T2DM

Tight Glycemic Control

What is it?
How to reach it?

Type 2 Diabetes
Mellitus (T2DM)
is a heterogeneous disorder
may have comorbid illness
treatment must be individualized
the common mistake in
management is early diagnosis or
to neglect treatment completely
FBG >126 mg/dL and PPG >200
mg/dL are risk for diabetic
2
complications

Optimal Treatment for

T2DM

Normalizes blood glucose levels:

(A1C 6-7.0%) by
increasing insulin sensitivity
Lifestyle

interventions of diet
Exercises: brisk walking for 20
minutes

Normalizes blood pressure:

<139/80 mmHg
Normalizes the lipid profile: LDLcholesterol <100 mg/dL 3

Treatment for T2DM

Education

OHA
Insulin
Others

Clinical
Nutrition Exercises

T2DM: Unmet Needs

Long-term glycemic
control
Reduce macro- and
micro-vascular
complications
Improve quality of life

Long-term Glycemic Control

Proportion of patients attaining treatment goal [UKPDS 49]

HbA1C 6-7%
Group

3 years 6 years 9 years

Diet
Insulin
SUs
Metformin*

25%
47%
50%
44%

12%
37%
34%
34%

9%
28%
24%
13%

*obese patients
Turner R, et al. JAMA 1999; 281: 2005-12

Relation of A1C levels and Risk of

Complications in Diabetes Mellitus
Diabetes complications
Per 10,000 patient/year

140
120

1032

100

745
655

80
487

60

359

40
20
0

10

11

Mean A1C levels during treatment

7 405-12
UKPDS 35. BMJ 2000; 321:

Management (1)
life-style
changes

Education

About DM
Risk of complications
Principles of Therapy
Oneself Skills

Tim Edukator
8

Non-pharmacological
Medical nutrition therapy
Small

frequent portion of diet

Eat if hungry and stop before sat
Need dietician help

Regular exercises
Part

of life part of treatment

Doa (patient)
9

Medical Nutrition
Dietary modification is an important
com-ponent of a weight loss program
(level 1)
Programs produce about 7% loss
decrease in body weight significant
changes in FBS (~200 mg/dL at
baseline to 150 mg/dL) after 3-6
months of weight loss (level 1)
The best predictor of the glycemic
10
response to weight loss is initial FBS

Medical Nutrition
Nutritional alias Dietary planning
Adjusted to body need
All allowed, but kendalikan nafsu
(stop sebelum kenyang,makan
waktu lapar)
Reach or maintain ideal
body weight
High CH, Low fat
11

Medical Nutrition
Caloric intake
Patients age
Dietitian
Consulitation
Sex
Height
Weight
Activity
Nutritional content
Timing of meal
12

Medical Nutrition
Weight loss of 5-10% of body weight
improve glycemic control long-term,
but it may require weight losses of
twenty percents of body weight to
normalize glucose levels (level 2)

Dietary modification is an
important component of a
weight loss program
(level 1)

13

Exercises
Should aimed at an increase general
physical activity
Improvement and/or normalization of
CV risk factors: hyperinsulinemia;
decreased HDL-cholesterol and
hypercholesterolemia
Decrease or inhibit the
atherosclerosis process
Should be weighed against
cardiovascular event: ACS,
Jalan kaki cepat lebih baik dari naik delman
arrhythmias and cardiac arrest14

Exercises
Exercises alone

vs. no exercises small

effects on glycemic control and
weight loss (level 1)
Diet + Exercises produces
better maintenance of weight
loss, but do not show
significant differences in
glycemic control (level 2) 15

Pharmacological
Treatment

Initial treatment for T2DM is

Insulin then Oral Hypoglycemic
Agents
Increasing duration of T2DM,
multiple OHAs in combination
are usually required
UKPDS demonstrated a 40%
progressive loss of insulinsecretory capacity as diabetes
16

Dont be sad
OHA
Sulfonylurea
Biguanide
Alpha-glucosidase
Insulin

sensitizer
Insulin first

Inhibitor
?
ALTERNATIF

17

Oral Hypoglycemic
Agents
Sulfonylurea (SU)

Decrease A1C by 1-2% (level 1A)

