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Intensifikasi Insulin
Makbul M Aman
DIABETES AND LIPID CENTRE RSUP. Dr. WAHIDIN SUDIROHUSODO
DEVISION ENDOCRINE AND METABOLISM DEPARTMENT OF INTERNAL MEDICINE
FACULTY OF MEDICINE HASANUDDIN UNIVERSITY /
RS. UNHAS
Tujuan Pembelajaran
HbA1c ≥7.0%
Adapted from Raccah et al. Diabetes Metab Res Rev 2007;23:257. Slide 3
Insulin can be initiated anytime
• Traditionally, insulin had been reserved as the last line of therapy
• Considering the benefits of normal glycemic status,
insulin can be initiated earlier, as soon as is required.
Inadequate + + +
Lifestyle 1 OAD 2 OAD 3 OAD
Initiate Insulin
5
Kapan Insulin Diperlukan?
Takut hipoglikemia
Kesalahpahaman bahwa peningkatan Menganggap insulin sebagai tanda
insulin meningkatkan risiko kegagalan pasien pribadi untuk
kardiovaskular mengendalikan penyakit
Insulin
Analog Human
Rapid Premixed
Long Short Inter
Acting Acting Acting mediate
Insulin di Indonesia
Mula
Jenis Insulin Puncak Durasi Kemasan
Kerja
Insulin Prandial (Berhubungan dengan makanan)
Insulin Campuran
Plasma
insulin Regular 6–8 hours
levels NPH 12–20 hours
LONG-ACTING:
Glargine 24 hours
Detemir 20 hours
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Hours
Mekanisme kerja Insulin
Glucose
Insulin
Insulin
receptor
PPARg
RXR
Synthesis GLUT 4
mRNA
PPRE transcription
Modified from Howard L. Foyt et al. Thiazolidinediones. Diabetes Mellitus: a Fundamental and Clinical Text, 2nd Ed.
Goal of Insulin Therapy
100
50
Basal glucose
0
7 8 91011121 2 3 4 5 6 7 8 9
AM
Time of Day PM
Adapted with permission from Bergenstal RM et al. In: DeGroot LJ, Jameson JL, eds. Endocrinology.
4th ed. Philadelphia, Pa: WB Saunders Co.; 2001:821
The Basal/Bolus Insulin Concept
• Basal Insulin
– Suppresses glucose production between meals
and overnight non-food related insulin needs.
– 50% of daily needs
• Bolus Insulin (Mealtime or Prandial)
– The amount of insulin required to cover the
food you eat.
– Limits hyperglycemia after meals
– Immediate rise and sharp peak at 1 hour
– 10% to 20% of total daily insulin requirement at
each meal
Basal/Bolus Treatment Program with
Rapid-acting and Long-acting Analogs
Glargine
Waktu
Continue regimen; check If fasting BG in target range, check BG before lunch, dinner, and bed.
HbA1c every 3 months Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)
Pre-lunch BG out of range: add Pre-dinner BG out of range: add NPH insulin at Pre-bed BG out of range: add
rapid-acting insulin at breakfast breakfast or rapid-acting insulin at lunch rapid-acting insulin at dinner
Continue regimen; check Recheck pre-meal BG levels and if out of range, may need to add another
HbA1c every 3 months injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin
Continue regimen; check If fasting BG in target range, check BG before lunch, dinner, and bed.
HbA1c every 3 months Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)
Pre-lunch BG out of range: add Pre-dinner BG out of range: add NPH insulin at Pre-bed BG out of range: add
rapid-acting insulin at breakfast breakfast or rapid-acting insulin at lunch rapid-acting insulin at dinner
Continue regimen; check Recheck pre-meal BG levels and if out of range, may need to add another
HbA1c every 3 months injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin
• If HbA1c is ≥7%...
– Move to Step Two…
Continue regimen; check If fasting BG in target range, check BG before lunch, dinner, and bed.
HbA1c every 3 months Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)
Pre-lunch BG out of range: add Pre-dinner BG out of range: add NPH insulin at Pre-bed BG out of range: add
rapid-acting insulin at breakfast breakfast or rapid-acting insulin at lunch rapid-acting insulin at dinner
Continue regimen; check Recheck pre-meal BG levels and if out of range, may need to add another
HbA1c every 3 months injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin
• If HbA1c is ≥7%...
– Move to Step Three…
Continue regimen; check If fasting BG in target range, check BG before lunch, dinner, and bed.
