Early Detection, Screening

Complications and
Standardized
Diabetes Management

Himawan Sanusi
Internal Departement
Wahidin Sudirohusodo Hospital

Slide 1

Slide 2

Early Detection

Classification of diabetes
Type 1 DM

Gestational
DM
Other Type

Type 2 DM

Slide 4

Type 2 diabetes is a progressive disease

HOMA: homeostasis model assessment

Lebovitz. Diabetes Reviews 1999;7:13953 (data are from the UKPDS population: UKPDS 16.
Diabetes 1995;44:124958)

Slide 5

The Importance of treating Type 2 Diabetes

Type 2 diabetes is a progressive disease
Postprandial glucose
Fasting glucose

Postprandial glucose

Diagnosis

Glucose

Fasting glucose

Insulin

Insulin resistance

Inadequate
-cell function

Insulin resistance
Insulin secretion

Microvascular changes

Macrovascular changes

NGT

Prediabetes
(IFG/IGT)

Diabetes

Adapted from Type 2 Diabetes BASICS. International Diabetes Center 2000

Insulin secretion

Slide 6

How to
Diagnose ?

Slide 7

4 Simple Steps from Screening to Diagnosis

Screen patients with

diabetes risk factors

Conduct 1st Blood Test

Inform Patient and

Initiate treatment

Conduct 2nd Blood Test

(if required) and
establish Diagnosis

Slide 8

Classical Diabetes Symptoms

Polyuria

Excessive Urination at night

Polyphagia

Excessive Hunger

Polydipsia

Excessive Thirst

Unexplained weight
loss

Weight Loss even if food in-take is

normal

Slide 9

Other Diabetes Symptoms

Blurred Vision

Damaging blood vessels in the eyes

Numbness and/or
Tingling

Numbness and tingling in hands, legs

and feet

Fatigue

Frequent fatigue regardless of

exercise

Itchy Skin

Affects legs, feet, and hands

Impotence

Physical and Physiological

Slide 10

Step 1: Risk Factors PERKENI screening risk factor guideline

Unmodifiable Risk

Diabetes Associated
Risk

Modifiable Risk

Race and Ethnic

Overweight (BMI >23)

Family History of

Hypertension

Diabetes

>

140/90

Polycystic

Ovary

Syndrome (PCOS) or

mmHg

another

Dyslipidemia (HDL < 35

condition related to

Diabetes

mg/dl

insulin resistance

History of delivery a

triglycerides >250 mg/dl

History of Gestational

and/or

clinical

Metabolic Syndrome

baby more than 4.000g

Unhealthy Diet

(IGT, IFG, History of

History of low birth

Limited Physical Activity

Coronary

weight <2.500g

Disease

Artery
,

and/or PAD)

Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

stroke

Slide 11

Diabetes elevated blood glucose due to

insufficient insulin secretion
Normal glucose and insulin
excursions
Glucose

Insulin

Glucose
120

80
60

200

40
100

20

300

80
60

200

40
100

20

06:00 10:00 14:00 18:00 22:00 02:00 06:00

Dinner

Lunch

Dinner

Lunch

Breakfast

Time of Day

100

Breakfast

06:00 10:00 14:00 18:00 22:00 02:00 06:00

120

Insulin U/mL

300

Insulin U/mL

100

Insulin

400

Glucose mg/dL

400

Glucose mg/dL

Early Type 2 Diabetes Glucose

and insulin excursions

Time of Day

Slide 12

Cut-points: Diabetes, IGT and IFG

Fasting Plasma Glucose (FPG)

mg/dL
Diabetes

126
IFG (Impaired
Fasting Glucose
100

IGT (Impaired
Glucose
Tolerance)

NGT (Normal
Glucose
Tolerance)

140

Diabetes

200

2-hour Plasma
Glucose (PPG)

mg/dL

Slide 13

Diagnosis of Type 2 Diabetes

KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

1. Classical symptoms of Diabetes (+) & Random plasma

glucose concentration 200 mg/dl
Or
2. Classical symptoms of Diabetes (+) & Fasting Plasma
Glucose 126 mg/dl.
Or
3. 2-hour post-OGTT 200 mg/dl.