Weight gain ~2-3 kg (level 1A)
Tight glycemic control by SU does
not cause increase risk of
mortality, myocardial infarction, or
other cardiovascular events (level
1A)
18

OHA
Biguanide (Metformin)

Decrease A1C by 1-2% (level 1A)

Less weight gain and less hypoglycemia vs. SU/Insulin (level 1A)
Tight glycemic control using
metformin is associated with
reduced all-cause mortality, any
diabetes-related end-points, and
stroke (level 1A)
19

OHA

Acarbose
Decrease A1C by 0.7 to 1.8% (level
1A)
In combination 0.2 to 1.4%,
without significant changes in
body weight or hypoglycemia
(level 1A)
Poor compliant due to flatulence
20
and diarrhea (level 1A)

OHA
Thiazolidinediones

Pioglitazone and Rosiglitazone

Monotherapy decreases A1C ~ 0.9
to 1.5% (level 1A)
In combination with metformin
reduces A1C ~1.0 to 1.2% (level
1A); increases body weight, dose
dependent, by ~0.7 to 1.9 kg, not
associated with hypo- glycemia
(level 1A)
21

OHA

Meglitinide Analogues

(after

meal)

Repaglinide and Nateglinide

May reduce A1C ~1.0 to 2.0%
(level 1A)
Risk of hypoglycemia similar
with SU use (level 1A)

22

OHA

Alternatives
Selected Minerals,
Vitamins, Fiber, and Herbs
Antioxidants: vitamin C,
vitamin E, Coenzyme Q,
biotin
Rationale? The impact on
glucose control? Doses?
Side effects?

23

The Cure
When I am sick,
then GOD restores me to health

Medical
Reflexology
Meditation
Reiki
24

Grading of T2DM Based on Level of Fasting

Glycemia & Suggestion of Insulin Treatment
FBG
(mg/dl)
< 140

Grade
Mild

Insulin Therapy & Dose required

Virtually never needed

140 - 200 Moderate Basal insulin is needed :

Intermediate acting insulin at bed time
or
Long-acting insulin 1 2X/day
Doses required : 0.3 0.4 /kg/day
> 200

Severe

Intermediate-acting 2X/day + shortacting insulin

Doses required : 0.5 1.5 /kg/day

>250

Very
severe

Treated as Type 1 diabetes (initially)

1 2X basal + 3X bolus (pre-meal)

25

Concern About Possible

Adverse Effects of
Hyperinsulinemia
Relationship of hyperglycemia and
macrovascular disease in T2DM is
difficult to demonstrate
Insulin resistance and/or hyperinsulinemia associated with T2DM,
hypertension, and dyslipidemia
CVD: a direct complication of DM
26

Early Insulinization
When FBS >160 mg/dL or A1C
>8.4% contributes more to
hyperglycemic exposure
FBS ~ poorly regulated hepatic
production subacute
glucotoxicity
Basic concept of basal insulin:
reduce FBS; using a bedtime
injection of NPH or glargine
OHA may enhance endogenous
prandial insulin production 27

Early Insulinization
The issues: dose amounts and
timing of insulin delivery
Risk

of hypoglycemia (high dose)

Hyperglycemia (not enough)

Need a basal insulin level to

overcome hepatic glucose
production
Need a rapid insulin to overcome
increase after meal glucose levels
(prandial hyperglycemia
28

Single Shot
480

Intermediate insulin

400

Plasma glucose

320
240
160
80
07.00

12.00

18.00

24.00

07.00

29

Twice Daily Shots

480

Intermediate insulin

400

Plasma glucose

320
240
160
80
07.00

12.00

18.00

24.00

07.00

30

Multiple Shots
480

Regular insulin

400

Plasma glucose

320
240
160
80
07.00

12.00

18.00

24.00

07.00

31

Summary
Diabetes is a chronic metabolic
disease
Risk of complications
Risk of -cell pancreas loss
overtime
At time T2DM need exogenous
insulin, but risk of hypoglycemia
and hyperglycemia
Mixed fast acting and long-acting
insulin is needed the art of
32
medicine

ALHAMDULILLAH
Matur nuwun
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