Guideline of

Type 2
Diabetes
Management
in Indonesia
2019
KURNIAWAN AGUNG YUWONO
Diabetes di Indonesia: Epidemiologi
 Epidemiologi Diabetes (IDF Atlas, 2019)

Number of people (20-79 years) with Top 10 countries or territories for number of adults
diabetes globally and by IDF Region (20–79 years) with diabetes in 2019, 2030 and 2045
 Diabetes di Indonesia: Pencapaian HbA1c

DiabCare 1998: 1932 subjects

Mean HbA1c 8,1%

IDMPS 2006-2007: 674 subjects

Mean HbA1c 8,27%;
HbA1c <7% : 34%

DiabCare 2008: 1832 subjects

Mean HbA1c 8,16%
HbA1c <7% : 32%

Indonesian HbA1c is the highest compared with other

DiabCare 2012: 1967 subjects participant countries in DISCOVER study, even after
initiating second line of therapy (mean+SD = 9.2+2%)1,
Mean HbA1c 8,3% almost 70% patient >8%).2
HbA1c <7% : 30.8%
1. Soeatmadji DW et al. 2nd ICE on IMERI, 7 November 2017, Jakarta, Indonesia
2. Ji L et al. 53rd EASD, 11–15 September 2017, Lisbon, Portugal.
 Current Practice in the Management of
DM2 in Indonesia: IDMPS Study
The HbAlc average was 8.27% and only 37.4% had reached the HbAIc target of <7%.

Target Achievement (HbA1c < 7%)

90.0
80.0 76.2
70.0 65.9
61.2 62.6
60.0
50.0
38.8 37.4
40.0 34.1
30.0 23.8
20.0
10.0
0.0
LSM OAD Insulin Total

yes no #REF!
Soewondo P. J Indon Med Assoc. 2011 IDMPS study: The International Diabetes Management Practices Study
 Discover Study:
Higher number of complications in Indonesia compared to
neighboring countries

HbA1c among Neighboring Countries Micro and macrovascular complications

26.9 28.3
Indonesia

Malaysia
16.3 16.5
India
9.7

3.2
7.0 7.5 8.0 8.5 9.0 9.5 Indonesia Malaysia India
Mean adjusted HbA1c (%) Micro (%) Macro (%)

Ji L et al. 53rd EASD, 11–15 September 2017, Lisbon, Portugal.

Kosiborod M et al., Caediovas Diabetol 2018. https://doi.org/10.1186/s12933-018-0787-8
Current challenges of diabetes in Indonesia

• Absolute number of patients with prediabetes and diabetes are

high
• The prevalence of undiagnosed diabetes is high
• Earlier beta cell dysfunction
• Many patients with diabetes have not adequately achieved glucose
targets
• Most patients with diabetes have not been sufficiently aggressive
in controlling risk factors
• Many patients with diabetes have poor adherence
to therapy
• Complications related diabetes are high
• Budget is relatively low, and its spending/cost almost come from
complications
Diabetes: Patogenesis, Klasifikasi, dan
Diagnosis
 Pathogenesis of T2DM

Schwartz SS et al. Diabetes Care 2016;39:179–186

 Pathogenesis of T2DM
Beta cells centric construct: Egregious eleven
The beta cell is a FINAL COMMON DENOMINATOR of beta cell
damage

Schwartz SS et al. Diabetes Care 2016;39:179–186

 Classification of diabetes

Perkeni 2019; ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31

Faktor Risiko
 Criteria for the diagnosis of diabetes

DCCT, Diabetes Control and Complications Trial; FPG, fasting plasma glucose; OGTT, oral glucose tolerance test; WHO, World Health
Organization; 2-h PG, 2-h plasma glucose. *In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test
results from the same sample or in two separate test samples.

Perkeni 2019; ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31

 Criteria for the diagnosis of prediabetes

Perkeni 2019; ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31

 Management of Diabetes in Indonesia: Aims

• Short-termly: relief complains, increase quality of

life, and prevent acute complications
• Long-termly: prevent, regress and inhibit
progressivity of chronic macro- and micro-
angiopathy
• Final aims: lower morbidity and mortality

Perkeni, 2019
Pilar Manajemen Diabetes
Melitus

Edukasi Pengaturan
makan

Monitoring Latihan
Fisik

Obat-
Obatan
 Prinsip Tatalaksana
• Terapi ditujukan untuk memperbaiki gangguan patogenesis, bukan
sekedar menurunkan HbA1c
• Pengobatan kombinasi yang diperlukan harus didasari atas kinerja obat
pada gangguan multipel dari patofisiologi DM tipe 2.
• Manajemen secara menyeluruh dimulai sedini mungkin untuk
memperlambat progresivitas penyakit.
 Penatalaksanaan Umum
Evaluasi medis yang lengkap pada pertemuan pertama, yang meliputi:
• Riwayat Penyakit
• Usia dan karakteristik saat onset diabetes.
• Pola makan, status nutrisi, status aktifitas fisik, dan riwayat perubahan
berat badan.
• Pengobatan yang pernah diperoleh sebelumnya secara lengkap,
termasuk terapi gizi medis dan penyuluhan.
• Faktor resiko (Merokok, hipertensi, riw PJK, obesitas, dan penyakit
endokrin lainnya)
 Skrining Komplikasi dan Komorbiditas

Penapisan komplikasi penyandang yang baru DMT2 :

• Tes fungsi ginjal (albuminuria, eGFR)
• Pemeriksaan funduskopi untuk melihat retinopati diabetik
• Profil lipid
• Tes fungsi hati
• Elektrokardiogram.
• Pemeriksaan kaki secara komprehensif.
• Foto Rontgen dada (bila ada indikasi: TBC, penyakit
jantung kongestif).
 Edukasi
Dokter, perawat, penyandang (pandu), ahli gizi, apoteker

