8/12/2019 Insulin in Type 2 DM
1/80
INSULIN THERAPY IN TYPE 2
DIABETES
8/12/2019 Insulin in Type 2 DM
2/80
Presentation Point of View
Background
Pathogenesis of Type 2 DM
Insulin choices Rationality of Insulin Therapy for Type 2 DM
INSULIN TREATMENT ON OUTPATIENT
8/12/2019 Insulin in Type 2 DM
3/80
Normal islet cell
Deposition of amyloid
in T2DM
8/12/2019 Insulin in Type 2 DM
4/80
0 10 20 30
Adapted from International Diabetes Center (IDC). Minneapolis, Minnesota
Years of Diabetes
-cell
function
Plasma
glucose
Insulin resistance
Insulin secretion
Fasting glucose
Post-prandial
glucose
Insulin Rx
Natural History of Type 2 Diabetes
Timing of Intervention(Window of Opportunity)
OADs
TLCOADACEIAIIA
8/12/2019 Insulin in Type 2 DM
5/80
Successful Insulin Therapy
Simple insulin initiation
Comfortable injections
Peralatan suntik sederhana & mudah
Emotional support
Education in diabetes management
Pasien taat / patuh menjalani
8/12/2019 Insulin in Type 2 DM
6/80
Persentation Point of View
Background
Pathogenesis of Type 2 DM
Insulin choices & KINETICS Rationality of Insulin Therapy for Type 2 DM
INSULIN REGIMEN
8/12/2019 Insulin in Type 2 DM
7/80
8/12/2019 Insulin in Type 2 DM
8/80
Insulin
secretion
time
Type 2diabetic
Non-diabetic
IV Glucose stimulus
Loss of the early peak of insulin
secretion
8/12/2019 Insulin in Type 2 DM
9/80
Four biochemical pathways that are sensitive to glucose and produce ROS. The islet is
particularly at risk for chronic oxidative stress when exposed to long-term hyperglycemia
because it expresses very low levels of antioxidant mRNA, protein, and activityRobertson et al, 2003
8/12/2019 Insulin in Type 2 DM
10/80
8/12/2019 Insulin in Type 2 DM
11/80
Persentation Point of View
Background
Pathogenesis of Type 2 DM
Insulin choices & Kinetics Rationality of Insulin Therapy for Type 2 DM
INSULIN REGIMEN
8/12/2019 Insulin in Type 2 DM
12/80
INDICATION OF INSULIN THERAPY
Type 2 DM in certain condition DM + secondary failure
DM + Celulitis/Gangren/Infeksi lainnya
DM + underweight
DM + Fracture DM + Chronic Hepatitis / Cirrhosis
DM + Pulmonary TBC
DM + Graves Disease
DM + Cancer DM + Severe liver dysfunction
DM + Late stage Nephropaty
Type 2 DM with Early Insulin Therapy
8/12/2019 Insulin in Type 2 DM
13/80
Insulin Therapy for Type 2
Diabetes:
Augmentation Supplemental or corrective
Replacement of Beta-Cell Function Short Term Rescue Therapy
8/12/2019 Insulin in Type 2 DM
14/80
Selecting a Regimen
Provide adequate control
Simple
Flexible
Suit patient needs
KISS = Keep It Safe and Simple
(Keep It Simple and Stupid)
N l I li S i
8/12/2019 Insulin in Type 2 DM
15/80
B DL HS
Insulin
Effect
Bolus Insulin
Basal Insulin
Endogenous Insulin
B, breakfast; L, lunch; D, dinner; HS, bedtime.Adapted from:
1. Leahy JL. In: Leahy JL, Cefalu WT, eds. Insulin Therapy. New York, NY: Marcel Dekker, Inc.; 2002.2. Bolli GB et al. Diabetologia. 1999;42:1151-1167.
