KONSENSUS DM ADA ESDA & PERKENI - Copy.ppt

Oleh:PRIMI MUTIARA RIZKA1102009219KONSENSUS DM ADA ESDA 2011 & PERKENI 2006

CONSENSUS ADA (American Diabetes Association), the European Association for the Study of Diabetes (EASD)

KRITERIA DIAGNOSTIC DIABETESall four criteria are included:A1C 6.5% The diagnostic test should be performed using a method certified by the National Glycohemoglobin Standardization Program (NGSP) and standardized or traceable to the Diabetes Control and Complications Trial (DCCT) reference assayFasting plasma glucose (FPG) 126 mg/dl (7.0 mmol/l) Fasting : no caloric intake for at least 8 hoursTwo-hour plasma glucose 200 mg/dl (11.1 mmol/l) during an OGTT the test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in waterA random plasma glucose 200 mg/dl (11.1 mmol/l), in patients with classic symptoms of hyperglycemia or hyperglycemic crisis patient with a hyperglycemic crisis or classic symptoms of hyperglycemia

This group was defined as having impaired fasting glucose (IFG) or impaired glucose tolerance (IGT)IFG: fasting plasma glucose (FPG) of 100-125 mg/dl (5.6-5.9 mmol/l)IGT: two-hour plasma glucose (2-h PG) on the 75-g oral glucose tolerance test (OGTT) of 140-199 mg/dl (7.8-11.0 mmol/l)A1C of 5.7-6.4%

It should be noted that the World Health Organization (WHO) and a number of other diabetes organizations define the cutoff for IFG at 110 mg/dl (6.1 mmol)IFG and IGT are associated with obesity (especially abdominal or visceral obesity), dyslipidemia with high triglycerides and/or low HDL cholesterol, and hypertension

Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (1)HDL cholesterol level 250 mg/dl (2.82 mmol/l)Women with polycystic ovarian syndrome (PCOS)A1C 5.7%, IGT, or IFG on previous testingOther clinical conditions associated with insulin resistance (e.g., severe obesity, acanthosis nigricans)History of CVD

*At-risk BMI may be lower in some ethnic groups.1. Testing should be considered in all adults who are overweight (BMI 25 kg/m2*) and have additional risk factors:

ADA. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S14. Table 4.

Physical inactivityFirst-degree relative with diabetesHigh-risk race/ethnicity (e.g., African American, Latino, Native American, Asian American, Pacific Islander)Women who delivered a baby weighing >9 lb or were diagnosed with GDMHypertension (140/90 mmHg or on therapy for hypertension)

ADA. Testing in Asymptomatic Patients. Diabetes Care 2011;34(suppl 1):S14. Table 4.Criteria for Testing for Diabetes in Asymptomatic Adult Individuals (2)

2. In the absence of criteria (risk factors on previous slide), testing for diabetes should begin at age 45 years

3. If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk status

Correlation of A1C with Estimated Average Glucose (eAG)ADA. V. Diabetes Care. Diabetes Care 2011;34(suppl 1):S18. Table 9.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, and no diabetes. The correlation between A1C and average glucose was 0.92. A calculator for converting A1C results into estimated average glucose (eAG), in either mg/dl or mmol/l, is available at http://professional.diabetes.org/GlucoseCalculator.aspx.

Mean plasma glucoseA1C (%)mg/dlmmol/l61267.071548.6818310.2921211.81024013.41126914.91229816.5

Recommendations:Detection and Diagnosis of GDM (1)Screen for undiagnosed type 2 diabetes at the first prenatal visit in those with risk factors, using standard diagnostic criteria (B)In pregnant women not previously known to have diabetes, screen for GDM at 24-28 weeks gestation, using a 75-g OGTT and the diagnostic cutpoints in Table 6 (B)

ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2011;34(suppl 1):S15.

Screening for and Diagnosis of GDMADA. III. Detection and Diagnosis of GDM. Diabetes Care 2011;34(suppl 1):S15. Table 6.

