Standards of Medical Care

PERKENI 2015
 Standards of Care:
PERKENI and ADA
• PERKENI created “Diabetes Mellitus National Clinical
Practice Guidelines” (2015)

• ADA Standards of Medical Care in Diabetes

composes all current and key clinical
recommendations from the ADA
 PERKENI: Standards of Care

• Diabetes care must be:

– Continuous, not episodic
– Proactive, not reactive
– Planned, not sporadic
– Patient centered rather than provider centered
– Population based, as well as individual based
– Team care
 PERKENI: Standards of Care
• Ideal core team members:
– A physician
– A nurse
– A dietician
– at least one of whom is certified diabetes educator

• Other team members will vary according to the patient need,

patient load, organization constraints, resources, clinical setting and
professional skills
– e.g.: podiatrist, pharmacist, psychological or social workers

Mensing C. Diabetes Care 2000:23:682-9.

 PERKENI: Screening
• Screening is conducted on those who have
diabetes risks, but do not show any symptoms
of DM.

• Screening seeks to capture undiagnosed DM

or prediabetes so it can be managed earlier
and more appropriately.

• Mass screening is not recommended considering

the costs, which are generally not followed by
action plan for those who were found abnormal.
 Prevention/
Delay of T2DM
 PERKENI: Diabetes Prevention
Early Detection
High-risk population at
>30-year old
• Family history of DM
• Cardiovascular disorder
• Overweight
• Sedentary life style
• Known IFG or IGT
• Hypertension
• Elevated triglyceride, low
HDL or both
• History of Gestational DM
• History of given birth
> 4000g
• PCOS
• 2-hour OGTT is the most
sensitive method for early
detection and a
recommended screening test
procedure
Management
Periodic Blood Glucose
Pharmacology
Lifestyle Changes & Risk Factor
Therapy Monitoring
• Medical Nutritional • Not yet • Hypertension
Therapy recommended
• Dyslipidemia
• Physical activity
• Physical health
• Weight reduction
• Body weight control
• If overweight,
reduce body weight
by 5-10%
• Physical exercise for
30 minutes,
5 times/week, or
150 minutes/week
 Prevention program

GHS / Obat DM & comorbid

treatment
GHS

Risk
In Health
Factors(+) Diagnosed DM

Complications (+)

Primordial
Primary
Seconder
Tertiary

Prevention programs
Diagnosis
 Screening/Testing
for Diabetes in
Asymptomatic Patients
 PERKENI Guidelines 2015
FBG = Fasting Blood Glucose
Diabetes Symptoms RBG = Random Blood Glucose
IGT = Impaired Glucose Tolerance
IFG = Impaired Fasting Glucose

Diabetes Classic Symptoms (+) Diabetes Classic Symptoms (-)

FBG ≥126 <126 FBG ≥126 100-125 <100

atau atau

RBG >200 <200 RBS >200 140-199 <140

FBG and PPG

FBG >126 <126

atau OGTT 2 hour BG
RBG ≥200 <200

>200 140-199 <140

Diabetes Mellitus
IGT IFG Normal

Evaluation of Nutritional Status Education

Evaluation Diabetic Complications Dietary Planning
Evaluation Dietary Need and Dietary Planning Physical Exercise
Achieving Ideal Body Weight
 PERKENI: Diagnostic
Criteria for Diabetes Mellitus
• Classic symptoms of diabetes + random glucose plasma level
≥ 200 mg/dL. Random glucose plasma level is a test which access glucose
plasma level at a single time without concerning about last meal schedule.
or
• Classical symptoms of diabetes + fasting plasma glucose
≥ 126 mg/dL. Fasting means patients not getting intake calories
for minimum 8 hours.
or
• 2-h plasma glucose at glucose tolerance test ≥ 200 mg/dL. Glucose
tolerance test done by the WHO standard using 75g anhydrous glucose
which solvent in the 100 cc water
or
• HbA1c ≥ 6.5%

