Currents Issues and Challenges in Chronic Disease Control 2012

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Currents Issues and Challenges

in Chronic Disease Control

Agus Widiyatmoko



2

Pulmonary conditions are among the mostprevalent types of chronic health problems

49,2

36,8

30,3

19,1

13,7

10,6

2,4

0 10 20 30 40 50 60 70

Stroke

Cancers

Diabetes

Heart disease

Mental disorders

Hypertension

Pulmonary conditions

Number (in millions) of Americans reporting specific chronic conditions*

Million

*This study evaluated the burden of seven of the most common chronic diseases/conditions (cancer, diabetes, heart disease,

hypertension, mental disorders, pulmonary conditions, and stroke.

Source: DeVol, R, Bedroussian, A, et al. An Unhealthy America: The Economic Burden of Chronic Disease. The Milken Institute.October 2007. Full report and methodology available at: www.chronicdiseaseimpact.com.

http://www.chronicdiseaseimpact.com/





3

Mental health conditions, such as depression,dramatically increase disability* when paired with other

chronic health conditions

Degree of disability due to select chronicdiseases

3,5

6 7 7

0

5

10

15

20

25

Degree of disability due to select chronic

diseases plus depression

Source: WHO World Health Survey, Moussavi, et al, (2007) Lancet

Diabetes Arthritis Angina Asthma Diabetes Arthritis Angina Asthma

D

e g r e e o f d i s a b i l i

t y

*Disability is the measure of difficulty completing important and ordinary life tasks and roles.

23

1720 19

0

5

10

15

20

25



4

Older adults are more likely to have chronic healthconditions, but Americans of all ages are affected

Percent of U.S. population with chronic conditions

26

40

68

90

615

42

72

0%

20%

40%

60%

80%

100%

0-19 20-44 45-64 65+

1 or more chronicconditions

2 or more chronicconditions

Ages

Source: Anderson, G. Chronic Conditions: Making the case for ongoing care. Johns Hopkins University. November 2007.



Cancer

Prevalence and Incidence of Cancer

More than 18 million new cases of cancer have been diagnosed in the

United States since 1990.American Cancer Society 2004, Cancer Facts and Figures

Approximately 1.37 million new cancer cases were expected to be

diagnosed in 2005.American Cancer Society 2005, Cancer Facts and Figures

The National Cancer Institute estimated that in January 2001, there were

approximately 9.8 million Americans with a history of cancer.American Cancer Society 2005, Cancer Facts and Figures

American men have approximately a one-in-two lifetime risk of developing cancer. American women have approximately a one-in-three

lifetime risk.American Cancer Society 2005, Cancer Facts and Figures



Cancer

Age—A Major Risk Factor

Age is the major risk factor for cancer — about 76% of all cancers are

diagnosed in individuals age 55 and over.American Cancer Society 2005, Cancer Facts and Figures

The incidence of colorectal cancer is more than 50 times higher in people

ages 60-79 than in those under 40. 91% of new cases and 94% of deaths

from colorectal cancer occur in individuals 50 and older.American Cancer Society 2005, Colorectal Cancer Facts and Figures

A woman’s risk of breast cancer increases with age— about 80% of breast

cancer cases occur in women over age 50.National Institute on Aging, Age Page: Cancer facts for people over 50

Age is the greatest risk factor for prostate cancer with more than 70% of all

cases diagnosed in men age 65 and older.Prostate Cancer Foundation



Cancer

The Burden of Cancer – The Human Burden

In 2002, cancer patients made 25.3 million office visits to their physicians.

Woodwell and Cherry 2004, National Ambulatory Medical Care Survey

In 2002, cancer patients made 2.1 million visits to hospital outpatient

departments.

Hing and Middleton 2004, National Hospital Ambulatory Medical Care Survey

45% of middle-age men who have been diagnosed with cancer in the last

year have recurring pain. 41% of middle-age women with a history of

cancer experience recurring pain.

Pfizer 2005, The Burden of Cancer in American Adults



Cancer

The Burden of Cancer – The Human Burden

1.3 million cancer patients were discharged from hospital inpatient stays in

2003. More than 650,000 of them were over 65.

DeFrances, Hall, and Podgornik 2005, National Hospital Discharge Survey

Less than 20% of 65-year-olds who have been diagnosed with cancer are

free of comorbidities and physical limitations.Joyce et al. 2005, The Lifetime Burden of Chronic Disease among the Elderly

43% of older men and 45% of older women with a history of cancer report

some type of activity limitation.

Pfizer 2005, The Burden of Cancer in American Adults



Cancer

The Burden of Cancer – The Economic Burden

The National Institutes of Health estimated the overall cost of cancer in

2004 was $189.8 billion. This figure includes $69.4 billion in direct

medical costs, $16.9 billion in indirect morbidity costs, and $103.5 billion

in indirect mortality costs.

American Cancer Society 2005, Cancer Facts and Figures

Colorectal cancer treatment costs about $6.5 billion per year; breast cancer

treatment costs nearly $7 billion per year; and cervical cancer treatment

costs around $2 billion per year.

