FARMAKOTERAPI DIABETES TIPE 2

Dra. Retnosari Andrajati , PhD. Apt.Fakultas Farmasi Universitas Indonesia

Forum Apoteker Indonesia Jakarta, 4 April 2012

WHO definition

Diabetes mellitus isa metabolic disorder of multiple

etiology, characterized by chronic hyperglycaemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.

Epidemiologi

Diabetes is highly prevalent, afflicting approximately 150 million people worldwide.

The number is expected to rise to 300 million in the year 2025 .

Much of this increase will occur in developing countries. (WHO 2003 Adherence to long –term therapies;Evidence for action)

DM di Indonesia

2006 ; Kematian di RS 2.38%(Indonesian Health Profile 2007)

2007 Kematian 5,7% (Indonesian Health profile 2008,Ministry of Health Republik Indonesia)

Prediksi WHO: 8.4 million 2000 21.3 million in 2030. (Konsesus Pengelolaan dan Pencegahan DMtipe 2 di

Indonesia, PB PERKENI)

DM Etiological Type Konsesus Pengelolaan dan Pencegahan DMtipe 2 di Indonesia, PB PERKENI

TypeType

Type 1Type 1 AutoimmuneAutoimmuneIdiopathicIdiopathic

Type 2Type 2 Predominantly insulin Predominantly insulin resistance.resistance.Predominantly secretory Predominantly secretory defectdefect

Other specific typesOther specific types

Gestational DiabetesGestational Diabetes

DiabetesTipe 2

90% DM Terkait dengan berat badan berlebih dan

resistensi insulin. Fungsi Sel beta pankreas menurun sejalan dengan

waktu terapi insulin dapat diperlukan. Gejala dapat sama dengan DM tipe 1 , tetapi

sering lemah terlambat diketahui.

Diagnosis berdasarkan gula darah

glucose plasma

fasting 2 hour postprandial

Normal <100 mg/dl < 140 mg/dlPradiabetes1 00-125 mg/dl -IFG/IGT - 140-199 mg/dlDiabetes ≥ 126 mg/dl > 200

mg/dl

IFG : Impaired fasting glucoseIGT : Impaired glucose tolerance

Glycated haemoglobin HBA1c

Apa akibat dari DM ?

Komplikasi akut : infeksi, hipoglikemia, ketoasidosis.Kronik: mata, ginjal, saraf dan kardiovaskuler.

Sasaran terapi

Mempertahankan kadar glukosa darah pada tingkat yang sedapat mungkin normal

Menghindari komplikasi akut dan kronik

Meningkatkan risiko penyakit jantung dan stroke 50% orang dengan DM meninggal karean penyakit jantung dan stroke.

Neuropati + menurunnya aliran darah ulkus kaki amputasi.

10-20% penderita DM gagal ginjal Diabetic neuropathy (50%) : kesemutan, nyeri, baal

dan lemah pada tangan dan kaki Diabetic retinopathy, krn kerusakan pembuluh darah kebutaan Sesudah 15 tahun 10 % gangguan penglihatan2%

buta.

Komplikasi DM

Tujuan terapi

• Mengeliminasi gejala hiperglikemia;• Mencapai kontrol optimum;• Menurunkan komplikasi mikro dan

makrovaskuler;• Menganani gangguan penyerta;• Sedapat mungkin membuat pasien

mencapai pola hidup normal

Terapi

EdukasiRekomendasi nutrisi Latihan Farmakoterapi

Obat hipoglikemik oralGolonganGolongan Contoh Contoh Mekanisme kerjaMekanisme kerjaSulfonilureaSulfonilurea Gliburid/glibenklaGliburid/glibenkla

mid, glipizid, mid, glipizid, glikazid, glikuidonglikazid, glikuidon

Merangsang sekresi kel Merangsang sekresi kel pankreaspankreas

BiguanidBiguanid MetforminMetformin Menurunkan produksi Menurunkan produksi glukosa hatiglukosa hati

MeglitinadMeglitinad ReplaginidReplaginid Merangsang sekresi kel Merangsang sekresi kel pankreaspankreas

ThiazolidindionThiazolidindion Rosiglitazon, Rosiglitazon, troglitazon, troglitazon, pioglitazonpioglitazon