Normal Insulin Secretion
The Basal-Bolus Insulin Concept
Time of Administration
8/12/2019 Insulin in Type 2 DM
16/80
Menurunkan produksi glukosaantar makan dan malam (overnight)
Bervariasi per individu
5060 % dari kebutuhan harian
Basal Insulin
8/12/2019 Insulin in Type 2 DM
17/80
Mengatasi hiperglikemia setelah makan
Meningkat segera dan mencapai puncakdalam 1 jam
10-20% dari total insulin tiap kali makan
Bolus Insulin
(Mealtime or Prandial)
8/12/2019 Insulin in Type 2 DM
18/80
Preparations Onset(h) Peak(h) Duration(h)
Lispro/Aspart < 0.25 1 - 2 3 - 4
Regular 0.5 - 1 2 - 4 6 - 8
NPH 1 - 3 5 - 7 13 - 16
Ultralente 2 - 4 8 - 14 < 20Glargine 1 - 2 - > 24
Action Profiles
Modified after Leahy JL. In: Leahy JL, Cefalu WT, eds. Insulin Therapy. New York, NY: Marcel Dekker, Inc.; 2002.
8/12/2019 Insulin in Type 2 DM
19/80
Insulin Left At 1, 2, 3, and 4 Hours After
A Dose Of Humalog Or Novorapid, Apidra
Dose Given
Units Left To Work After:
1 Hr 2 Hr 3 Hr 4 Hr 5 Hr
1 unit 0.80 u 0.60 u 0.40 u 0.20 u 0
2 units 1.60 u 1.20 u 0.80 u 0.40 u 0
3 units 2.40 u 1.80 u 1.20 u 0.60 u 0
4 units 3.20 u 2.40 u 1.60 u 0.80 u 0
5 units 4.00 u 3.00 u 2.00 u 1.00 u 0
6 units 4.80 u 3.60 u 2.40 u 1.20 u 0
7 units 5.60 u 4.20 u 2.80 u 1.40 u 0
8 units 6.40 u 4.80 u 3.20 u 1.60 u 0
9 units 7.20 u 5.40 u 3.60 u 1.80 u 0
10 units 8.00 u 6.00 u 4.00 u 2.00 u 0
20% of a dose will be used each hour after it is given
8/12/2019 Insulin in Type 2 DM
20/80
A chainGly IIe Val Glu Gln Cys Cys Thr Ser Ile Cys Ser Leu Tyr Glu Leu Glu Asn Tyr Cys Asn
1 5 10 15 21
S S
1 5 10 15 20
25
30
B chainS
S S
S
Phe Val Asn Gln His Leu Cys Gly Ser His Leu Val Glu Ala Leu Tyr Leu Val Cys Gly Glu Arg Gly
Phe
PheTyr
Thr
LysPro
The
Phe
HUMAN INSULIN
Regular : Poor prandial, poor basal
NPHL: Poor prandial, fair basal (better w ith smal l do se QID,small at daytim e, large at night)
Ultralente: Fair basal
8/12/2019 Insulin in Type 2 DM
21/80
HUMAN INSULIN
A chain
Gly IIe Val Glu Gln Cys Cys Thr Ser Ile Cys Ser Leu Tyr Glu Leu Glu Asn Tyr Cys Asn
1 5 10 15 21
S S
1 5 10 15 20
25
30
B chainS
S S
S
Phe Val Asn Gln His Leu Cys Gly Ser His Leu Val Glu Ala Leu Tyr Leu Val Cys Gly Glu Arg Gly
Phe
PheTyr
Thr
LysPro
The
Phe
A chain
Gly IIe Val Glu Gln Cys Cys Thr Ser Ile Cys Ser Leu Tyr Glu Leu Glu Asn Tyr Cys Asn
1 5 10 15 21
S S
1 5 10 15 20
25
30
B chainS
S S
S
Phe Val Asn Gln His Leu Cys Gly Ser His Leu Val Glu Ala Leu Tyr Leu Val Cys Gly Glu Arg Gly
Phe
Phe
TyrThr
Pro
Lys
The
Phe
INSULIN LISPRO
Lispro
Excellent prandial, excellent basal ifused in a CSII program
8/12/2019 Insulin in Type 2 DM
22/80
HUMAN INSULIN
A chain