HbA1c every 3 months Depending on BG results, add second injection
(can usually begin with ~4 units and adjust by 2 units every 3 days until BG in range)
Pre-lunch BG out of range: add Pre-dinner BG out of range: add NPH insulin at Pre-bed BG out of range: add
rapid-acting insulin at breakfast breakfast or rapid-acting insulin at lunch rapid-acting insulin at dinner
Continue regimen; check Recheck pre-meal BG levels and if out of range, may need to add another
HbA1c every 3 months injection; if HbA1c continues to be out of range, check 2-hr postprandial levels
and adjust preprandial rapid-acting insulin
• If HbA1c is still ≥ 7%
– Check 2-hr postprandial levels
– Adjust preprandial rapid-acting insulin
Continue regimen; Recheck pre-meal BG level and if out of range, may need to add another injection; if HbA1c
check HbA1c every 3 continues to be out of range, check 2-hr postprandial levels and adjust preprandial rapid-acting
months insulin
Mengatasi Hambatan Insulin
Hambatan Intervensi
“Sekali memulai insulin Sarankan untuk mencoba dalam kurun
maka saya tidak pernah waktu tertentu (contoh: 1 bulan),
menghentikannya” kemudian dievaluasi kembali
“Saya belum Insulin bukan suatu hukuman; edukasi
menyelesaikan pasien mengenai progresivitas penyakit
pekerjaan dengan baik” diabetes
“Insulin dapat membuat Edukasi pasien mengenai progresivitas
kebutaan” penyakit diabetes
Medical Management of Type 2 Diabetes. 7th Edition. American Diabetes Association, 2012.
Pilihan untuk Follow-Up Pasien
Thank you
Contoh Kasus
Pendahuluan
Tn M, usia 50 tahun, suku jawa, memiliki diabetes sudah 4
tahun. Saat ini tidak ada keluhan, namun khawatir dengan
gula darahnya yg tak terkendali. Pada pemeriksaan fisik
TD 130/80 mmHg, Tinggi 167 cm, Berat. Hasil lab terakhir
GDP 210 mg/dl, 2JPP 455 mg/dl, dan A1C 9.5%.
Diskusi
• Bagaimana status kesehatan Tn.M?
• Bagaimana manajemen selanjutnya pada pasien
ini?
• Kapan sebaiknya kita memulai insulin?
Contoh Kasus
Diskusi
• Insulin jenis apa yang akan disarankan pada pasien ?
• Dimulai pada dosis berapa?
• Bagaimana menyesuaikan dosis insulin jika
diperlukan?
• Materi edukasi apa saja yang perlu diberikan pada
pasien?
Contoh Kasus
Tn M kembali
Tn M gula darahnya sdh terkendali selama 6 bulan dengan basal
insulin glargin 14 U sebelum tidur, glimepirid 1x4mg, metformin
3x500mg, namun beberapa minggu lalu gula darahnya naik lagi. A1C
sekarang 9,5%. Berikut hasil glukosa darahnya :
Sebelum Sebelum
Hari Catatan
sarapan makan malam
Minggu 120 285
Senin 160 305 Dosis Glargine ditingkatkan 2 U
Selasa 130 190
Rabu 165 276 Lupa menyuntik Glargine
Kamis 120 289
Jumat 110 233
Sabtu - 312
Contoh Kasus
Diskusi
• Sebutkan masalah dari Tn.M?
• Bagaimana saran anda untuk manajemen
selanjutnya?
• Bagaimana saran anda untuk penggunaan insulin
selanjutnya?
• Bagaimana penyesuaian dosis insulin yang anda
sarankan?
Contoh Kasus
Follow-up
•Tiga bulan kemudian Tn.M kembali. A1C sekarang 8,7%. Obatnya
glimepiride 1x4 mg, metformin 3x500mg, glargin 1x14 U sebelum tidur,
glulisine 8 U sebelum makan malam, Gula darahnnya kemudian:
Sebelum Sebelum
Hari Sebelum sarapn Catatan
makan siang makan malam
Minggu 110 190 160
Senin 108 205 154
Selasa 120 198 160
Rabu 115 212 152
Kamis 98 200 170
Jumat 108 180 156
Sabtu 99 190 160
Contoh Kasus
Diskusi
• Bagaiman status Tn.M?
• Bagaimana saran anda selanjutnya dalam penggunaan
insulin?
Contoh Kasus
6 bulan kemudian …
Pertanyaan
• Apa yg akan anda sarankan?
• Jika anda menyarankan insulin campuran,
bagaimana anda menyesuaikan dosis nya?