PERKENI GUIDELINES 2015-

 PERKENI: Standard Values of Random Blood Glucose
and Fasting Blood Glucose for Screening and Diagnosis
of DM (mg/dL)

Non DM Uncertain DM DM
Random blood Venous plasma <100 100-199 ≥200
glucose level Capillary blood <90 90-199 ≥200
(mg/dL)
Fasting blood Venous plasma <100 100-125 ≥126
glucose level Capillary blood <90 90-99 ≥100
(mg/dL)
Note:
For high-risk groups which show no abnormal results, the test should be done
every year. For those aged > 45 years without other risk factors, screening can
be done every 3 years.

PERKENI GUIDELINES 2015

 HbA1c

• Check at first visit

– Used as tool for diagnosis (≥6.5%)
• Every 3 months later on (at least every 6 months)
– For blood control evaluation

PERKENI GUIDELINES 2015

Diabetes Care
 Target of Treatment
Risk CVD (-) Risk CVD (+)
BMI (kg/m2) 18.5 – <23 18.5 – <23
Blood Glucose
• FPG (mg/dL) <100 <100
• Post Prandial BG (mg/dL) <140 <140-180
A1C (%) <7.0 <7.0
Blood Pressure <130/80 <130/80
Lipid
Total Cholesterol (mg/dL) <200 <200
Triglyceride (mg/dL) <150 <150
HDL Cholesterol (mg/dL) >40 / >50 >40 / >50
LDL Cholesterol (mg/dL) <100 <70

PERKENI GUIDELINES 2015

Strategies for Improving
Diabetes Care
 Diabetes Self-Management

Team Care: Role of Team Members

Physician
To prepare people with
Nurse diabetes to make
Dietitian self-management decisions
on their own
Educator
People with diabetes
are at the center of the
health team and can
learn to
self-manage
their diabetes

Who’s teaching the diabetics? Etzwiler DD. Diabetes 1967:16:111-7.

 PERKENI: Patient Education
• Daily activities
– Be active most of the time
– Be productive
• Self-management skills
– Preparing pills, insulin
– Follow drug schedule
– Side effect awareness
• Foot care
– Daily foot care & appropriate shoes
• Medical checkup
 PERKENI: Patient Education
• Healthy eating:
– healthy food choices, food composition (carbs, protein,
fat, fiber)
• Body weight maintenance:
– achieved target of BMI or reduced 5 – 10% of body
weight
• Exercise
• Monitoring:
– self-monitoring of blood glucose, A1C
• Hypoglycemia: awareness & self-treatment
 Self-Monitoring
of Blood Glucose (SMBG)

SMBG: one tool to assess therapy in diabetic patients that is

recommended especially in:

• Patients that will undergo insulin therapy

• Patients receiving insulin therapy
• Patients with A1C level did not reach the target
• Women planned for pregnancy / pregnant women with
hyperglycemia
• Patients with recurrent hypoglycemia.
 Diabetes Management – DiabCare Asia 2008 –
Type of Management

Diabetes Management Variable n (%)*

Type of Management
• Diet only -
• OAD Insulin monotherapy 1133 (61.88)
• Insulin monotherapy 317 (17.31) 35
• Insulin and OAD combination 356 (19.44)
• Herbal 5 (0.27)
• None 20 (1.09)
*n = 1785

Soewondo P. Med J Indones 2010;19(4):235-244

 Diabetes Management – DiabCare Asia 2008 –
Type of OAD Therapy

Diabetes Management Variable n (%)*

Type of OAD Therapy
• Biguanides 1085 (59.26)
• Sulphonylureas 1036 (56.58)
• Meglinitides 8 (0.44)
• Alpha glucosidase inhibitors 461 (25.18)
• TZDs 51 (2.79)
• Other OADs 48 (2.62)
• Traditional herbal medicines 5 (0.27)
• Double drug fixed dose combination 88 (4.81)