Gly IIe Val Glu Gln Cys Cys Thr Ser Ile Cys Ser Leu Tyr Glu Leu Glu Asn Tyr Cys Asn
1 5 10 15 21
S S
1 5 10 15 20
25
30
B chainS
SS
S
Phe Val Asn Gln His Leu Cys Gly Ser His Leu Val Glu Ala Leu Tyr Leu Val Cys Gly Glu Arg Gly
Phe
PheTyr
Thr
Lys
Pro
The
Phe
INSULIN ASPART
A chain
Gly IIe Val Glu Gln Cys Cys Thr Ser Ile Cys Ser Leu Tyr Glu Leu Glu Asn Tyr Cys Asn
1 5 10 15 21
S S
1 5 10 15 20
25
30
B chainS
S S
S
Phe Val Asn Gln His Leu Cys Gly Ser His Leu Val Glu Ala Leu Tyr Leu Val Cys Gly Glu Arg Gly
Phe
PheTyr
Thr
Lys
Asp
The
Phe
Aspart
Excellent prandial, excellent basal if
used in a CSII program
8/12/2019 Insulin in Type 2 DM
23/80
Human insulinA chain 21 amino acids
B chain 30 amino acids
HUMAN INSULINA chain
Gly IIe Val Glu Gln Cys Cys Thr Ser Ile Cys Ser Leu Tyr Glu Leu Glu Asn Tyr Cys Asn
1 5 10 15 21
S S
1 5 10 15 20
25
30
B chain S
S S
S
Phe Val Asn Gln His Leu Cys Gly Ser His Leu Val Glu Ala Leu Tyr Leu Val Cys Gly Glu Arg Gly
Phe
PheTyr
Thr
LysPro
The
Phe
INSULIN GLARGINE
A chain
Gly IIe Val Glu Gln Cys Cys Thr Ser Ile Cys Ser Leu Tyr Glu Leu Glu Asn Tyr Cys Gly
1 5 10 15 21
S S
1 5 10 15 20
25
30
B chain S
S S
S
Phe Val Asn Gln His Leu Cys Gly Ser His Leu Val Glu Ala Leu Tyr Leu Val Cys Gly Glu Arg Gly
Phe
PheTyr
Thr
LysPro
The
Phe
ArgArg
32 31Glargine, Detemir
Promise to be excellent basal insulin
8/12/2019 Insulin in Type 2 DM
24/80
Figure. Pharmacokinetincs on various insulin drugs, and insulin frompancreas http://www.medscape.com/viewarticle/501976_6
8/12/2019 Insulin in Type 2 DM
25/80
HumaPenLUXURAHumaPenErgo II
8/12/2019 Insulin in Type 2 DM
26/80
8/12/2019 Insulin in Type 2 DM
27/80
Insulin Glargine versus NPH-Insulin
clear solution vs. suspension
NPH Glargine NPH NPH
8/12/2019 Insulin in Type 2 DM
28/80
Factors that speed insulin
absorption
Injecting into an exercised area such asthe thigh
High temperatures, for example, shower,
bath, hot water bottle, spa or sauna Massaging the area around the injection
site
Injecting into musclethe deeper theinjection into muscle, the faster the insulinwill be absorbed
8/12/2019 Insulin in Type 2 DM
29/80
Factors that delay insulin
absorption
Cigarette smoking.
Over-use of the same injection site, which
causes the flesh to become hard, lumpy or
scarred, and leads to erratic absorption of
insulin.
Cold insulin, for example, injecting
immediately after taking the insulin from
the fridge.
8/12/2019 Insulin in Type 2 DM
30/80
8/12/2019 Insulin in Type 2 DM
31/80
Persentation Point of View Background
Pathogenesis of Type 2 DM
Insulin choices & KINETICS
Rationality of Insulin Therapy for T2DM INSULIN REGIMEN
8/12/2019 Insulin in Type 2 DM
32/80
KAPAN INSULIN
DIPERLUKAN?