Brown, Lipscomb, and Snyder 2001, The Burden of Illness of Cancer

Direct annual spending for prostate cancer is $3.6 billion.Pfizer 2005, The Burden of Cancer in American Adults



Cancer

The Burden of Cancer – The Economic Burden

The annual national cost of informal caregiving for cancer patients is an

estimated $1 billion.

Hayman et al. 2001, Estimating the Cost of Informal Caregiving for Elderly Patients with Cancer

Every year, $38.4 billion of direct medical services is spent on cancer-

associated care for community-dwelling adults.Pfizer 2005, The Burden of Cancer in American Adults



Chronic Disease

and Tobacco:

Effects of Cigarette Smoking on

Chronic Disease



Effects of Smoking

Smoking harms nearly every organ of the body.Generally, smoking causes many diseases andreduces the overall health of smokers.

The adverse health effects from cigarettesmoking account for an estimated 438,000deaths, or nearly 1 of every 5 deaths, each year in the United States. More deaths are causedeach year by tobacco use than by all deaths

from human immunodeficiency virus (HIV),illegal drug use, alcohol use, motor vehicleinjuries, suicides, and murders combined.



Effects of Smoking

Diseases known to be caused by smoking, include:bladder, esophageal, laryngeal, lung, oral, and throatcancers, chronic lung diseases, coronary heart and

cardiovascular diseases, as well as reproductive effectsand sudden infant death syndrome.

The list of diseases caused by smoking has beenexpanded to include abdominal aortic aneurysm, acutemyeloid leukemia, cataract, cervical cancer, kidney

cancer, pancreatic cancer, pneumonia, periodontitis, andstomach cancer.

Source: 2004 Surgeon General’s Report—The Health Consequences of Smoking



Effects of Smoking: Cancer

• Cancer is the second leading cause of death and wasamong the first diseases causally linked to smoking.

• Lung cancer is the leading cause of cancer death, andcigarette smoking causes most cases.

• Compared to nonsmokers, men who smoke are about 23

times more likely to develop lung cancer and womenwho smoke are about 13 times more likely. Smokingcauses about 90% of lung cancer deaths in men andalmost 80% in women.

• Cancer-causing agents (carcinogens) in tobacco smoke

damage important genes that control the growth of cells,causing them to grow abnormally or to reproduce toorapidly.




Effects of Smoking: Cancer • Cigarette smoking is a major cause of esophageal cancer in the United

States. Reductions in smoking and smokeless tobacco use could preventmany of the approximately 12,300 new cases and 12,100 deaths fromesophageal cancer that occur annually.

• The combination of smoking and alcohol consumption causes mostlaryngeal cancer cases. In 2003, an estimated 57,400 new cases of bladder cancer were diagnosed and an estimated 12,500 died from the disease.

• For smoking-attributable cancers, the risk generally increases with thenumber of cigarettes smoked and the number of years of smoking, andgenerally decreases after quitting completely.

• Cigarette smoking increases the risk of developing mouth cancers. This riskalso increases among people who smoke pipes and cigars.

• Reductions in the number of people who smoke cigarettes, pipes, cigars,

and other tobacco products or use smokeless tobacco could prevent mostof the estimated 30,200 new cases and 7,800 deaths from oral cavity andpharynx cancers annually in the United States.




Lung Cancer



Effects of Smoking: Coronary Heart

Disease and Stroke

• Coronary heart disease and stroke, the primary types of cardiovascular disease caused by smoking, are the first andthird leading causes of death in the United States.

• More than 61 million Americans suffer from some form of cardiovascular disease, including high blood pressure, coronaryheart disease, stroke, congestive heart failure, and other conditions. More than 2,600 Americans die every day becauseof cardiovascular diseases, about 1 death every 33 seconds.

• Toxins in the blood from smoking cigarettes contribute to thedevelopment of atherosclerosis. Atherosclerosis is a

progressive hardening of the arteries caused by the deposit of fatty plaques and the scarring and thickening of the artery wall.Inflammation of the artery wall and the development of bloodclots can obstruct blood flow and cause heart attacks or strokes.




Coronary Heart Disease



Effects of Smoking: Coronary Heart

Disease and Stroke

• Smoking-related coronary heart disease may contributeto congestive heart failure. An estimated 4.6 million

Americans have congestive heart failure and 43,000 diefrom it every year.

• Strokes are the third leading cause of death in the UnitedStates. Cigarette smoking is a major cause of strokes.

• The U.S. incidence of stroke is estimated at 600,000cases per year, and the one-year fatality rate is about

30%.• The risk of stroke decreases steadily after smoking

cessation. Former smokers have the same stroke risk asnonsmokers after 5 to 15 years.




Stroke



Effects of Smoking:

Respiratory Health• In 2001, chronic obstructive pulmonary disease (COPD) was the fourthleading cause of death in the United States, resulting in more than118,000 deaths. More than 90% of these deaths were attributed tosmoking.

