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Type 2 DM: Management to Achieve Comprehensive Glycaemic Controldr. Ivan Lumban toruan, SpPD1Why are We Concerned about Diabetes?Every 24 hours...

3,600 new cases of diabetes are diagnosed580 people die of diabetes-related complications225 people have a diabetes-related amputation120 people with diabetes progress to end-stage renal disease55 people with diabetes become blind2A Constellation of ComplicationsGastropathyAutonomic NeuropathyRenal DiseasePeripheral NeuropathyRetinopathy/ Macular EdemaHypertensionCardiovascular DiseaseDyslipidemiaPeripheral Vascular DiseaseErectile DysfunctionDiabetes3Leading cause of adult blindness

Results in 2- to 4-fold increase in cardiovascular risk

Nearly double the rates of diagnosed depressionDiabetes Care in the U.S. Improvements NeededGoalPercent at GoalA1C < 7.043% (18% at > 9.5)LDL < 10011% (58% at > 130)BP < 140/90(ADA goal is 130/80)66%Dilated Eye Exam63%Foot Exam55%NHANES III and Behavioral Risk Factors Surveillance Study4

UKPDS: Glucose Control Study ResultsChange in risk P value

Any diabetes-related endpoint12% 0.029 Diabetes-related deaths 10% NSMyocardial infarction16% 0.052Microvascular disease25% 0.0099Stroke14% NSAdapted from UKPDS Group. Lancet. 1998; 352:837-853.Intensive Blood- Glucose Control6Whay is it important to control glucose? Lower glucose leads to decrease in complications.Effect of Each 1% Rise in A1C on Risk of Developing Complications Incidence of retinopathy

Progression of retinopathy

Progression to PDR

Visual loss

Proteinuria

Amputation

Ischemic heart death 0.5 1 1.5 2 2.5

Risk Ratio and 95% CIKlein. Diabetes Care 18:258-268, 199510-Year follow-up in older-onset patients7For each reduction in A1C levels there can be a decrease in the risk of complications.Why Arent Patients Achieving Blood Glucose Goals?Physicians not setting appropriate glycemic targetsType 2 diabetes is progressive - what works now may not work in the futureType of medications used and/or doses not appropriateInsulin therapy only used as a threat8We as health care providers need to know blood glucose goals and develop strategies for our patients to reach these goals.

However, it must be made clear that regardless of appropriate control, changes in blood glucose is part of the diseases progressions. This may have a psychological impact on the patient.

Insulin is used as a punishment, therefore, it is often used too late. Insulin must be presented as a wonderful tool to control blood glucose levels.DiabetesDiagnostic Cut Points for IFG, IGT, and DiabetesADA=American Diabetes Association; IFG=impaired fasting glucose; IGT=impaired glucose toleranceAdapted from American Diabetes Association. Diabetes Care. 2006; 29(suppl 1): S4S42.2-h Postload GlucoseFasting Glucose100 mg/dL140 mg/dL

NormalGlucose 200 mg/dL

IGT126 mg/dLIFGIFG + IGTADA Diagnostic Cut Points for IFG, IGT, and Diabetes This slide represents American Diabetes Association (ADA) diagnostic criteria for diabetes and for the prediabetic conditions, impaired fasting glucose (IFG) and impaired glucose tolerance (IGT).1 It is important to note that the depictions of each category are not meant to represent the relative proportions of numbers of persons with each syndrome. Hyperglycemia that is insufficient to meet the criteria for diabetes may be classified as IFG, defined by a fasting plasma glucose (FPG) level of 5.6 to 6.9 mmol/L (100 to 125 mg/dL) or as IGT, defined by a 2-hour postload plasma glucose level of 7.8 to 11.0 mmol/L (140 to 199 mg/dL) during an oral glucose tolerance test (OGTT) using a 75-g glucose load.In 1997, the ADA lowered its cut point for the diagnosis of diabetes from an FPG of 7.7 mmol/L (140 mg/dL) to 7.0 mmol/L (126 mg/dL), recognizing a threshold beyond which patients are at increased risk for adverse outcomes of diabetes (eg, microvascular complications).2 This change not only increased the number of patients diagnosed, but also allowed more patients to be diagnosed earlier.

ReferencesAmerican Diabetes Association. Standards of medical care in diabetes2006. Diabetes Care. 2006; 29(suppl 1): S4S42.American Diabetes Association. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 1997; 20: 11831197.Prevalence of IGT and DM In IndonesiaKnown DMUndiagnosed DMTotal DMIGT1,5 %4,2 %5,7 %10,2 %Indonesian National Health Survey, 2007

N = 24.400> 15 yearsPost 75 mg glucose load10Provinces Prevalence of DM and IGT With Higher Than The Average of National Figure

Indonesian National Health Survey, 2007The DiabCare Asia 2008 Study Outcomes on Control and Complications of Type 2 Diabetic Patients in IndonesiaPradana Soewondo, Sidartawan Soegondo, Ketut Suastika, Agung Pranoto, Djoko Wahono Soeatmadji, Askandar Tjokroprawiro

Objective To collect information on diabetes management, diabetes complications, and awareness of self-control in diabetic population of the country. This study also evaluated the physician perspectives, psychological aspects, and quality of life of diabetic patients.

VariableDataAge (Years)* (n=1719)58.939.57Gender** (n=1803) Male/ Female793 (43.3) / 1010 (55.16)Age at Onset (Years)* (n=1686)49.686.8Duration of Diabetes (Years)* (n=1704)8.615.97Type of Diabetes**Type 1Type 2Others17 (0.9)1785 (97.5)2 (0.1)BMI (Kg/m2)14 * (n=1646)