UKPDS Study data
50% DMT2 perlu insulin setelah 6 tahun
Lowest B-cell function at diagnosis
greatest risk of OAD failure
Marre M. Int J Obesity (2002) ; 26 (Suppl 3) : S25-S30
8/12/2019 Insulin in Type 2 DM
33/80
Rationale for Early insulin therapy
UKPDS demonstrated that early intervention toachieve tight glycemic control (A1C 7.0%)resulted in 25% reduction (P=.0099) in the riskfor microvascular complications and a 16% risk
reduction (P=.052) for mycocardial infarction.
During the first 6 years of UKPDS, slightly more
than half (53%) of the patients treated withmaximal sulfonylurea therapy could not maintainglucose control
8/12/2019 Insulin in Type 2 DM
34/80
Rationale for Early insulin therapy
The addition of insulin to sulfonylurea therapyresulted in significantly improved glycemiccontrol. Without an increased incidence ofhypoglycemia or weight gain
These data underscore a critical concept in type2 diabetes: Given the progressive decline inbeta-cell function, combination therapy, such as
oral agent(s) with insulin, is often necessary toachieve treatments goals
UKPDS Lancet 1998: 837-853
I li I U il D l d
8/12/2019 Insulin in Type 2 DM
35/80
Insulin Is Unnecessarily Delayed
Hayward de Sonnaville de Grauw Rosendal Vahataloet al.30 et al.31 et al.32 et al.33 et al.34
USA Netherlands Netherlands Netherlands Finland
Initiation of insulin in Type 2 diabetes. Data from retrospective or prospectivelongitudinal surveys where the glycaemic level of initiation of insulin is notprotocol driven.
Davies M. Int J Obesity (2004) ; 28 (Suppl. 2) : S14-S22
N=735
N=883
N=31N=52
N=272
5
6
7
8
9
1011
MeanHbA1c(%HB)
Before insulin initiation After insulin initiation (1-4y)
I li I t ifi ti Eff t BG
8/12/2019 Insulin in Type 2 DM
36/80
Insulin Intensification -Effects on BG
Knight Mohrie Howorka Reichard Schifferdeckeret al.37 et al.38 et al.39 et al.40 et al.35
Intensification of insulin therapy. Data from Schifferdecker et al.
Davies M. Int J Obesity (2004) ; 28 (Suppl. 2) : S14-S22
5
6
7
8
9
10
11
12
HbA1c(%)
Before intensification After intensification
8/12/2019 Insulin in Type 2 DM
37/80
7
8
9
10
11
12
0 1 2 3 4 5 6
Time (months)
HbA1c
(%) Two injections daily
(Mix Insulin)
Morning insulin(Insulin NPH) + SU
Evening insulin(Insulin NPH) + SU
Twice-daily insulin therapy, or combination therapy with asulphonylurea (SU) markedly improved metabolic control in
patients where OADs had failed.Marre M. Int J Obesity (2002) ; 26 (Suppl. 3) : S25-S30
Insulin Improved Glycaemic Control
8/12/2019 Insulin in Type 2 DM
38/80
7
8
9
10
0 3 6 9 12
Time (months)
HbA1
c(%)
Sulphonylurea group
Insulin group
Long-Term Control With Insulin
Insulin therapy can improve and maintain glycaemic control more effectively thansulphonylurea treatment. Patients had an HbA1cof 8-10% on entry and were stablycontrolled at that level.
Marre M. Int J Obesity (2002) ; 26 (Suppl. 3) : S25-S30
8/12/2019 Insulin in Type 2 DM
39/80
Figure 1. ADA consensus on therapy for type 2 diabetes. Adapted with
permission from the American Diabetes Association. Diabetes Care.
1995;18:1516.2
8/12/2019 Insulin in Type 2 DM
40/80
Persentation Point of View
Background
Pathogenesis of Type 2 DM
Insulin choices & KINETICS Rationality of Insulin Therapy for Type 2 DM
INSULIN REGIMEN
8/12/2019 Insulin in Type 2 DM
41/80
Insulin regimens
No insulin injection regimen satisfactorily
mimics normal physiology
The choice will depend on many factors:
age,
duration of diabetes,
lifestyle (dietary patterns, exercise schedules, school,
work commitments, etc),
targets of metabolic control and,
particularly, individual patient/family preferences
8/12/2019 Insulin in Type 2 DM
42/80
Selecting a Regimen
Provide adequate control
Simple
Flexible
Suit patient needs
KISS = Keep It Safe and Simple
(Keep It Simple and Stupid)
8/12/2019 Insulin in Type 2 DM
43/80
Insulin Treatment in
Type 2 Diabetes
Options:
Terapi oral + Suntik NPH atau Glarginesebelum tidur
NPH + short acting insulin BID
Multiple daily injections (MDI)
Meltzer et al. CMAJ 1998;159(Suppl 8):S1-S29.
