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Pengelolaan Prediabetes Di Faskes Primer
Pengelolaan Prediabetes Di Faskes Primer
Pradana Soewondo
Division of Metabolism and Endocrinology, Department of Internal
Medicine FMUI / RSCM, Jakarta, Indonesia
Faktor Risiko Penyakit Tidak Menular
Cancer NCDs
Diabetes
Chronic
Respiratory
Cardiovascular Diseases
Sco
Disease
pe
Underlying
Social Trade & causes
Urbanization Globalisation
determinants marketing
Regional
Regional Targets
Targets for
for NCD
NCD Household
Household airair
pollution
pollution
50%
50% reduction
reduction
in
in SFU
SFU for
for Essential
Essential NCD
NCD
Harmful
Harmful use
use cooking
cooking medicines
medicines and
and
of
of alcohol
alcohol technologies
technologies
10%
10% 80%
80% coverage
coverage
reduction
reduction
Physical
Physical
25% reduction
inactivity
inactivity Drug
Drug therapy
therapy &
&
counseling
counseling
10%
10%
50%
50% coverage
coverage
in NCD mortality
reduction
reduction
by 2025
Salt/sodium
Salt/sodium
intake
intake Diabetes/obesity
Diabetes/obesity
30%
30% 0%
0% increase
increase
reduction
reduction
Tobacco
Tobacco use
use Raised
Raised blood
blood
30% pressure
pressure
30%
reduction
reduction 25%
25% reduction
reduction
Apakah Pre-diabetes ?
Pre-diabetes suatu istilah untuk
menggambarkan konsentrasi glukosa darah
Impaired
atau HbA1c diatas normal tapi belum
Impaired
Glucose
Tolerance
Fasting Increased
HbA 1c
memenuhi kriteria diabetes ( Pedoman
Glucose
(IGT) (IFG) Pengelolaan & Pencegahan Pre-diabetes di
Indonesia 2019)
References:
1. National Institute of Diabetes and Digestive and Kidney Disease. Diagnosis of Diabetes and Prediabetes. http://www.niddk.nih.gov/health- . information/health-
topics/Diabetes/diagnosis-diabetes-prediabetes. Accessed Sept. 2015. 2. American Diabetes Association. Diabetes Care. 2013;36(S1):S11-S66 . 3. Ryden L et al.
European Heart Journal.2013;34:3035–3087. 4. American Diabetes Association. Diabetes Care. 2015;38(1):S8-S16.
IDF Atlas 2017 : Indonesia
IDN/MULD/0319/0005 5
Mengapa Pre-diabetes Harus di
Intervensi ?
• Menyebabkan komplikasi
IGT 7.9%
Data from the Diabetes Prevention
Program (DPP) study group : the
Newly diagnosed diabetes 12.6%
incidence of retinopathy:
Prediabetes diabetes
(IGT,IFG)
Glucose(mg/dl)
Postmeal glucose Fasting glucose
Years
Plasma Glucose
(mmol/L)
11 11.1
IFG: Impaired fasting glucose; IGT: Impaired glucose tolerance. Adapted from: The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus 3 and
Nathan DM et al. Diabetes Care. 2007.
References:
1. Aroda VR and Ratner R. Approach to the Patient with Prediabetes. J Clin Endocrinol Metab. 2008;93:3259–3265. 2. NICE Public Health Guidance. Preventing the
progression from pre-diabetes to type 2 diabetes in adults. Final scope. 3. The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care.
1997;20:1183-1197.4. Nathan DM et al. Diabetes Care. 2007; 30(3):753-759.
Konversi Prediabetes – Kohort Bogor
Insiden Konversi Pada Subjek Prediabetes
Regresif Normoglikemik Tetap Prediabetes Progres Diabetes Pada 371 subjek prediabetes, 5 tahun follow up,
Konversi Tahun Ke-5 42.05% 36.93% 21.02% 156 subjek regresivitas normoglikemik,
137 subjek tetap prediabetes,
Konversi Tahun Ke-3 40.16% 50.67% 9.16%
78 subjek progresivitas menjadi diabetes.