Meningkatkan kepekaan Meningkatkan kepekaan reseptor insulinreseptor insulin

Inhibitor Inhibitor aglukosidaseaglukosidase

Akarbose, miglitolAkarbose, miglitol Menghambat enzimMenghambat enzim--enzim enzim pencernaanpencernaan

ROTDPaling umum: ggn saluran cerna, mual, panas, rasa penuh.Hipoglikemi, reaksi alergi pd kulit, eksim, pruritis, eritema, urtikaria, fotosensitif, leukopenia, trombositopenia, anemia aplastik, agranulositosit, anamia hemolitik, lemah, parestresia, tinitus, pusing, vertigo, malaise, test fungsi hati meningkat.

Monitoringhipoglikemia, Syndrome of inappropriate secretion of antidiuretic hormone (SIADH):retensi air dg hiponatremia

Thiazolidinedion

Rosiglitazon, pioglitazon, troglitazon

Mekanisme kerja:Memperbaiki sensitivitas insulinpd sel otot dan lemakMenghambat glukoneogenesis di hati

ROTD gangguan Kardiovaskuler

Alfa glukosidase inhibitor

Akarbose

oligosakarida kompleks

MK: menghambat pencernaan karbohidratglukosa yg diabsorpsi<

ROTD:77%: flatuluns33%: diare21%: nyeri perutReksi hipersensitivitas : ruam : jarang

Obat ADO baru

DPP-4 Inhibitors: menghambat enzim (DPP-4) yang secara normal mendeaktivasi protein (GLP-1) yang mempertahankan sirkulasi insulin

.Sitagliptin. Incretin Mimetics: menyerupai kerja inkretin untuk

merangsang pembentukan insulin

Criteria of Controlled Diabetes

good borderline poor

Fasting blood glucose 80-<100 100-125 ≥126

2 hour postprandial 80-144 145-179 ≥180

Hba1c (%) <6.5 6.5-8 >8

Total cholesterol <200 mg/dl 200-250 >250

HFL cholesterol >45 (male) 35-45 <35

>55(female) 45-55 <45

LDL cholesterol <100 100-130 >130

Fasting triglycerides <200 200-250 >250

Criteria of Controlled Diabetes

good borderline poor

Body mass index(kg/m2)

male <25.0 25.0-27.0 >27.0

female <24.0 24.0-26.0 >26

Blood pressure (mmHg) <130/80 - -

Essential components of diabetic counseling

Counseling regarding the disease Counseling regarding lifestyle

modifications Counseling regarding medications Counseling regarding acute complications Counseling regarding chronic complications Counseling in special populations Counseling regarding self Monitoring of Glucose

Counseling regarding lifestyle modifications

Diet Carbohydrates 46-65% Protein 10-20% Fat 20-25%

Exercise and physical activity

Alcohol intake and smoking

Counseling points for oral hypoglycemic agents

Counseling points for insulin

References1. Konsensus Pengelolalan dan Pencegahan Diabetes Melitus Tipe 2 di Indonesia 2006.

Available at: http://www.perkeni.net (Accessed on 2 th August 2010) 2. Pharmaceutical care untuk penyakit diabetes. Departemen Kesehatan RI, 2006.3. Diabetes fact sheet no.312,World Health Organization 2009. Available at

http://www.who.int/mediacentre/factsheets/fs312/en/print.html (accessed on 4th August 2010)

4. Khatib OMN ed.Guidelines for the prevention, management and care of Diabetes mellitus. World Health Organization 2006. Available at http://www.who.int(accessed on 2th August 2010).

5. Palaian S., Role of pharmacist in counseling Diabetes Patients. The Internet Journal of Pharmacology 2005 : Volume 4 Number 1. (accessed on 2th August 2010)

6. Jennings DL., Ragucci KR., Chumney ECG., Wessel AM., Impact of clinical pharmacist intervention on diabetes related quality of life in an ambulatory care clinic. Pharmacy Practice 2007:5(4): 169-173. Available at www.pharmacy.practice.org((accessed on 2th August 2010)

7. Working together to manage diabetes. A guide for pharmacy, podiatry, optometry and dental professional .National Diabetes Education Program 2007. Available at www.cdc.gov/phtnonline ((accessed on 2th August 2010)

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