Perform a 75-g OGTT, with plasma glucose measurement fasting and at 1 and 2 h, at 24-28 weeks of gestation in women not previously diagnosed with overt diabetesPerform OGTT in the morning after an overnight fast of at least 8 hGDM diagnosis: when any of the following plasma glucose values are exceededFasting 92 mg/dl (5.1 mmol/l)1 h 180 mg/dl (10.0 mmol/l)2 h 153 mg/dl (8.5 mmol/l)

Recommendations:Detection and Diagnosis of GDM (2)Screen women with GDM for persistent diabetes 6-12 weeks postpartum (E)Women with a history of GDM should have lifelong screening for the development of diabetes or prediabetes at least every three years (E)

ADA. III. Detection and Diagnosis of GDM. Diabetes Care 2011;34(suppl 1):S15.

At diagnosis :LifeStyle+MetforminTier 1 : Well validated core therapesLifestyle + Metformin+Basal insulinLifestyle + Metformin+SulfonylurcaaLifestyle + Metformin+Intensive InsulinSTEP 1STEP 2STEP 3

Lifestyle + Metformin+PioglitazoneNo hypoglycemiaOedema/CHFBone lossTier 2 : Less Well validated therapicsLifestyle + Metformin+GLP-1 agonistbNo hypoglycemiaWeight lossNausca/vomitingLifestyle + Metformin+Pioglitazone+SulfonylurcaLifestyle + Metformin+Basal insulin

Figure 2 Algorithm for the metabolic management of type 2 diabetes : Reinforce lifestyle interventions at every visit and check A 1 C every 3 month until A 1 C is < 7% and then at least every 6 months. The interventions should be changed if A1C is > 7%. aSulfonylureas other than glybenclamide (glyburide) or chlorpropamide. binsufficient clinical use to be confident regarding safety.

Nathan DM et al Diabetes Care 2008 ; 31 Dec 2008

INDIKASI INSULIN1. Diabetes Melitus Tipe 12. Diabetes Melitus Gestasional3. Diabetes Melitus Tipe 2Penurunan berat badan cepatHiperglikemi berat dengan ketosisKetoasidosis DiabetikaHiperglikemia Hiperosmolar Non KetotikHiperglikemia dengan asidosis laktat

Gagal dengan kombinasi OHOStress berat ( infeksi sistemik, operasi besar, IMA, stroke )Gangguan fungsi ginjal dan hati yang beratKontra Indikasi/alergi terhadap OHO

Macam- Macam InsulinInsulin kerja cepat (Rapid Acting): Humulin RInsulin kerja sedang (Intermediate Acting): Humulin MInsulin kerja lama (Long Acting)Insulin kerja campur (Pre mixed): insulin pen

KONSENSUS PERKENI 2006

THANK YOU

The three primary criteria for testing for diabetes in asymptomatic adult individuals (Table 4) are summarized on two slides; this slide (Slide 1 of 2) includes:Testing should be considered in all adults who are overweight (BMI 25 kg/m2) and have additional risk factorsTesting should be considered in adults of any age with BMI 25 kg/m2 and one or more of the known risk factors listed on this slideIt is important to know that the at-risk BMI may be lower in some ethnic groups, such as Asians*ReferenceAmerican Diabetes Association. Standards of medical care in diabetes2011. Diabetes Care 2011;34(suppl 1):S14. Table 4.The three primary criteria for testing for diabetes in asymptomatic adult individuals (Table 4) are summarized on two slides; this slide (Slide 2 of 2) includes:In the absence of criteria (risk factors on previous slide), testing diabetes should begin at age 45 yearsIf results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk statusAge is a major risk factor for diabetes; therefore, testing of individuals without other risk factors should begin no later than at age 45 yearsThe rationale for the 3-year interval is that false negatives will be repeated before substantial time elapses, and there is little likelihood that an individual will develop significant complications of diabetes within 3 years of a negative test resultGiven the need for follow-up and discussion of abnormal results, testing should be conducted within the health care settingCommunity screening outside a health care setting is not recommended because people with positive tests may not seek, or have access to, appropriate follow-up testing and careConversely, there may be failure to ensure appropriate repeat testing for individuals who test negativeCommunity screening may also be poorly targeted; i.e., it may fail to reach the groups most at risk and inappropriately test those at low risk (the worried well) or even those already diagnosed

*ReferenceAmerican Diabetes Association. Standards of medical care in diabetes2011. Diabetes Care 2011;34(suppl 1):S14. Table 4.Table 9, as shown on this slide, contains the correlation between A1C levels and mean plasma glucose (PG) levels based on data from the international A1C-Derived Average Glucose (ADAG) trial using frequent SMBG and continuous glucose monitoring (CGM) in 507 adults (83% Caucasian) with type 1, type 2, and no diabetes1The ADA and the American Association of Clinical Chemistry have determined that the correlation (r = 0.92) is strong enough to justify reporting both an A1C result and an estimated average glucose (eAG) when a clinician orders the A1C test2A calculator for converting A1C results into eAG, in either mg/dl or mmol/l, is available at http://professional.diabetes.org/eAG.

