Profil Insulin Analog sangat mirip dengan Insulin Endogen

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Insulin endogen
Levemir
NovoRapid
NovoMix

Makan
Pagi

Makan
Siang

Makan
Malam

Sebelum tidur

Analog vs Human Insulin

Profil farmakokinetik analog yang lebih mirip insulin
alami, sehingga menghasilkan : Efektivitas, Keamanan
dan Flexibility lebih baik dibanding human Insulin

Efektivitas :
Superior mengendalikan GD 2 jam pp
Superior mengendalikan GD puasa
Superior mengendalikan HbA1c

Keamanan Risiko Hipoglikemi lebih minimal

Fleksibilitas Waktu penyuntikan lebih fleksibel
(tidak menunggu 30 menit)

Pasien sudah menggunakan Human

Insulin?

Dose to Dose (1:1)

Sebelumnya Actrapid 6 unit 3x sehari NovoRapid 6 unit 3 x sehari
Mixtard 14 unit malam dan 16 unit siang NovoMix 14 unit malam dan 16 unit siang
Insulatard 14 unit malam Levemir 14 unit malam

Presentation Point of View

1. Rationality of Insulin Therapy for Type 2
DM
2. What is Analogue Insulin?
3. How & Strategy of Insulin Treatment ?
4. Barrier of using insulin
5. Take Home Message

How to Start
Insulin Therapy ?

Glycemic Control: Recommended goals

Measurement

Normal

IDF1

ADA/EASD2

AACE3

PERKENI

A1c*

<6%

<6.5%

<7%

<6.5%

<6.5%

Fasting Gluc

<100

<110

90-130

<110

80-110

PP (2h) Gluc

<140

<155

<180

<140

80-145

* Realistic Target: Lowest A1c possible without unacceptable adverse effects

IDF = International Diabetes Federation
ADA = American Diabetes Association.
AACE = American Association of Clinical Endocrinology
1. Global guideline for type 2 diabetes clinical guidelines taskforce (Brussels: IDF,2005)
2. Nathan DM et al. Diabetologia 2006;49:1711-21.
3. http://www.aace.com/pub/odimplementation/roadmap.pdf

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

2 OAD

1 OAD

Initiate

3 OAD

Insulin

Indication: Permanent

Not permanent

T1DM

Infection

OAD failure

Pregnancy

OAD Contra Indication

Hospitalized

Diabetic Ketoacidosis

Perioperative

Strategy of
Insulin Treatment ?

1. If Fasting BG is elevated, start for basal insulin

with long acting insulin (Levemir)
2. If Prandial BG is elevated, start for prandial
/bolus insulin with rapid acting insulin
(NovoRapid)
3. If Fasting and Post Prandial are elevated :
- Oral agent with basal insulin
- premix insulin (NovoMix)
- basal/bolus as in multiple daily injection (MDI)

Treatment Based on Type of Hyperglycemia

BASAL PRANDIAL CONCEPT
Prandial

Hyperglycemia

Basal

Treat fasting hyperglyc. first

Continue oral agent
SMBG is important

Prandial Insulin

Basal Insulin (Levemir)

(NovoRapid)

Untuk mensimplekan terapi gunakan NovoMix

(30% : Prandial Insulin & 70% : Basal Insulin)

Strategies for initiation &

intensification of insulin therapy in
patients with type 2 diabetes mellitus
Increasing
need to
cover PPG

Disease
progression

Premix once
daily start*

Basal once
daily start*

Intensification

Intensification

Premix twicedaily

Premix threetimes daily

Basal bolus
therapy
(+ Prandial
Insulin)

Basal bolus
therapy
(+ Prandial
Insulin)

*continue with appropriate OAD

Recommendation

Fix the Fasting First

Start with basal insulin