
- Control of blood glucose
- Control your blood pressure
- Dietary protein 0.8 g / kg / day. If a decline in kidney function gets worse, given
dietary protein from 0.6 to 0.8 g / kg / day
- Treatment with angiotensin II receptor, ACE inhibitors, or a combination of both
- If there are contraindications to ACE or angiotensin receptor blockers, calcium
antagonists non dihidropirin can be administered.
- If serum creatinine> 2.0 mg / dL shouldbe involved nephrologys expert.
- Ideally if creatinine clearance
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
31/33
- Need identified a variety of patients consumed drugs that affect the onset of erectile
dysfunction.
- First-line treatment is psychosexual therapy and oral medications such as sildenafil
and vardenafil.
IV. Diabetes in Pregnancy / Gestational Diabetes Mellitus
- Diabetes mellitus gestational (DMG) is a disorder of carbohydrate tolerance (IGT,
GDPT, DM) which was first known to occur or when the pregnancy is ongoing.
- Assessment of the risk needs to be done since DMG's first visit to check her
pregnancy.
- DMG risk factors include: obesity, a history of never having DMG, glucosuria, a
family history of diabetes, recurrent abortion, a history of having a baby with
congenital defects or birth to a baby weighing> 4000 grams, and a history of
preeclampsia. In patients with risk DMG should be done immediately clear
examination of blood glucose. When we got the result when blood glucose 200 mg /
dL or fasting blood glucose 126 mg / dL in accordance with the limits for the
diagnosis of diabetes, it is necessary to check at any other time for confirmation.Pregnant patients with IGT and GDPT managed as a DMG.
- Diagnosis based on examination results TTGO done with a 75 gram glucose load
after fasting 8-14 hours. Later examination of fasting blood glucose, 1 hour and 2
hours after the load.
- DMG enforced if found to be the results of fasting blood glucose 95 mg / dL, 1
hour after the load
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
32/33
morbidity and mortality. This can only be achieved if the state of normoglycaemia
can be maintained during pregnancy until delivery,
- Target normoglycaemia DMG is a fasting blood glucose 95 mg / dL and 2 hours
after eating 120 mg / dL. If the target blood glucose levels are not achieved by
setting eating and physical exercise, directly administered insulin.
V. Diabetes with Fasting Worship
- People with diabetes is controlled with meal arrangements alone would not have
difficulty to fast. During fasting, to be seen a change in schedule, the amount and
composition of food intake.
- Elderly diabetic people have a tendency to dehydration when fasting, therefore it is
recommended to drink enough.
- Need to increase patient awareness of symptoms of hypoglycemia. To avoid the
occurrence of hypoglycemia during the day, approached the recommended schedule
of meal times imsak / subuh, reduce physical activity during the day and when
physical activity is recommended in the afternoon.
- People with diabetes are quite restrained with OHO single dose, is also not difficult
to fast. OHO given when fasting. Beware of the occurrence of hypoglycemia in
patients receiving maximal doses of OHO.
- For those who are controlled by OHO divided doses, dosing of drugs administered
in such a way that dose before buka is greater than the dose in sahur.
- For people with type 2 diabetes mellitus who use insulin, used intermediate-acting
insulin is given when breaking it.
- It takes a higher vigilance against the occurrence of hypoglycemia in diabetic insulin
users. Need more stringent monitoring with adjustment of dose and schedule of
insulin injections. When symptoms of hypoglycemia, fasting is stopped.
- For patients who need to use multiple doses of insulin is recommended for not
fasting in Ramadan.
VI. Perioperative Management of Diabetes
-
8/3/2019 DM Tinjauan Pustaka Eng Upload
33/33
- Operation, especially with general anesthesia is a stress factor triggering the
occurrence of acute complications of diabetes. Therefore any elective surgery in
people with diabetes should be prepared as optimal as possible (target fasting blood
glucose levels