Status Konversi 5 Tahun Cut off Point Sensitivitas Spesifisitas AUC CI 95%
Regresi Normoglikemik <4,51
83,9% 80,1% 0,913 0,875-0,943
Tidak Konversi 4,51 - 4,54
Progres Diabetes >4,54 80,8% 73,1% 0,858 0,807 - 0,900
Nilai Prediksi TyG index Terhadap Status Konversi Pada Subjek Normoglikemik
Status Konversi 5 Tahun Cut off Point Sensitivitas Spesifisitas AUC CI 95%
Tidak Konversi ≤4,43
Progres Prediabetes 4,44 - 4,47 80,1% 71,1% 0,834 0,812 - 0,854
90
80
intervensi , 65.8% pasien
menjadi diabetes dalam 6 tahun
70
diabetes (%)
60
50
40
6-year intervention hazard rate ratio:
30
0.49(95%CI 0.33-0.73) Tingkat progresi diabetes
20
20-year follow-up hazard rate ratio :
10 0.57(95%CI 0.41-0.81)
92.8% lebih dari 20 tahun
0
0 2 4 6 8 10 12 14 16 18 20
Years of follow-up
• A six-year clinical trial was conducted in daqing, China from 1986 to 1992 ,577 adults with impaired glucose tolerance were randomly assigned to either the control
group(n=138) or to one of three lifestyle intervention groups (diet, exercise, or diet plus exercise,n=438), After 6 years of lifestyle interventions, subjects were followed up
until 2008 , We aimed to assess whether intensive lifestyle interventions have a long-term effect on the risk of diabetes
Li G,et al.Lancet,2008,371:1783-1789.
Pre-diabetes Merupakan Situasi Ideal untuk Intervensi
"
Pre-diabetes patients has been experienced severe beta cell decline
Lost up to 80% by the new diagnosis stage
resistance (disposition) index
40 "
30
insulin secretion/insulin
(△I/△G÷IR)
20
10
0 2-hour PG
0 <100 <120 <140 <160 <180 <200 <240 <280 <320 <360 <400 >400 (mg/dl)
DeFronzo RA,et al.Diabetes Care. 2013 Aug;36 Suppl 2:S127-38. (ΔI/ΔG ÷ IR):the gold standard measure of β-cell function in vivo in man
Pasien Pre-diabetes Harus Melakukan Intervensi
untuk Mengurangi Beban Keuangan
For pre-diabetes patients, lifestyle intervention ( diet + exercise ) or metformin treatment has cost-
effectiveness advantages
• Using an epidemiological modelling approach, we calculated the cost-effectiveness of screening to identify individuals with pre-diabetes,
followed up by treatment with a pharmaceutical or lifestyle intervention , aimed to evaluate the costeffectiveness of a screening programme
for pre-diabetes, which was followed up by treatment with pharmaceutical interventions (acarbose, metformin, orlistat) or lifestyle interventions
(diet, exercise, diet and exercise)
Bertram MY, et al. Diabetologia. 2010 May;53(5):875-81. CER : Median cost-effectiveness ratio , DALY : disability-adjusted life year
Dapatkah Diabetes Ditunda atau Dicegah ?
Prediabetes & Komplikasi Dapat Dicegah
• As early as 2008, Europe and the United States developed a special pre-diabetes management
Guidelines , while the Asia - Pacific region lacks a pre-diabetes management guide
2013
2007
-Guidelines for the treatment of
-ADA pre-diabetes consensus pre-diabetes
2008
2018-ADA Guidelines
-Guidelines for the treatment of pre-diabetes A pre-diabetes screening program
was clearly put forward
shoulder
chest
42% 28.5%
58% 58%
67.4%
1.Pan XR, et al.Diabetes Care. 1997 Apr;20(4) : 537-44.. 2.Tuomilehto J, et al. N Engl J Med. 2001 May 3;344(18)1343-50. 3.Knowler WC, et al.N Engl J Med. 2002 Feb 7;346(6)393-403.
4.Kosaka K, et al. Diabetes Res Clin Pract. 2005 Feb;67(2):152-62. 5. Ramachandran A et al. Diabetologia 2006;49_289–297.
Keterbatasan Intervensi Gaya Hidup
% of subjects
80%
60% 47% • Less than 50% of
43%
40% 26% 26%
patients success
25%
20% 13% 11% 12% achieving the goals of
Finland DPS 0% Weight reduction Fat intake <30% of Saturated-fat Fiber intake
the intervention by
>5% energy intake intake<10% of energy >15g/1000
one year according to
intake kcal treatment group
diabetes in lifestyle
-2
6 4.8
-4
Intensive lifestyle intervention 4
-6
2
-8
0
DPP(2.8 year) DPPOS(15-years)
(n=3234) (n=1994)
Follow-up years
United States DPP 4572
2281 Expensive
expenses,
medical
Direct
752
$*
0
Intensive lifestyle Standard lifestyle Standard lifestyle
intervention intervention intervention
+ metformin + placebo
Prediabetes: Metode Intervensi
shoulder
chest
Pour OR,et al.Clin Chem. 2011 Feb;57(2):215-20.