• About 10 million people in the United States have been diagnosed with

COPD, which includes chronic bronchitis and emphysema. COPD isconsistently among the top 10 most common chronic health conditions.

• Smoking is related to chronic coughing and wheezing among adults.

• Smoking damages airways and alveoli of the lung, eventually leadingto COPD.

• Smokers are more likely than nonsmokers to have upper and lower respiratory tract infections, perhaps because smoking suppressesimmune function.

• In general, smokers’ lung function declines faster than that of nonsmokers.




COPD (Chronic Obstructive

Pulmonary Disorder)



Statewide Impact



Tobacco-Related Mortality

• Tobacco use is the leading preventable cause of death in the United States. Cigarette smokingcauses an estimated 438,000 deaths, or about 1of every 5 deaths, each year. This estimateincludes approximately 38,000 deaths fromsecondhand smoke exposure.

• Cigarette smoking kills an estimated 259,500men and 178,000 women in the United Stateseach year.



Tobacco-Related Mortality

• More deaths are caused each year by tobacco use thanby all deaths from human immunodeficiency virus (HIV),illegal drug use, alcohol use, motor vehicle injuries,suicides, and murders combined.

• On average, adults who smoke cigarettes die 14 yearsearlier than nonsmokers.

• Based on current cigarette smoking patterns, anestimated 25 million Americans who are alive today willdie prematurely from smoking-related illnesses, including5 million people younger than 18.6



Chronic Disease and Tobacco:

Health Effects of Cigarette Smoking and Chronic Disease

Source: CDC SAMMEC, MMWR 2005; Vol. 54, No. 25:625 –8.

The pie chart represents the

estimated annual number of

smoking-attributable deaths in

the United States during 1997

through 2001 by specific

causes, as follows:

• Lung cancer: 123,800 deaths

• Other cancers: 34,700 deaths

• Chronic lung disease: 90,600

deaths

• Coronary heart disease: 86,800

deaths

• Stroke: 17,400 deaths

• Other diagnoses: 84,600 deaths



Currents Issues

• Hypertension

• Diabetes Mellitus



EPIDEMIOLOGI DAN PREVALENSIHIPERTENSI



Latar Belakang

Hipertensi adalah salah satu penyebabkematian nomor satu, secara global.

Komplikasi pembuluh darah yang disebabkanhipertensi dapat menyebabkan penyakit

jantung koroner, infark miokard, stroke, dangagal ginjal.

Komplikasi pada organ tubuh menyebabkanangka kematian yang tinggi.



Hipertensi dan komplikasinya

menyebabkan

penderita, keluarga dan negara harusmengeluarkan lebih banyak biayapengobatan dan perawatan,

menurunkan kualitas hidup penderita.



Natural History of Hypertensive Disease

From endothelial dysfunction to target-organ damage

Renaldysfunction

MI/CAD

LVH

Stroke

Target organdamage

ElevatedBP

Vasculardysfunction

Endothelialdysfunction

Hypertension,

Aging,

Smoking,

Dyslipidemia



Hiperinsulinemia

Toleransiglukosa terganggu

Peningkatan risiko

Peny.

serebrovaskuler

DM tipe 2

Resistensi insulin

Mikroalbuminuria Hiperkoagulabilitas

Obesitas viseral

Dislipidemia

Hipertensi

Berbagai kondisi yang berhubungan

dengan risiko serebrovaskuler



Prevalensi Hipertensi

Prevalensi hipertensi meningkat sejalandengan perubahan gaya hidup sepertimerokok, obesitas, inaktivatas fisik, dan strespsikososial.

Hipertensi sudah menjadi masalah kesehatanmasyarakat (public health problem) dan akan

menjadi masalah yang lebih besar jika tidakditanggulangi sejak dini.



Prevalensi di Dunia

Secara umum, prevalensi hipertensi pada usialebih dari 50 tahun berkisar antara 15%-20%.

Prevalensi di Vietnam pada tahun 2004 mencapai 34,5%,

Thailand (1989) 17%,

Malaysia (1996) 29,9%,

Philippina (1993) 22%, dan

Singapura (2004) 24,9%.

Di Amerika, prevalensi tahun 2005 adalah 21,7%.