8/12/2019 Insulin in Type 2 DM
44/80
DERAJAT KEPARAHAN DM
DMT2 ringan: GDP < 126 mg/dl (Jarang
perlu insulin)
DMT2 sedang: GDP 126200 mg/dl
(Insulin basal)
DMT2 berat: GDP > 200 mg/dl
(Insulin premixed 2 x)
DMT2 sangat berat: GDP > 250300 mg/dl
(Insulin dosis multipel)
Skyler, 2004
R d d St t i f I iti ti
8/12/2019 Insulin in Type 2 DM
45/80
Recommended Strategies for Initiating
Insulin in Type 2 Diabetes*A1C Threshold Therapeutic
Strategy
Suggested
Initial Dose
Follow-up
7.0% to 10.0%
despite 2 oral
medications
Initiate basal
insulin
10 U every day
for insulin
glargine
Advance insulin dose
weekly until FPG is
within target
Continue oral
medications
10 U every day
or twice daily for
NPH
If A1C remains >
7.0% and PPG is
elevated, add
prandial insulin
starting with largest
daily meal
Monitor A1C every 3
months until < 7.0%;
every 6 months
thereafter
Hirsch, 2005
8/12/2019 Insulin in Type 2 DM
46/80
Pagi Siang Malam Sebelumtidur
Terapi Kombinasi Oral Insulin Glargine
Suntik Insulin Glargine
Oral
8/12/2019 Insulin in Type 2 DM
47/80
Sample Plan for Bedtime Basal Insulin Dosing in T2DM
FBG target is 70 100 mg/dl, plans should be individualized
Start 10 unitsbedtime basal insulin, adjust the dose weekly
If mean FBG during the previous 4 days is > 180mg/dl
Increase the dose with 8 unit
If mean FBG during the previous 4 days is 140 - 180mg/dl
Increase the dose with 6 unit
Increase the dose with 4 unit
Increase the dose with 2 unit
Maintain current dose
Return to the previous dose
Reduce the dose by 24 units
If mean FBG during the previous 4 days is 120 - 140mg/dl
If mean FBG during the previous 4 days is 100 - 120mg/dl
If mean FBG during the previous 4 days is 70 - 100mg/dl
If mean FBG during the previous 4 days is 140 - 180mg/dl
If mean FBG during the previous 4 days is 140 - 180mg/dl
Sk ler 2004
Recommended Strategies for Initiating
8/12/2019 Insulin in Type 2 DM
48/80
Recommended Strategies for Initiating
Insulin in Type 2 Diabetes*A1C
Threshold
Therapeutic
Strategy
Suggested Initial
Dose
Follow-up
> 10.0%
despite 2
oral
medications
Initiate
basal-
prandial
insulin
Basal, as above Optimize prandial
doses for each meal
Discontinueoral
secretagogu
es
Prandial: 5-10 U ateach meal
(Approximately 1 U for
every 10-15 g of
carbohydrate to start)
Advance insulin doseweekly until PPG and
FPG are within target
Premixed insulin is notusually recommended,
but can consider 10 U
before breakfast and
dinner
Monitor A1C every 3
months until < 7.0%;