Pemberian pemahaman yang komprehensif

secara bertahap sesuai dengan kondisi dan
latar belakang pasien dan keluarga
 TGM DIABETISI

• Anjuran makan sama dengan

makanan sehat keluarga pada
umumnya
• Makanan dengan Gizi seimbang
• Pengaturan jumlah kalori yang
dibutuhkan untuk mengontrol kadar
gula
YANG PERLU DIPERHATIKAN ADALAH
3J (JADWAL, JUMLAH, JENIS)
 Medical Nutrition Therapy
• Carbohydrate 45-60%
• Protein 10-20%
• Fat 20 – 25% Basal calories need: 25-30 kcal/ideal BW
• saturated fat <7% Ideal BW: 90% (height in cm -100) x 1kg
• Polyunsaturated fat <10%
• Sufficient vitamin & minerals
• Na : <2300 mg/day

CDC.gov
Perkeni 2019, ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31
Penghitungan Kebutuhan Kalori Harian
• Kalori Basal sesuai jenis kelamin dan berat badan ideal
• (+) Derajat aktivitas
• (+) Derajat Stres
• (-) Rentang Usia
• (-) Kelebihan/kekurangan berat badan
• dibagi dalam 3 porsi makan : pagi (20%) Siang (30%) dan Malam (25%)
ditambah selingan 2-3x sebesar (10-15%)
contoh kasus:
• Tn. Joko Usia 50 tahun Penderita DM Tipe 2, tinggi badan 170cm dan
berat badan 90kg, bekerja sebagai PNS di KUA, saat ini kondisi sehat dan
tanpa keluhan, berapakah kebutuhan kalorinya?
• (1) BMI : 30,1 kg/m2(0besitas); berat ideal = (170-100)x0,9 = 63kg
• (2) kebutuhan basal = 30 KKal x 63kg = 1900 kkal
• (3) usia 40-59 th dikurangi 5%
• (4) aktivitas sedang : ditambah 20%
• (5) stress : 0%
• (6) obesitas : dikurangi 20%
• Total = kalori basal ditambah Faktor koreksi = 1800kkal + [(-5%)+ (20%)+(-
20%)] = 2000 kkal
 Latihan Jasmani/ Olah raga

Continous
Rhytmic
Interval
Progressive
Endurance
Bertahap, terstruktur, menyesuaikan
kondisi komorbid, target yang jelas
• Aerobic,
• 150 minutes/weeks,
• >3 days/week Perkeni 2019, ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31
Algorithm of type 2 diabetes management in
Indonesia (Perkeni, 2019)
 Estimated average glucose (eAG)
A1C (%) mg/dL* mmol/L
5 97 (76–120) 5.4 (4.2–6.7)
6 126 (100–152) 7.0 (5.5–8.5)
7 154 (123–185) 8.6 (6.8–10.3)
8 183 (147–217) 10.2 (8.1–12.1)
9 212 (170–249) 11.8 (9.4–13.9)
10 240 (193–282) 13.4 (10.7–15.7)
11 269 (217–314) 14.9 (12.0–17.5)
12 298 (240–347) 16.5 (13.3–19.3)

Data in parentheses are 95% CI. A calculator for converting A1C results into eAG, in either mg/dL or
mmol/L, is available at professional.diabetes.org/eAG. *These estimates are based on ADAG data of ;2,700
glucose measurements over 3 months per A1C measurement in 507 adults with type 1, type 2, or no
diabetes. The correlation between A1C and average glucose was 0.92 (6,7). Adapted from Nathan et al.

Perkeni 2019; ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31

 Pathogenesis of T2DM
Beta cells centric construct: Egregious eleven
Treated treatments for mediating pathway of hyperglycemia

Schwartz SS et al. Diabetes Care 2016;39:179–186

Antihyperglycemics tackle fasting and postprandial plasma
glucose through different mechanisms of action

Glucose storage
and production
Metformin
Sulfonylureas
Meglitinides Insulin
secretion Glucose
storage and use
Insulins

Delayed gastric Islet β-cell

Amylin mimetics emptying
BLOOD Glucose uptake
GLUCOSE and FFA release Thiazolidinediones
GLP-1
receptor agonists
Glucagon
Glucose SGLT-2 inhibitors
secretion
DPP-4 inhibitors reabsorption
Islet α-cell

Incretin Neurotransmitter
-glucosidase inhibitor release release
Dopamine agonists
Bile acid sequestrants

• Bailey CJ, et al. Clin Pharmacol Therapeutics 2015;98:170–84

DeFronzo RA, et al. Diabetes 2009;58:773–95
INDIKASI INSULIN
 Summary of glycemic recommendations for
many nonpregnant adults with diabetes

A1C < 7.0% (53 mmol/mol)*

Pre prandial capillary plasma 80–130 mg/dL* (4.4–7.2
glucose mmol/L)
Peak postprandial capillary
plasma glucose† <180 mg/dL* (10.0 mmol/L)
*More or less stringent glycemic goals may be appropriate for individual patients.
Goals should be individualized based on duration of diabetes, age/life expectancy,
comorbid conditions, known CVD or advanced microvascular complications,
hypoglycemia unawareness, and individual patient considerations. †Postprandial
glucose may be targeted if A1C goals are not met despite reaching preprandial
glucose goals. Postprandial glucose measurements should be made 1–2 h after the
beginning of the meal, generally peak levels in patients with diabetes.

Perkeni 2019; ADA, 2020. Diabetes Care 2020;43(Suppl. 1):S14–S31

 Kasumasa

Matur Suwun
‫شكرا جزيال‬