Prevalensi di Yogyakarta

Dari data penelitian di Kecamatan MlatiKabupaten Sleman didapatkan angkaprevalensi hipertensi (berdasar kriteria JNCVII) sebesar 26,2% (Sja’bani, Wijayanti, dan

Prasanto, 2006) dan 11,4% pada studi denganstratification random sampling 9 dari 45

dusun (Sja’bani dan Bawazier, 2007)



• Measurement

Hypertension management issues

• Investigation

• Non-pharmacological treatment

• Thresholds for drug treatment

• Targets for drug treatment

• Drug choices – trial update

• Other treatments

• Follow-up



BHS classification of blood pressure levels

CategorySystolic blood

pressure (mmHg)

Diastolic blood

pressure

Optimal blood pressure <120 <80

Normal blood pressure <130 <85

High-normal blood pressure 130-139 85-89

Grade 1 Hypertension (mild) 140-159 90-99

Grade 2 Hypertension (moderate) 160-179 100-109

Grade 3 Hypertension (severe) >180 >110

Isolated Systolic Hypertension (Grade 1) 140-159 <90

Isolated Systolic Hypertension (Grade 2) >160 <90



Potential indications for the use of ambulatory

blood pressure monitoring

• Unusual variability

• Possible white coat hypertension

• Informing equivocal treatment decisions

• Evaluation of nocturnal hypertension

• Evaluation of drug-resistant hypertension

• Determining the efficacy of drug treatment over 24 hours

• Diagnoses and treatment of hypertension in pregnancy

• Evaluation of symptomatic hypotension



Routine investigations

• Urine strip test for protein and blood

• Serum creatinine and electrolytes

• Blood glucose - ideally fasted• Blood lipid profile (at least total and high

density lipoprotein (HDL) cholesterol) – ideally

fasted for consideration of triglycerides

• Electrocardiogram



Lifestyle measures

• Maintain normal weight for adults (body mass index 20-25 kg/m2)

• Reduce salt intake to <100 mmol/day (<6g NaCl or <2.4 g Na+/day)

• Limit alcohol consumption to 3 units/day for men and 2 units/day

for women

• Engage in regular aerobic physical exercise (brisk walking rather

than weight lifting) for 30 minutes per day, ideally on most of days

of the week but at least on three days of the week

• Consume at least five portions/day of fresh fruit and vegetables• Reduce the intake of total and saturated fat



Suggested target blood pressures during antihypertensive

treatment. Systolic and diastolic blood pressures should

both be attained, e.g. <140/85 mmHg means less than 140

mmHg for systolic blood pressure and less than 85 mmHgfor diastolic blood pressure

Clinic BP (mmHg) No diabetes Diabetes

Optimal treated BP pressure <140/85 <130/80 Audit Standard <150/90 <140/80

Audit standard reflects the minimum recommended levels of blood pressure control.Despite best practice, the Audit Standard will not be achievable in all treated hypertensives. For ambulatory (mean daytime) or home blood pressure monitoring - reducing these targets by ~10/5 is

recommended.





Compelling and possible indications, contraindications, and cautions for the major classes of antihypertensive drugs

Class of drug

Compellingindications

Possibleindications Caution

Compellingcontra-indications

Alpha-blockers

Benign prostatichypertrophy

Posturalhypotension,heart failure

Urinaryincontinence

ACE-inhibitors

Heart failure,LV dysfunction, post

MI or established CVD,Type I diabeticnephropathy, 2o strokeprevention

Chronic renaldisease,

Type II diabeticnephropathy,proteinuric renaldisease

Renal impairment

PVDPregnancy,renovascular

disease

ARBs ACE inhibitor-intolerance,Type II diabetic

nephropathy,hypertension with LVH,heart failure in ACE-intolerant patients, postMI

LV dysfunctionpost MI, intol-erance of other

antihypertensivedrugs, proteinuricrenal disease,chronic renaldisease,

heart failure

Renal impairmentPVD

Pregnancy,renovascular disease



Compelling and possible indications, contraindications, andcautions for the major classes of antihypertensive drugs

Class of drugCompellingindications

Possibleindications Caution

Compellingcontraindications

Beta-blockers MI, Angina

Heart failure Heart failure,PVD,

Diabetes(except withCHD)

Asthma/COPD,Heart block

CCBs(dihydropyridine)

Elderly, ISH Angina - -

CCBs(rate limiting)

Angina Elderly Combinationwith beta-blockade

Heart blockHeart failure

Thiazide/thiazide-like diuretics

ElderlyISHHeart failure2 o strokeprevention

Gout



Other medications for hypertensive patients

Primary prevention(1) Aspirin: use 75mg daily if patient is aged 50 years with blood pressure

controlled to <150/90 mm Hg and either; target organ damage, diabetes

mellitus, or 10 year risk of cardiovascular disease of 20% (measured by

using the new Joint British Societies’ cardiovascular disease risk chart)

(2 ) Statin: use sufficient doses to reach targets if patient is aged up to at

least 80 years, with a 10 year risk of cardiovascular disease of 20%

(measured by using the new Joint British Societies’ cardiovascular

disease risk chart) and with total cholesterol concentration 3.5mmol/l

(3) Vitamins—no benefit shown, do not prescribe



Secondary prevention

(including patients with type 2 diabetes)

(1) Aspirin: use for all patients unless contraindicated

(2 ) Statin: use sufficient doses to reach targets if patient is

aged up to at least 80 years with a total cholesterol

concentration 3.5 mmol/l

(3) Vitamins— no benefit shown, do not prescribe

Other medications for hypertensive patients



Targets for lipid lowering

Ideal - TC<4.0mmol/l

or LDL <2.0mmol/l

or 25% in TC

or 30% in LDL-Cwhichever is the greater

‘Audit’ - TC <5.0mmol/l

or LDL <3.0mmol/l

or 25% in TC

or 30% in LDL-C

whichever is the greater

Lipid targets



Current Issues



Clinical Development CYT006-AngQb

The randomized, double-blind and placebo-controlled

study was designed to evaluate the safety, tolerability andexploratory efficacy of the vaccine candidate.

