Slide 1

Early Detection, Screening

Complications and Standardized
Diabetes Management

Himawan Sanusi

Internal Departement
Wahidin Sudirohusodo Hospital
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Early Detection
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Classification of diabetes

Type 1 DM Type 2 DM

Gestational
DM

Other Type
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Type 2 diabetes is a progressive disease

HOMA: homeostasis model assessment

Lebovitz. Diabetes Reviews 1999;7:139–53 (data are from the UKPDS population: UKPDS 16.
Diabetes 1995;44:1249–58)
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The Importance of treating Type 2 Diabetes

Type 2 diabetes is a progressive disease

Postprandial glucose
Postprandial glucose
Fasting glucose Diagnosis

Glucose Fasting glucose

Insulin Insulin resistance

Inadequate
β-cell function Insulin secretion
Insulin resistance Microvascular changes
Insulin secretion
Macrovascular changes

Prediabetes
NGT Diabetes
(IFG/IGT)

Adapted from Type 2 Diabetes BASICS. International Diabetes Center 2000

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4 Simple Steps from Screening to Diagnosis

1 2 3
Screen patients with Conduct 1st Blood Test Conduct 2nd Blood Test
diabetes risk factors (if required) and
establish Diagnosis

4
Inform Patient and
Initiate treatment
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Classical Diabetes Symptoms

Polyuria • Excessive Urination at night

Polyphagia • Excessive Hunger

Polydipsia • Excessive Thirst

Unexplained weight
• Weight Loss even if food in-take is
loss
normal
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Other Diabetes Symptoms

Blurred Vision • Damaging blood vessels in the eyes

Numbness and/or • Numbness and tingling in hands, legs

Tingling and feet

Fatigue • Frequent fatigue regardless of

exercise

Itchy Skin • Affects legs, feet, and hands

Impotence • Physical and Physiological

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Step 1: Risk Factors – PERKENI screening risk factor guideline

Diabetes Associated
Unmodifiable Risk Modifiable Risk
Risk

• Race and Ethnic • Overweight (BMI >23) • Polycystic Ovary

• Family History of • Hypertension > 140/90 Syndrome (PCOS) or
Diabetes mmHg another clinical
• History of Gestational • Dyslipidemia (HDL < 35 condition related to
Diabetes mg/dl and/or insulin resistance
• History of delivery a triglycerides >250 mg/dl • Metabolic Syndrome
baby more than 4.000g • Unhealthy Diet (IGT, IFG, History of
• History of low birth • Limited Physical Activity Coronary Artery
weight <2.500g Disease , stroke
and/or PAD)

Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

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Diabetes – elevated blood glucose due to

insufficient insulin secretion
Normal glucose and insulin Early Type 2 Diabetes Glucose
excursions and insulin excursions

Glucose Insulin Glucose Insulin

400 120 400 120

100 100
Glucose mg/dL

Glucose mg/dL
Insulin U/mL

Insulin U/mL
300 300
80 80

200 60 200 60

40 40
100 100
20 20

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

Breakfast
Time of Day Time of Day
Breakfast

Dinner
Lunch

Dinner
Lunch
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Cut-points: Diabetes, IGT and IFG

mg/dL
Fasting Plasma Glucose (FPG)

Diabetes

126

IFG (Impaired
Fasting Glucose

100
IGT (Impaired
Glucose Diabetes
NGT (Normal Tolerance)
Glucose
Tolerance)

140 200 mg/dL

2-hour Plasma
Glucose (PPG)
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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
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D/ Type 2 DM

What next ??
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Step 4: Inform Patient and Initiate Treatment

Diabetes Mellitus IGT IFG

• Evaluation of Nutritional Status • Education

• Evaluation of Required Food • Food Regulation
Regulation and exercise • Physical Exercise
• Evaluation of Diabetes • Ideal Body Weight
Complications • OADs are unnecessary at
• Decision on medicines this stage
• Monitoring

Source: KONSENSUS: Pengelolaan Dan Pencegahan DM Type 2

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Updated PERKENI Type 2 Diabetes Treatment

Algorithm

Diabetes STEP 1 STEP 2 STEP 3

Healthy life style Healthy life style

Note:
1. Therapy failed if
target of HbA1c <
7% is not achieved
within 2-3 months
for each step
2. 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)
+
Mono therapy Healthy life style
+ Healthy life style
2 OAD Combination +
Alternative option, if : Combination 2 OAD
• No insulin is available +
• The patient is objecting insulin Basal insulin
• Blood glucose is still not optimally
controlled
Healthy life style
Insulin
+
Intensification*
3 OAD Combination

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

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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 HbA1c PPG

<130 mg/dL < 7.0% <180 mg/dL

IDF2 FPG HbA1c PPG

<110 mg/dl < 6.5% <145 mg/dL

PERKENI3 FPG HbA1c PPG

<100 mg/dl < 7% <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 .
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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
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Risk of hyperglycemia

• Acute complications : DKA & HONK

• Chronic Complications :
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Risk of Complications increases as Hb1Ac

increases and that’s why diabetes must be treated

80

60 Microvascular disease
Incidence per 1.000
patient-years

40 Myocardial infarction

20

0
5 6 7 8 9 10 11 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;321:405–12

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The benefits of good blood glucose control are

clear

Myocardial
Good control is infarction
≤ 7.0% HbA1c
-14%
HbA1c measures
the average
blood glucose Microvascular
level over the HbA1c complications
last three
-1% -37%
months

Deaths related
to diabetes

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

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009
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Practical Monitoring Scheme Cont…

Source: Konsensus Pengelolaan dan Pencegahan DMT2 di Indonesia. PERKENI. 2011. Diabetes Care 2012. Penatalaksanaan
Diabetes Melitus Terpadu. 2009
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Individualized Treatment based on several criteria

to control blood glucose

Inzucci SE, et al. Diabetologia. 2012

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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
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