Soewondo P. Med J Indones 2010;19(4):235-244

 PERKENI Guidelines 2015

DM Phase - I Phase - II Phase - III

Lifestyle
Lifestyle
Modification
Modification
+ Lifestyle
Modification
OAD Monotherapy Lifestyle
+ Modification
2 OADs +
Combination
2 OADs
Alternative: Combination
• Insulin not available
• Patient preference
Lifestyle +
• Glucose control not optimal Modification
Basal Insulin
+
3 OADs
Notes: Intensive Insulin
Fail: not achieving A1c target < 7% after 2-3 months of treatment Combination
(A1c = average blood glucose conversion, ADA 2010)
Algoritma Pengelolaan DM Tipe-2 di Indonesia, KONSENSUS PERKENI 2015
HbA1C <7.5%
Monoterapi* dengan salah Kombinasi 2 obat* dengan
satu dibawah ini mekanisme yang berbeda
- Metformin
Metformin atau obat lini pertema yang lain
- Agonis GLP1
- Penghambat
DPP4
- Penghambat
glukosidase alfa
- Penghambat
SGLT2 **
- Tiazolidindion
- Sulfonilurea
- Glinid
Jika HbA1C belum
mencapai <7 dalam
3 bulan, tambahkan
obat ke-2
(kombinasi 2 obat)
MODIFIKASI GAYA HIDUP SEHAT
HbA1C >7.5%
- Agonis GLP1
- Penghambat
DPP4
Metformin atau obat lini pertema yang lain
- Tiazolidindion
- Penghambat
SGLT2 **
- Insulin basal
- SU / Glinid
- Kolesevelam**
- Bromokriptin
QR
- Penghambat
glukosidase alfa
Jika HbA1C belum
mencapai sasaran
dalam 3 bulan,
tambahkan obat ke-3
(kombinasi 3 obat)
HbA1C >9.0%
Gejala (-) Gejala (+)
Kombinasi 2 obat
Insulin ± obat lain
Kombinasi 3 obat Kombinasi 3 obat
- Agonis GLP1
- Penghambat
DPP4
- Tiazolidindion
- Penghambat
2 Obat lini kedua
SGLT2 **
- Insulin basal Mulai intensifikasi insulin
- SU / Glinid
- Kolesevelam**
- Bromokriptin
QR
Keterangan:
- Penghambat
glukosidase alfa * Obat yang terdaftar, pemilihan dan penggunaannya
disarankan mempertimbangkan faktor keuntungan,
kerugian dan ketersediaan sesuai tabel 11.
Jika HbA1C belum mencapai ** Kolesevelam belum tersedia di Indonesia dan
sasaran dalam 3 bulan, mulai Bromokriptin QR umumnya digunakan pada terapi
terapi insulin atau tumor hipofisis
intensifikasi terapi insulin
PERKENI, 2015
Individualized target of therapy
Suggested goals for Glycemic Treatment in Patients with Type-2
Diabetes
Glycated Hemoglobin Range

Most Intensive Level Factors Least Intensive Level

Approximately 6.0% Approximately 8.0%
Highly motivated, Less motivated, non-
adherent, Psychosocial adherent, less
knowledgeable, strong considerations knowledge, weak self-
self-care capability care capability
Adequate Resources or support inadequate
systems
Low Risk of hypoglycemia High
Short Duration of type-2 DM long
Long Life expectancy Short
None Microvascular disease Advances
None Cardiovascular disease Established
None Coexisting conditions Multiple, severe, or both
Ismail-Beigi. N Engl J Med 366:1319, 2012
 Profiles of Antidiabet Medications

METF DPP-4 I GLP1 RA TZD AGI COL BCR SU/glini INSULIN SGLT2 PRAML
SVL OR de
HYPOs Moderate Moderate
to severe to severe
Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral
Mild