Note:
.

Classical symptom of diabetes (+), only need 1 abnormal BG

No classical symptom of diabetes, need 2 x abnormal BG level in a different days

Slide 14

D/ Type 2 DM

What next ??

Slide 15

Step 4: Inform Patient and Initiate Treatment

Diabetes Mellitus

IGT

IFG

Evaluation of Nutritional Status

Education

Evaluation

Food Regulation

Regulation and exercise

Physical Exercise

Evaluation

Ideal Body Weight

OADs are unnecessary at this

of

Required
of

Food

Diabetes

Complications

Decision on medicines

Monitoring

Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

stage

Slide 16

Updated PERKENI Type 2 Diabetes Treatment

Algorithm

Diabetes

STEP 1

Healthy life style

STEP 2

STEP 3

Healthy life style

+
Mono therapy

Healthy life style

Note:
1.

2.

Therapy failed if
target of HbA1c <
7% is not achieved
within 2-3 months
for each step
In case of no HbA1c
test, the use of blood
glucose level is also
permitted. Average
blood glucose level
for a few BG test in
one day can be
converted to HbA1c
(ref: ADA 2010)

Healthy life style

2 OAD Combination

+
Combination 2 OAD

Alternative option, if :

No insulin is available

The patient is objecting insulin

Basal insulin

Blood glucose is still not

optimally controlled
Healthy life style
+
3 OAD Combination

*Intensive Insulin: use of basal insulin together with insulin prandial

Insulin
Intensification*

Slide 17

What is good glycemic control?

Overall aim to achieve glucose levels as close to normal as possible
Minimise development and progression of microvascular and
macrovascular complications

ADA1

FPG
<130 mg/dL

HbA1c
< 7.0%

PPG
<180 mg/dL

IDF2

FPG
<110 mg/dl

HbA1c
< 6.5%

PPG
<145 mg/dL

PERKENI3

FPG
<100 mg/dl

HbA1c
< 7%

PPG
<140 mg/dl

1. American Diabetes Association Diabetes Care 2009;32 (Suppl 1):S1-S97

2. IDF Clinical Guidelines Task Force. International Diabetes Federation 2005. 3. PERKENI 2011 Konsensus .

Slide 18

HbA1c correlation with blood glucose level

The relationship between A1C and eAG is described by the formula 28.7 X
A1C 46.7 = eAG

David M. Nathan, Judith Kuenen, Rikke Borg, Hui Zheng, David Schoenfeld, and Robert J. Heine, for the A1c-Derived
Average Glucose (ADAG) Study Group. Diabetes Care 2008

Slide 19

Risk of hyperglycemia
Acute complications : DKA & HONK
Chronic Complications :

Slide 20

Risk of Complications increases as Hb1Ac

increases and thats why diabetes must be treated

Incidence per 1.000

patient-years

1/18/17
1/18/17

Mean HbA1c (%)

97

126

154

183

212

240

269

Mean mg/dl

Adjusted for age, sex, and ethnic group. The relationship between A1C and mg/dl is described by
the formula 28.7 X A1C 46.7 = mg/dl.

Stratton IM et al. BMJ 2000;321:40512

Slide 21

The benefits of good blood glucose control are

clear

Good control is
7.0% HbA1c
HbA1c measures
the average
blood glucose
HbA1c
level over the
last three
-1%
months

Myocardial
infarction

-14%
Microvascular
complications

-37%
Deaths related
to diabetes

-21%
Source: UKPDS = United Kingdom Prospective Diabetes Study. Stratton IM
et al. BMJ. 2000;321(7258):405-412.

Slide 22

Practical Monitoring Scheme

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009

Slide 23

Practical Monitoring Scheme Cont

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009

Slide 24

Individualized Treatment based on several criteria

to control blood glucose

Inzucci SE, et al. Diabetologia. 2012

Slide 25

Summary

Diabetes is a progressive disease that must be

treated in order to avoid long-term complications

Good glycemic control according to PERKENI is:

HbA1c <7%
FPG: <100 mg/dl
PPG: <140 mg/dl
]

Patient treatment need to be individualized

according to the characteristics of each particular
patients

Slide 26