every 6 months
thereafter
Hirsch 2005
8/12/2019 Insulin in Type 2 DM
49/80
SAMPLE MIXED-SPLIT INSULIN REGIMEN (1)
Meals
B L S HS B
Regular Insulin
NPH/Lente NPH/Lente
8/12/2019 Insulin in Type 2 DM
50/80
SAMPLE MIXED-SPLIT INSULIN REGIMEN (2)
Meals
B L S HS B
Regular Insulin
NPH/Lente NPH/Lente
SAMPLE MULTIPLE COMPONENT INSULIN
8/12/2019 Insulin in Type 2 DM
51/80
SAMPLE MULTIPLE COMPONENT INSULIN
REGIMEN (1)
Meals
B L S HS B
Regular Insulin
NPH/Lente
SAMPLE MULTIPLE COMPONENT INSULIN
8/12/2019 Insulin in Type 2 DM
52/80
SAMPLE MULTIPLE COMPONENT INSULIN
REGIMEN (2)
Meals
B L S HS B
Regular Insulin
NPH/Lente
SAMPLE MULTIPLE COMPONENT INSULIN
8/12/2019 Insulin in Type 2 DM
53/80
SAMPLE MULTIPLE COMPONENT INSULIN
REGIMEN (3)
Meals
B L S HS
Regular Insulin
Glargine
8/12/2019 Insulin in Type 2 DM
54/80
http://www.medscape.com/viewarticle/501976_6
8/12/2019 Insulin in Type 2 DM
55/80
INJECTION DEVICE DEVELOPMENT IN THE 80S
8/12/2019 Insulin in Type 2 DM
56/80
INJECTION DEVICE DEVELOPMENT IN THE 80SAND 90S HAS ADDRESSED THESE ISSUES
From syringes to safe
and convenient portablepens with insulin
cartridges
1925
1960
1920s
1985
1989
1990sMore insulin pen introductions in the
8/12/2019 Insulin in Type 2 DM
57/80
FUTURE INSULIN TREATMENT
8/12/2019 Insulin in Type 2 DM
58/80
NON INJECTABLE INSULIN DELIVERIES
8/12/2019 Insulin in Type 2 DM
59/80
Transdermal insulin delivery
Oral insulin delivery
Buccal insulin deliveryPulmonary insulin delivery
NON INJECTABLE INSULIN DELIVERIES
http://www.generex.com/images/rapidmistrollover8/12/2019 Insulin in Type 2 DM
60/80
Treatment Options
Bedtime Insulin and Daytime OHA
Replacement Insulin Therapytwice dailyinsulin
Intensive therapy QID (rarely indicated)
ALGORITMA KOMBINASI INSULIN DAN OHO
8/12/2019 Insulin in Type 2 DM
61/80
Jika jml Ins > 30 U/hari, hentikanOHO
OHO + 10 U Insulin (kerja menengah/panjang)
OHO* (TT & TK)
STT**
- Insulin Kombinasi (basal + bolus)
- Insulin Campuran (2/3 pagi dan 1/3 malam)
OHO stop jk
nyaman
Sesuiakan dosis
2-4 U dlm 3-4
hari
ALGORITMA KOMBINASI INSULIN DAN OHO
Konsensus Perkenii 2006
*: obat hipo- oral, terapi tunggal,
kombinasi
**: sasaran tak tercapai
8/12/2019 Insulin in Type 2 DM
62/80
Dose titration schedule
Mean of self-monitored FPG
values from preceding 2 days
Increase in
insulin dosage (IU/day)
>10 mmol/L (180 mg/dl) 8
>7.810.0 mmol/L (140180
mg/dl)
6
>6.77.8 mmol/L (120140mg/dl)
4
>5.66.7 mmol/L (100120
mg/dl)
2
Riddle M et al. Diabetes Care2003;26(11):30806.