The phase I part of the study included 16 normotensivesubjects and the phase IIa part 72 hypertensive participantswith mild to moderate hypertension.

In the phase I study part, the 16 participants received oneinjection of the vaccine (100 μg) or placebo.

In the phase IIa study part, two dose levels of the vaccine(100 μg and 300 μg) were compared to placebo. The 72hypertensive participants received 3 injections of the

vaccine or placebo at weeks 0, 4 and 12. Exploratory efficacy of the vaccine was assessed in

individual subjects by 24-hour ambulatory blood pressuremonitoring at baseline and post-treatment (i.e. 2 weeksafter the last injection).

50



50

Achtung, Achtung

What comes to you of good is

verily from Allah; and what comes

to you of ill is from your own self

(your actions) …

[Al Qur’an s. an-Nisa’ (4): 79]

? Type 2 Diabetes mellitus

(T2DM)

51



51

T2DM: The Growing Epidemic

• Progressive metabolic disease• Increased prevalence globally

• Potential causes

Aging population

Lifestyle changes

Limited physical activity

Obesity

High caloric intake

• Indonesia 4th world-rank

52



52

Prevalence of T2DM

Estimation of DM patients in2020

• Worldwide: 306 mio (Mc Carthy/Zimmet,1993)

• Indonesia: 21.3 mio (Konsensus, 2006)

Estimation of T2DM in ASEAN 1995: 8.5 mio

2000: 12.3 mio

2010: 19.4 mio



The diabetes epidemic: facts• DM 246 million people worldwide (380 million by 2025)

• Each year 7 million people develop diabetes.

• Each year, 3.8 million deaths

• Every 10 seconds a person dies

• Every 10 seconds two people develop diabetes.

IDF , Diabetes ATLAS 2006

INDONESIA

2000 5.6 million people with DM2020 8.2 million people with DM

World 5th largest prevalence !!

(International Diabetes Federation)

RISKESDAS 2008: Prevalensi 5,7%

Th 2000 DM di Indonesia 8,426,000

IGT is driving the worldwide



Harris. Consultant. 1997;37 Suppl:S9

IGT

Undiagnosed

type 2 diabetes

Diagnosed

type 2 diabetes

50

45

40

35

30

25

20

15

10

50

20-44 45-54 55-64 65

Age (years)

% o

f p o p u l a t i o n

IGT is driving the worldwide

diabetes pandemic



United Nations Resolution 61/225:20 December 2006

• This landmark Resolution recognizes diabetes

as a chronic, debilitating and costly disease

associated with major complications that pose

severe risks for families, countries and the entireworld.

• It designates 14 November, World Diabetes Day

For the first time, a non-infectious disease has beenseen as posing as serious a global health threat as

infectious epidemics such as HIV/AIDS.

56



Prevalence …

Indonesia: 1.1 –

2.3% 7.3 ~ 12.7%Jakarta (urban): 1.7% (1982) 5.7%

(1993)

Makassar (urban): 1.5% (1981) 2.9%

(1998)

Manado: 6.1% (1995)

Depok: 12.7% (2000)

Singaraja: 7. 3% (2003)

Yogyakarta (urban, semiurban, rural):1.5% (1986)

Pemeriksaan Laboratorium Gula Darah (GD)



57

HbA1C (%) GD rata-rata

6 - 7 135 - 170

7 - 8 170 - 205

8 - 9 205 - 240

9 - 10 240 - 275

> 10 > 275

mg/dL Normal Prediabetes Diabetes

GDs <100 100-199

> 200

GDp <100 100-125 > 126

GDpp

<100 100-199 > 200

( )

J i J i Di b t



58

Jenis-Jenis Diabetes

Diabetes tipe 2

•Diabetes hanya pada saat kehamilan

•Setelah melahirkan GD kembali normal

•Kemungkinan beberapa tahun kemudian

menetap menjadi Diabetes tipe 2

Diabetes tipe 1 •Kerusakan pankreas•Membutuhkan suntikan insulin

•terjadi pada masa bayi/kanak2 / remaja

Diabetes pada kehamilan

(gestasional)

•Kasus diabetes yang sering ditemui

•Sering tanpa gejala

•Silent Killer

Diabetes tipe lain • Karena kelainan genetik• Infeksi• Obat-obatan

• dll

Faktor Resiko Diabetes



59


Dapat dimodifikasi

kurang gerak/malas Pola makan tidak sehat

Hipertensi(≥140/90 mmHg)

Penyakit jantung/stroke

Kegemukan

(IMT > 23 kg/m2)

Dislipidemia

(HDL ≤ 35 mg/dL dan atau

trigliserida ≥ 250 mg/dL)

makan berlebihan

Prediabetes

Prediabetes

GDs : 100-199

GDp:100-125

GDpp:100-199




60


Tidak dapat dimodifikasi

Mereka yang mempunyai faktor resiko dianjurkan melakukanpermeriksaan gula darah untuk tujuan skrining/penyaring.

