DHIANCINANTYAN WINDYDACA B. P., S.Farm., M.Farm.

, Apt

TERAPI FARMAKOLOGI DIABETES

MELLITUS
Main Pathophysiological Defects in T2DM
pancreatic
incretin insulin
effect secretion
pancreatic
glucagon

gut
- secretion ?
carbohydrate
delivery &
absorption HYPERGLYCEMIA

-
+
peripheral
hepatic glucose
glucose uptake
production Adapted from: Inzucchi SE, Sherwin RS in: Cecil Medicine 2011
MANAGEMENT NON-FARMAKLOGI
 PERUBAHAN DI LIFESTYLE, MELIPUTI:

 WEIGHT OPTIMIZATION

 HEALTHY DIET

 INCREASED PHYSICAL ACTIVITY

 MANAGEMENT NON-FARMAKLOGI
 POLA MAKAN/HEALTHY DIET DIABETES,
MELIPUTI:
 JUMLAH MAKANAN
 MANAGEMENT NON-FARMAKLOGI
 POLA MAKAN/HEALTHY DIET DIABETES,
MELIPUTI :
 JADWAL MAKANAN
 MANAGEMENT NON-FARMAKLOGI
 POLA MAKAN/HEALTHY DIET DIABETES,
MELIPUTI :
 JENIS MAKANAN
 MANAGEMENT FARMAKOLOGI
 Pharmacologic therapy is mandatory for patients who
are unable to achieve glycemic control with lifestyle
modifications or who have significant symptoms at the
time of diagnosis.
 Implementation strategies:
- Initial therapy
- Advancing to dual combination therapy
- Advancing to triple combination therapy
- Transitions to & titrations of insulin
TREATMENT ON DIABETES
TREATMENT ON DIABETES
TREATMENT ON DIABETES
TARGET TREATMENT DM
 TREATMENT DIABETES MELLITUS
 SULFONILUREA
 OBAT ORAL ANTI DIABETES PERTAMA KALI YANG
DIGUNAKAN SEJAK TAHUN 1950.
 MEKANISME KERJANYA MENINGKATKAN SEKRESI
INSULIN DARI SEL BETA PANCREAS.
 EFEK SAMPING:
 HIPOGLIKEMIA
 BB MENINGKAT
 PENURUNAN KADAR GULA MENCAPAI 60-70 mg/dl
DAN KADAR HbA1C 1,5- 2 %
 TREATMENT DIABETES MELLITUS
 SULFONILUREA
 First generation : chlorpropamide
 Second generation : glibenclamide, glipizide,
gliclazide
 Third generation : glimepiride
 TREATMENT DIABETES MELLITUS
 MECHANISM OF ACTION SULFONILUREA
 TREATMENT DIABETES MELLITUS
 INSULIN SECRETOGOGUS
 MEKANISME KERJANYA MENINGKATKAN SEKRESI
INSULIN DI SEL BETA PANCREAS
 DAYA KERJANYA PENDEK (QUICK ON- QUICK OFF)
 PENURUNAN KADAR GULA DARAH 60-70 mg/dl DAN
KADAR HbA1C 1,7-1,9%
 EFEK SAMPING:
 HYPOGLIKEMIA
 BB MENINGKAT
 TREATMENT DIABETES MELLITUS
 MECHANISM OF ACTION REPAGLINIDE
 TREATMENT DIABETES MELLITUS
 MECHANISM OF ACTION NATEGLINID
 TREATMENT DIABETES MELLITUS
 BIGUANIDES
 MEKANISME KERJANNYA MEMPERBAIKI
SENSITIVITAS INSULIN DI PERIFER SERTA
MENURUNKAN GLUKONEOGENESIS DI HATI