Start with 10 IU/day bedtime basal insulin doseand adjust weekly in addition to current oral therapy
Smaller dose reductions allowed in the event that FPG drops below 3.0 mmol/L (56 mg/dl) or of a severe hypoglycaemic episode
8/12/2019 Insulin in Type 2 DM
63/80
Target
Improve BG controltarget :
HbA1C< 6.5%
Fasting sugar of < 108 mg/dL
PP sugars of < 144 mg/dL
Initiating Insulin in Type 2 DM
8/12/2019 Insulin in Type 2 DM
64/80
If more than 30-36 IU of insulin necessaryto obtain good metabolic control, considerstopping insulin secretagogues and
continue on same total dose of insulin +metformin or TZD
Divide the dose into 2 daily injections:
2/3 before breakfast
1/3 at bedtime
Sepuluh Langkah Untuk Mencapai Sasaran
8/12/2019 Insulin in Type 2 DM
65/80
p g p
Glikemik Penderita Diabetes
1. Sasaran Kendali Glikemik yg baik adalahA1C < 6,5%
2. Pantau A1c setiap 3 bln disamping
pemeriksaan glukosa darah
3. Pengelolaan agresif hiperglikemia,dislipidemia dan hipertensi dengan intensitas
yang sama untuk mencapai luaran penderitayang terbaik
4. Rujuk semua penderita diabetes baru ke unit
perawatan diabetes bila memungkinkan
Sepuluh Langkah Untuk Mencapai
8/12/2019 Insulin in Type 2 DM
66/80
p g p
Sasaran Glikemik Penderita Diabetes
5. Pengobatan ditujukan kepada dasarpatofisiologinya termasuk resistensi insulin
6. Obati penderita secara intensif hinggamencapai sasaran A1C < 6,5% dalam waktu 6bulan setelah didiagnosis
7. Setelah 3 bulan, jika sasaran A1C < 6,5% tidaktercapai pertimbangkan terapi kombinasi
8. Mulai dengan terapi kombinasi atau insulinsegera untuk semua penderita dengan A1C 9% pada saat diagnosis
Sepuluh Langkah Untuk Mencapai
8/12/2019 Insulin in Type 2 DM
67/80
Sepuluh Langkah Untuk Mencapai
Sasaran Glikemik Penderita Diabetes
9. Gunakan kombinasi obat oral denganmekanismekerja yang saling melengkapi
10. Lakukan pendekatan tim multidisiplindalam pengelolaan diabetes untukmeningkatkan pemahaman penderita
meliputi edukasi, perawatanmandiri,tanggung jawab bersama untukmencapai sasaran glukosa yang baik
A1C
8/12/2019 Insulin in Type 2 DM
68/80
A1C
Patients average glycemia over the preceding 2-3 months
First at initial assessment and then as a part of continuing care
At least two times a year (stable glycemic control)
Mean plasma glucose
A1C (%) mmol/l mg/dl
4
56
7
8
9
10
11
12
3.5
5.57.5
9.5
11.5
13.5
15.5
17.5
19.5
65
100135
170
205
240
275
310
345
Table. MPG as estimated from the regression line and approximate
MPG (based on MPG change of 35 mg/dl or 2 mmol/l per 1%
change in A1C) at different A1C levels (assessed in the DCCT)
Rohlfing et al. Diabetes Care 25: 275-278, 2002
8/12/2019 Insulin in Type 2 DM
69/80
CARA PEMBERIAN INSULIN
Pasien rawat jalan :
dapat dimulai dgn insulin kerja menengah
dosis rendah pagi hari
Penyesuaian : 24 unit setiap 34 hari
Bila dosis dibutuhkan tinggi : dapat dibagi
pagi malam, perbandingan 2:1
8/12/2019 Insulin in Type 2 DM
70/80
CARA PEMBERIAN INSULIN
Pasien rawat inap :
Makanan tidak selalu dalam bentuk padat
dosis insulin basal dan insulin nutrisional
Insulin nutrisional :
Jumlah insulin yang dibutuhkan untuk mengatasi
glukosa yg diberikan lewat intravena, TPN, sonde
lambung, nutrisi tambahan dan makanan bebas
Bila hanya makan makanan padat : kebutuhan
insulin nutrisional setara (equivalen) dengan
insulin prandial
8/12/2019 Insulin in Type 2 DM
71/80
CARA PEMBERIAN INSULIN
Pasien rawat inap :
Kebutuhan insulin meningkat akibat pengaruh
hormon kontrainsulin (respons thd stres) o.k:
tindakan operasi, kortikosteroid,pressor agent,obat diabetogenik, dll.