Usia > 45 tahun Riwayat keluarga

diabetesRiwayat pernah

Diabetes

gestational

riwayat melahirkan

bayi > 4 Kg

Komplikasi



61

p

Diabetes

Akut(Muncul Tiba-tiba)

Kronik(muncul perlahan-lahan,

dalam hitungan tahun)

Stroke

Retinopati danKatarak

Serangan Jantung

(infark)

Gagal Ginjal

Neuropati

(kesemutan,baal)

Penyakit Pembuluh Darah

Tepi (luka di kaki, ulkus)

Bagaimana “Bersahabat” dengan diabetes ??



71

Bagaimana “Bersahabat” dengan diabetes ??

prediabetes /non diabetes

Diabetes

Diabetes

Komplikasi

diabetes

Should we attempt to prevent



Should we attempt to prevent

diabetes?

• important health problem

• the early development is understood

• a test to detect the predisease (OGTT)

• safe, effective, and reliable method(s) to

prevent or at least delay the disease

PRIMARY PREVENTION



PRIMARY PREVENTION

• In the Finnish study

– 1 year number needed to treat (NNT): 22

– 5 year NTT: 5• In the DPP

– Lifestyle 3 years NNT: 7

– Metformin 3 years NTT: 7

None of the interventions were associated

with any major harmful effects

Therapy: safe, effective, and reliable



PRIMARY PREVENTION

• Individuals at high risk

• Screening & Intervention strategy• Follow-up counseling

• Monitoring for the development of diabetes

• Treatment for other CVD risks

• Drug therapy should not be routinely &

must be cost-effectiveness.

Recommendations to prevent or delay diabetes

SECONDARY PREVENTION



Knowledge from UKPDS and DECODE

Hyperglycaemia

Tissuedamage

Diabetescomplication

Total load(HbA

1c

)

Chronicglucose toxicity

Microangiopathy

UKPDS1

Postprandialpeaks

Acuteglucose toxicity

Macroangiopathy

DECODE2

DECODE: Diabetes Epidemiology: Collaborative Analysis

of Diagnostic Criteria in Europe, HbA1c: haemoglobin A1c,UKPDS: UK Prospective Diabetes Study

1. Stratton IM, et al. BMJ 2000;321:405 –12.2. DECODE. Diabetes Care 2003;26:688 –96.

SECONDARY PREVENTION

Pengendalian gula darah



77

Pengendalian gula darah

Diabetes Komplikasi

Mengendalikan gula darah terkontrol baik :

1. Pengaturan Makan

2. Kegiatan Jasmani3. Memakan obat-obat yang dianjurkan dokter

1. Pengaturan Makan



78

1. Pengaturan Makan

Pengaturan

Pola makan

Diabetes

Pola makan

orang sehat

normal

3J

Pengaturan Makan



79

Jadwal Makan

07.00-08.00 10.00 12.00-13.00 16.00 19.00 21.00

Makan pagi Makan siang Makan malam

Selingan Selingan Selingan*

Jenis

Jumlah

Sumber zat tenaga

Sumber zat pembangun

Sumber zat pengatur

•

Karbohidrat 60 - 70 %• Protein 10 - 15 %

• Lemak 20 - 25 %



85

Makanan yang harus dibatasi/dihindari

• Makanan yang mengandung banyak kolesterol(kuning telur, otak, jeroan, daging berlemak, keju, kerang)

• Makanan yang mengandung lemak jenuh(gorengan, minyak kelapa, santan kental)

• Makanan yang mengadung gula murni(sirup, permen,kue manis, coklat manis, dsb)

•Gula < 5% kebutuhan kalori sehari

•Garam < 1 sendok teh (6-7 g) sehari.

Pengaturan Makan



86

Makanan Khusus

Produk bubuk :kandungan gizi makanan lengkap untuk penyandang DM

Diperlukan dalam keadaan tertentu:

• Saat tidak nafsu makan/sakit

• Sibuk/tidak sempat makan• Bekal dalam perjalanan

Pemanis alternatif

tujuan meningkatkan kualitas rasa

produk makanan rendah kalori & untuk penyandang Diabetes

aman digunakan asal tidak melibihi batas aman (Accepted Daily Intake)



90

2. Kegiatan Jasmani

Kegiatan Jasmani



91

Kegiatan Jasmani

Kurangi Aktifitas

Hindari aktifitas sedenter

•menonton televisi,

•menggunakan internet,

•main game komputer

Persering AktifitasMengikuti olahraga rekreasi dan

beraktifitas fisik tinggi pada waktu liburan

•Jalan cepat

•Golf

•Berenang

•Bersepeda•Berkebun

Aktifitas HarianKebiasaan bergaya hidup sehat

•Berjalan kaki ke pasar

(tidak menggunakan mobil)