Obat untuk Pencegahan Diabetes Yang Diinginkan
Efficacy Adiposity
• should equal or exceed the efficacy
• should induce weight loss or be
of lifestyle intervention
weight neutral
Durability Cost
• effects should outlast the period of
• should cost less than the least
medication exposure
expensive drug for diabetes treatment
Is drug
Is drug intervention
intervention Tolbutamide/Nateglinide
Tolbutamide/Nateglinide Rosiglitazone/Pioglitazo
Rosiglitazone/Pioglitazo AGI
AGI Metformin
Metformin
worth doing?
worth doing? ne/insulin
ne/insulin
1997 Limitations of 1982 2010 2006 2012 2009 2017 Experienced 2002-now
Da Qing: intensive Bedford NAVIGATOR DREAM ORIGIN Victory ACE DPP/DPPOS
2017 study:
Lifestyle lifestyle study : study: 2011 study: ABC study:
intervention interventions Tolbutamid Nateglinide ACT NOW positive Acarbose Metformin
Study:
does not can reduce
has residual e did not did not delay study: results, Voglibose
did not improve the risk and
risks reduce the diabetes osiglitazone/ rarely CVD
reduce the has
risk of IGT progression Pioglitazone used. outcomes Microvascul
risk of CVD
to diabetes and increased can reduce ar benefits
the risk of the risk,but
hypoglycemia have safety
burden
1.Barbara Westerhaus,et al.Prim Care Diabetes. 2011 Jul; 5(2) 73–80. 2. Chiasson JL, et al. Lancet. 2002 Jun 15;359(9323)2072-7. 3.Chiasson JL, et al. JAMA. 2003 Jul 23;290(4): 486-94. 4.DREAM Trial Investigators, et al. Lancet. 2006 Sep 23;368(9541): 1096-
105. 5.Kawamori R, et al.. Lancet. 2009 May 9;373(9675): 1607-14. 6. NAVIGATOR Study Group, et al. N Engl J Med. 2010 Apr 22;362(16): 1463-76. 7. DeFronzo RA, et al. N Engl J Med. 2011;364(12): 1104-15 8. Gerstein HC ,et al.N Engl J Med 2012;367:
319–328. 9.Asakura M, et al. Cardiovasc Drugs Ther. 2017 Aug;31(4): 401-411. 10.Holman RR, et al. Lancet Diabetes Endocrinol. 2017 Nov;5(11): 877-886. 11.Hemmingsen B, et al. Cochrane Database Syst Rev. 2017 May 10;5: CD012204.
12, Knowler WC, et al. N Engl J Med. 2002 Feb 7;346(6): 393-403 13.DPP.Lancet Diabetes Endocrinol. 2015 Nov; 3(11): 866–875.
Intervensi Obat Dapat Menurunkan Risiko Kejadian Kardiovaskular pada
Pasien Pre-diabetes
Risk decreased
by
49%
HR=0.51,95CI,0.28-0.95
P=0.03
• International, multicenter double-blind, placebo-controlled, randomized trial, undertaken in hospitals in Canada, Germany, Austria, Norway, Denmark,
Sweden, Finland, Israel, and Spain ,1429 Patients with IGT were randomized to receive either placebo (n = 715) or 100 mg of acarbose 3 times a day (n =
714). , The average follow-up was 3.3 years , To evaluate the role of acarbose in preventing T2DM
a
Median cost-effectiveness ratio (CER); b Probability (%); DALYs, disability-adjusted life year
30, 28108
25867 26177
25,
20,
15,
10,
5,
0
安慰剂 2 型糖尿病 糖尿病前期
生活 /NGR
Placebo Lifestyle modification Metformin intervention
* Societal perspective = total direct medical cost+direct nonmedical cost+indirect cost.
• Cost effectiveness was analysed from 2010–2012 using a decision-based model to estimate the rates of getting diabetes, healthcare costs and
health-related quality of life. Cost per quality-adjusted life year (QALY) was estimated using costs relevant to the time horizon of the study from
Singapore. All costs are expressed in 2012 US dollars.
- Puskesmas
- Klinik/Praktek Dokter Umum - Puskesmas
- BP, BKIA, Praktek Bidan
Strata-1
- Posyandu, Polindes,
- UKBM: Posyandu, Polindes, Posbindu, dll
Posbindu, dll Masyarakat
Perorangan/Keluarga
Prediabetes Process for Diagnosing
Adapted from:
American Diabetes Association. Testing for Diabetes in Asymptomatic Patients. Diabetes Care.
2014;37(suppl 1):S17; Table 4
Modifiable Risk Factors of
Diabetes/Prediabetes for CV Disease
Non-modifiable Modifiable
Race/Ethnicity Overweight/Obesity
Gender Hypertension
Lifestyle therapy
+
Pharmacotherapy
1: DPP (Diabetes Prevention Program Research Group). Reduction in the incidence of type 2 diabetes with lifestyle intervention or
metformin. N Engl J Med. 2002;346:393-403.