Tambahan kebutuhan = insulin koreksi
(supplement)
Komponen insulin utk rawat inap tdd.: Insulin basal
Insulin prandial (nutrisional)
Insulin koreksi (supplemental)
8/12/2019 Insulin in Type 2 DM
72/80
CARA PEMBERIAN INSULIN
Dosis insulin basal dan insulin prandial dicatat sebagaiinsulin program (scheduled insulin)
Dosis insulin koreksi dicatat sebagai algoritme untukditambah pada insulin program
Tujuan algoritme koreksi : mengatasi hiperglikemia yangmelampaui target dan sering tak terduga pada pasiendgn stres
Jenis insulin koreksi : insulin kerja cepat dan insulin kerjapendek
Dosis insulin koreksi : berdasarkan glukosa preprandialdan kebutuhan insulin total perhari
ALGORITME INSULIN KOREKSI PREPRANDIAL
8/12/2019 Insulin in Type 2 DM
73/80
Glukosa
preprandial
(mg/dl)
Dosis insulin koreksi (unit)
Algoritmedosis rendah Algoritmedosis sedang Algoritmedosis tinggi
150199
200249250299
300349
> 349
1
23
4
5
1
35
7
8
2
47
10
12
Catatan :
Gunakan algortime dosis rendah bila pasien membutuhkan < 40 unit insulin/hari
Gunakan algortime dosis sedang bila pasien membutuhkan 40-80 unit insulin/hari
Gunakan algortime dosis tinggi bila pasien membutuhkan > 80 unit insulin/hari
8/12/2019 Insulin in Type 2 DM
74/80
CARA PEMBERIAN INSULIN
Dosis insulin perhari : 0,31,5 U/kgBB
Dua per tiga dari total dosis dalam bentuk insulin kerja pendek
diberikan setengah jam sebelum makan Sepertiga dari total dosis
Dalam bentuk insulin kerja menengah atauinsulin kerja panjang
Diberikan malam hari Insulin program dan insulin koreksidinaikkan bertahap untuk mencapaikebutuhan tertinggi dari insulin basal daninsulin prandial
8/12/2019 Insulin in Type 2 DM
75/80
MENYUNTIK INSULIN
Kebanyakan diberikan subkutan
Semua insulin suspensi : kocok secara lembut
sebelum disuntikkan
Untuk mencampur insulin kerja cepat / pendekdengan insulin kerja menengah / panjang :
insulin kerja cepat / pendek harus disedot
lebih dahulu baru insulin kerja menengah /
panjang
8/12/2019 Insulin in Type 2 DM
76/80
MENYUNTIK INSULIN
Bila area suntikan cukup bersihtidak
perlu dibersihkan lagi dengan alkohol
Suntikan intramuskuler mempercepatabsorbsisecara rutin tidak dianjurkan
Melakukan pijatan / pemanasan pada
tempat suntikanmempercepatabsorbsi insulin
8/12/2019 Insulin in Type 2 DM
77/80
TEKNIK MENYUNTIK SUBKUTAN
Jepit kulit dengan dua jaritusukkanjarum dengan posisi 90 derajat
lepaskan jepitan sambil disuntik
tunggu + 5 detik baru jarum dicabut
Untuk pasien kurus : arahkan jarum 45derajat agar insulin tidak masuk ke otot
Ketika jarum sudah berada di subkutan,sebelum disuntikkan tidak perludilakukan penyedotan
8/12/2019 Insulin in Type 2 DM
78/80
TEMPAT SUNTIKAN
Abdomen : 2 inchi di sekeliling pusat
Sisi lateral lengan atas
Sisi anterolateral paha
Untuk menghindari variasi absorbsi
rotasi suntikan pada 1 tempat saja,
misalnya di abdomen
EFEK SAMPING DAN
8/12/2019 Insulin in Type 2 DM
79/80
EFEK SAMPING DAN
KOMPLIKASI SUNTIKAN INSULIN
Hipoglikemia
Reaksi alergi (lokal, sistemik)
Lipohipertrofi (penebalan lemak subkutan
pada tempat suntikan)
Lipoatrofi (penipisan lemak subkutan pada
tempat suntikan)
8/12/2019 Insulin in Type 2 DM
80/80