•Menggunakan tangga

(tidak menggunakan lift)•Menemui rekan kerja

(tidak hanya melalui telepon )

•Berjalan-jalan

•Membereskan rumah

Kegiatan Jasmani



92

Manfaat Latihan jasmanibagi Diabetes tipe 2

1. Kadar glukosa darah

2. Kegemukan

3. Lipid (lemak) darah

4. ResikoTekanan darah tinggi

5. Resiko penyakit jantung koroner

6. Kualitas hidup & kemampuan kerja

P l h b i d Di b



93

1.Konsultasi dengan dokter atau edukator (pra latihan)

2. Persiapan latihan jasmani

3. Pengawasan selama latihan dengan memonitor:a. Denyut nadi

b. Keluhan seperti: pusing, gemetaran, lemas, sesak, dll

4. Gunakan sepatu olahraga yang sesuai :

Perencanaan olahraga bagi penyandang Diabetes

Bahaya/risiko olahraga pada penyandang Diabetes



94

1. Memperburuk kadar glukosa darah

2. Hipoglikemia akibat olahraga

3. Gangguan pada kaki

4. Komplikasi jantung & pembuluh darah

5. Cedera otot dan tulang

Bahaya/risiko olahraga pada penyandang Diabetes



95

3. Obat-obatan oral & Insulin

Intervensi obat-obat untuk mengurangi



96

Setiap penurunan 1% HBA1C Mengurangi kejadian*

1%

Kematian karena diabetes

Serangan jantung

Komplikasi mikrovaskular

(mata, ginjal, saraf)

Penyakit pembuluh darah tepi

(Luka di kaki)

*p<0.0001

Intervensi obat obat untuk mengurangi

Komplikasi akibat diabetes

UKPDS 35 BMJ 2000;321:405-412

Ob b l ( k )

Obat-obat Oral dan Insulin



97

Obat-obat oral (makan)

Metformin Glimepiride

Acarbose

(Glucobay)

Repaglinide Rosiglitazone




98

• Obat -obat oral diperlukan bila sasaran gula darah belumtercapai dengan pengaturan makan & latihan

jasmani.

• Penyandang Diabetes yang harus selalu minum obat

agar kadar glukosa darahnya terkendali. Untuk

penyandang Diabetes seperti ini, tentu sepanjang hidupnya harus selalu

memerlukan obat.

• Pemakaian Obat Oral jangka panjang dapat mengendalikan kadar

glukosa darah sehingga bermanfaat mencegah

komplikasi Diabetes termasuk kerusakan ginjal.

Obat-obat oral (makan)

InsulinObat-obat Oral dan Insulin



100

Cara pemberian insulin dapat dilakukan dengan menggunakan:

• Semprit dan jarum

• Pen insulin

• Pompa insulin

Insulin

Indikasi penggunaan insulinObat-obat Oral dan Insulin



103

Keadaan lain yang memerlukan terapi insulin adalah:

1. Penurunan berat badan yang cepat

2. Hiperglikemia berat disertai ketosis3. Ketoasidosis diabetik

4. Hiperglikemia hiperosmolar non ketotik

5. Hiperglikemia dengan asidosis laktat

6. Stres berat (infeksi sistemik, operasi besar, stroke, serangan jantung)

7. Kehamilan dengan DM (DM gestasional) yang tidak terkendali

dengan perencanaan makan.

8. Gangguan fungsi ginjal atau hati yang berat

9. Adanya kontraindikasi dan atau alergi terhadap OHO

Terapi DiabetesObat-obat Oral dan Insulin



104

Terapi Diabetes

1 2

3 4

5 +

+ +

KONSERVATIF ( LAMA)

Cara konservatif :



Bertindak Setelah Gagal

7

6

9

8

HbA1c

(%)10

Merubah Gaya

Hidup

Kemajuan pasien Diabetes

Minum

Obat

satu

Menaikan

Dosis

Obat

Kombinasi

Obat

Minum Obat

+ Single InsulinMinum Obat

+ Multiple Insulin

KerusakanPancreas

/Komplikasi

Regrets …… and



New Solution

Mengurangi

kwalitas hidupBlindness, Amputation,

Neuropathic Pain

Kita telah mengabaikan

Dalam waktu lamaHyperglycemia

Kita Telah Gagal

Memelihara /

memperbaikifungsi

Beta-cell

DeathHeart Attack

Stroke

Intensive Insulin Therapy

Pengobatan dng IntensiveInsulin



Pengobatan dng Insulin adala

Cara pengobatan yang palingEffective utk menurunkan

Kadar Gula Darah

Dengan Obat Oral banyakPasien gagal mencapai

normoglycemia.