Weight Slight loss Neutral Loss Gain Neutral Neutral Neutral Gain Gain Loss Loss

Renal / GU Contra Exenaitide May More More hypo

indicated Neutral ? contra worsen Neutral Neutral Neutral hypoglyc risk & fluid Infection Neutral
grd 3B,4,5 indicate in fluid emia retention
clr crt<30% retention

GI Sx Moderate Neutral Moderate Neutral Moderate Mild Moderate Neutral Neutral Neutral Moderate

CHF Neutral Neutral Neutral Moderate Neutral Neutral Neutral Neutral Neutral Neutral Neutral

CVD Benefit Neutral Neutral Neutral Neutral Neutral Benefit ? Neutral Neutral Neutral

BONE Neutral Neutral neutral Moderate Neutral Neutral Neutral Neutral Neutral Bone Neutral
bone loss loss?

Few adverse events or possible benefits Used with caution Likelihood of adverse events
 Treatment Approach
Other drugs than metformin can be used as initial treatment in some cases
Type-2 Diabetic Patients Lifestyle intervention + 1st initial drug

A1c not at target

Stringent group Less Stringent group

A1c target <7% A1c target ±8%

Existing A1c and A1c Target of Tx

Gap between existing A1c and
target of Tx > 2% Gap between existing A1c and
target of Tx < 2%

insulin Comorbid Drugs

Recurrent HYPOs Metformin / GLP-1RA / DPP4-inh / AGI / TZD

Overweight / Obese GLP-1RA / DPP4-I / Metformin / AGI

Cardiovascular Diseases Metformin / TZD / incretin Tx (?)

Congestive Heart Failure Insulin / Metformin (±) / Incretin Tx

Chronic Kidney Disease Insulin / DPP4-I or AGI (adjust dose)

Liver diseases Insulin, TZD (hepatosteatosis), DPP4-I (?)

 Treatment Targets
• Controlled DM:
– FBG, PBG, HbA1c, Lipid profile, Blood pressure, Nutrition
status
TREATMENT TARGETS
Parameter Targets
IMT (kg/m2) 18,5 - < 23*
Sistolik BP (mmHg) < 140 (B)
Diastolik BP (mmHg) <90 (B)
Preprandial BG – kapiler (mg/dl) 80-130**
1-2 Hours Postprandial BG kapiler (mg/dl) <180**
HbA1c (%) < 7 (individual) (B)
LDL (mg/dl) <100 (<70 high risk CVD) (B)
HDL (mg/dl) Man : >40; Woman: >50 (C)
Trigliseride (mg/dl) <150 (C)
 Hypoglycemia

 Hipoglycemia: blood glucose < 70 mg/dl.

 With or without autonomic symptoms
 Whipple’s triad:
 Terdapat gejala-gejala hipoglikemia
 Kadar glukosa darah yang rendah
 Gejala berkurang dengan pengobatan.
 Hypoglycemia due to SU (long acting) must be observed until
48-72 hours
 Hypoglycemia treatment

Mild hypoglycemia
1. Give simple carbohydrate diit (E)
2. Fat in meal reduce glucose absorption
3. 15–20 g glucose for consiousness patients (E)
4. Check blood glucose after 15 minute, if was not in target
repead oral glucose (E), when on target, ask patient for
taking snack or meal (E).
 Hypoglycemia treatment

Severe Hypoglicemia
1. Sign of neuroglicopenia  D5 or D10 infusion + 100 cc D20
2. Check blood glucose 15 min after D20 bolus, repeat bolus
when blood glucose when target is not achieved
3. Blood glucose measurement 1-2 hourly
4. Identify risk factors of hypoglycemia (E)
 Hypoglycemia prevention
1. Hypoglycemic awareness education
2. SMBG
3. Insulin secretagouge and insulin used (time of consumption,
dose, side effects, monitoring)
4. Hypoglycmic risk factors identification
5. Evaluation of treatment program
6. Change to the less hypoglycemic effect of drugs