*ReferenceNathan DM, Kuenen J, Borg R, et al., for the A1c-Derived Average Glucose Study Group. Translating the A1C assay into estimated average glucose values. Diabetes Care. 2008;31:1473-1478.American Diabetes Association. Standards of medical care in diabetes2011. Diabetes Care 2011;34(suppl 1):S18, Table 9.Recommendations for the detection and diagnosis of gestational diabetes mellitus (GDM) are summarized on two slides; this slide (Slide 1 of 2) includes:As the ongoing epidemic of obesity and diabetes has led to more type 2 diabetes in women of childbearing age, the number of pregnant women with undiagnosed type 2 diabetes has increased[24]Because of this, it is reasonable to screen women with risk factors for type 2 diabetes for diabetes at their initial prenatal visit, using standard diagnostic criteria; women with diabetes found at this visit should receive a diagnosis of overt, not gestational, diabetes

*ReferencesAmerican Diabetes Association. Standards of medical care in diabetes2011. Diabetes Care 2011;34(suppl 1):S15.Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002;25:1862-1868.GDM carries risks for the mother and neonate1The Hyperglycemia and Adverse Pregnancy Outcomes (HAPO) study,2 a large-scale (25,000 pregnant women) multinational epidemiologic study, demonstrated that risk of adverse maternal, fetal, and neonatal outcomes continuously increased as a function of maternal glycemia at 2428 weeks, even within ranges previously considered normal for pregnancy. For most complications, there was no threshold for risk. These results have led to careful reconsideration of the diagnostic criteria for GDMAfter deliberations in 20082009, the International Association of Diabetes and Pregnancy Study Groups (IADPSG), an international consensus group with representatives from multiple obstetrical and diabetes organizations, including ADA, developed revised recommendations for diagnosing GDM. The group recommended that all women not known to have diabetes undergo a 75-g OGTT at 2428 weeks of gestationAdditionally, the group developed diagnostic cut points for the fasting, 1-h, and 2-h plasma glucose measurements that conveyed an odds ratio for adverse outcomes of at least 1.75 compared with the mean glucose levels in the HAPO studyCurrent screening and diagnostic strategies, based on the IADPSG statement,3 are outlined in Table 6, which is summarized on this slide*ReferencesAmerican Diabetes Association. Standards of medical care in diabetes2011. Diabetes Care 2011;34(suppl 1):S15. Table 6.Metzger BE, Lowe LP, Dyer AR, et al, for the HAPO Study Cooperative Research Group. Hyperglycemia and adverse pregnancy outcomes. N Engl J Med 2008;358:19912002.Metzger BE, Gabbe SG, Persson B, et al, for the International Association of Diabetes and Pregnancy Study Groups Consensus Panel. International Association of Diabetes and Pregnancy Study Groups recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676682.Recommendations for the detection and diagnosis of gestational diabetes mellitus (GDM) are summarized on two slides; this slide (Slide 2 of 2) includes:Women with a history of GDM have a greatly increased subsequent risk for diabetes2; therefore, they should be screened for diabetes 6-12 weeks postpartum, using nonpregnant oral glucose tolerance test (OGTT) criteria, and should be followed for the development of diabetes or prediabetes (see Section II, Testing for Diabetes in Asymptomatic Patients)Information on the National Diabetes Education Program campaign to prevent type 2 diabetes in women with GDM can be found at: http://ndep.nih.gov/media/NeverTooEarly_Tipsheet.pdf

*ReferencesAmerican Diabetes Association. Standards of medical care in diabetes2011. Diabetes Care 2011;34(suppl 1):S15.Kim C, Newton KM, Knopp RH. Gestational diabetes and the incidence of type 2 diabetes: a systematic review. Diabetes Care 2002;25:1862-1868.