Se Dini anda mulai dengan

Pengobatan intensive

Fungsi beta cell masih bisa

Dipertahankan dan Anda dapat

Hidup sehat tanpa minum Obat

Segera BertindakCapailah normoglycemia

HbA1c < 6.5%

Pakailah Cara terbaik

Insulin

Jangan Menunggu sampai

Mengalami hyperglycemia

Atau komplikasi

Setelah pengobatan Oral

Yg lama Secara bertahap

Tidak berhasil

Fungsi beta-cell

Tidak dapat dikembalikan.

Proactive

Insulin

SecepatMungkin

Kriteria Pengendalian DM




108

Kriteria Pengendalian DM

Baik Sedang Buruk

Gula darah puasa (mg/dL) 80 - 99 100 - 125 ≥ 126

Gula darah 2 jam (mg/dL) 80 -144 145 - 179 ≥ 180

A1c (%) < 6,5 6,5 - 8 > 8

Kolesterol total (mg/dL) < 200 200 - 239 ≥ 240

Kolesterol LDL (mg/dL) < 100 100 - 129 ≥ 130

Kolesterol HDL (mg/dL) > 40 (Pria)

> 50 (wanita)

Trigliserida (mg/dL) < 150 150 - 199 ≥ 200

IMT (kg/m2) 18,5 - <23 23 - 25 >25

Tekanan darah (mmHg) ≤ 130/80 > 130-140/

> 80-90

> 140/90

Upaya Mempertahankan Target Terapi pada DM Tipe-2 (Perkeni,2006)



A1C (%)

Saat Ini

GDP

(mg/dL)

saat ini

T

E

RU

S

K

A

N

P

E

R

U

BA

H

A

N

G

A

YA

H

ID

U

P

Terapi Saat Ini Tindak Selanjutnya Terapi diiteruskan

(2-3 bulan)

6-6.5

6.5-8.5

> 8.5

110

200

> 300

Terapi tunggal

atau

terapi kombinasi

• Terapi diteruskan bila tercapai target terapi

• Penyesuaian terapi bila diperlukan untuk

mencapai target GDP dan 2 jam PP

Diawasi dan dilakukan

penyesuaian Rx untuk

mencapai target

Terapi Tunggal

Meglitinide, SU, AGI

Metformin, TZD

Insulin analog pre-mixed

Insulin analog kerja cepat

atau insulin basal

Dimulai terapi kombinasi

• Metformin + SU atau Meglitinide

• Metformin, + TZD atau AGI

• TZD + SU

• Increatin mimetic + metformin dan/atau SU

• Basal atau insulin analog pre-mixed

• Kombinasi lain



mencapai target

Terapi Kombinasi

Meglitinide, SU, AGI

Metformin, TZD

Insulin analog pre-mixed

Insulin analog kerja cepat

atau insulin basal

Terapi kombinasi maksimal

Terapi insulin maksimal

• Bila GDP meningkat tambahkan insulin basal

• Bila GDPP meningkat tambahkan bolus

• Bila GDP dan GDPP meningkat, tambahkan

terapi basal-bolus atau insulin analog pre-

mixed



mencapai target

Terapi tunggal

atauterapi kombinasi

Dimulai terapi insulin (Basal-Bolus)

• Insulin kerja panjang ditambah kerja cepat• Insulin analog pre-mixed


penyesuaian Rx untukmencapai target

• Insulin analog kerja cepat dapat ditambahkan pada setiap

bentuk terapi pada setiap saat untuk menurunkan GDPP

• Insulin basal ditujukan untuk menurunkan GDP

Target terapi

A1C < 6.5%

GDP < 110 mg/dL

GDPP < 140 mg/dL

Misconceptions in Indonesia



Misconceptions in Indonesia

• Insulin menyebabkanketergantungan

• Insulin untuk DM yang berat;

• Insulin merusak ginjal

• Insulin dapat mematikan• Terapi Undur-undur

• Jalan tanpa alas kakimenyehatkan

Strategi agar setara dengan orang



g g g g

normal

1) Menemukan pasien DM sedini mungkin

2) Pemantauan metabolik teratur

3) Optimalisasi & Intensifikasi pengobatan

4) Memulai terapi Insulin tepat waktu

5) Treat to target untuk semua kelainan

metabolik

Pranoto, 2009

In 2007, the world will spend an estimated

215-375 billion USD to care for diabetes

and its complications (WDF)

TANTANGAN DI INDONESIA



• Fasilitas pelayanan DM di Pelayanan

Primer

• Pelayanan di RS sebagai pusat rujukan

• Misconception pasien DM

• Peningkatan jumlah DM

• Biaya pengobatan DM yang tinggi

• Meningkatkan kemampuan tenaga Medis

THANK YOU



Joslin 75-Year

Medalists Spencer

Wallace Joslin 50-Year

Medalists C. Lynn

Wickwire (left) and

Sandy Asherman Joslin 75-Year

Medalists Robert

L. Bates

THANK YOU



Selalulah tersenyum

dan bahagia

Documents

Currents Issues and Challenges in Chronic Disease Control 2012