 EFEK SAMPING:
 GANGGUAN SALURAN CERNA
 ASIDOSIS LAKTAT
 DEFISIENSI B-12
 PENURUNAN KADAR HbA1C 1,5 %
 KEUNTUNGAN:
 BB MENURUN
 TIDAK MENYEBABKAN HIPOGLIKEMIA
 TREATMENT DIABETES MELLITUS
 MECHANISM OF ACTION BIGUANIDE
 TREATMENT DIABETES MELLITUS
 BIGUANIDES
 TREATMENT DIABETES MELLITUS
 THIAZOLIDINDION
 MEKANISME KERJANNYA MENINGKATKAN
SENSITIVITAS JARINGAN TERHADAP INSULIN
MELALUI AKTIVASI RESEPTOR INTRASELULAR,
MENURUKAN PROSES GLUCONEOGENESIS
DENGAN MENGAKTIVASI PPAR-GAMMA
 PENURUNAN KADAR HbA1C 1-1,5 %
 EFEK SAMPING:
 BB MENINGKAT
 HEART FAILURE
 HEPATIC INJURY
 KERUSAKAN PADA TULANG
 LDL MENINGKAT
 TREATMENT DIABETES MELLITUS
 MECHANISM OF ACTION THIAZOLIDINDION
 TREATMENT DIABETES MELLITUS
 ALPHA GLYCOSIDASE INHIBITORS
 MEKANISME KERJANNYA MENGHAMBAT LAJU
ABSORPSI KARBOHIDRAT DI USUS.
 EFEK SAMPING:
 FLATULENSI
 KRAM
 PENURUNAN KADAR GULA DARAH PUASA 20-30
mg/dl, GULA 2 JAM PP 40-60 mg/dl DAN KADAR
HbA1C 0,5-1 %
 TREATMENT DIABETES MELLITUS
 MECHANISM OF ACTION ALPHA INHIBITORS
 TREATMENT DIABETES MELLITUS
 GLP 1
 MEKANISME KERJANYA MENSTIMULASI SEKRESI
INSULIN, MENURUKAN PRODUKSI GLUKOSA,
MEMPERLAMBAT KEKOSONGAN LAMBUNG.
 EFEK SAMPING:
 MUAL
 MUNTAH
 DIARE
 NYERI PERUT
 PENURUNAN KADAR HbA1C 0.8-1,0%
 TREATMENT DIABETES MELLITUS
 MECHANISM OF ACTION GLP 1
 TREATMENT DIABETES MELLITUS
 MECHANISM OF ACTION GLP 1
 TREATMENT DIABETES MELLITUS
 DPP-4 INHIBITOR
 MEKANISME KERJANYA MEMPERLAMBAT T1/2 GLP-
1 ENDOGEN, SEHINGGA PELEPASAN INSULIN
MENINGKAT
 EFEK SAMPING:
 NASOPHARINGITIS
 ISK
 SAKIT KEPALA
 PENURUNAN KADAR HbA1C 0,5 – 0,7 %
 TREATMENT DIABETES MELLITUS
 MECHANISM OF ACTION DPP-4 INHIBITOR
 TREATMENT DIABETES MELLITUS
 MECHANISM OF ACTION DPP-4 INHIBITOR
 TREATMENT DIABETES MELLITUS

 INSULIN
 MEKANISME KERJANYA MENURUNKAN
KONSENTRASI GLUKOSA DARAH DENGAN CARA
MENINGKATKAN AMBILAN GLUKOSA KE DALAM
JARINGAN
 EFEK SAMPING:
 HYPOGLICEMIA
 BB MENINGKAT
 TREATMENT DIABETES MELLITUS
 Indication for the use of insulin:
• In severe metabolic decompensation
• Ketoacidosis
• Hyperosmolar non ketotic coma
• Lactic acidosis
• Severe stress :
Systemic infection
Major surgery
• Weight loss within a short period of time
• Pregnancy if diet does not succeed to control glycemia
• OHA failure or contra-indication of OHA
 TREATMENT DIABETES MELLITUS
 MECHANISM OF ACTION INSULIN
TREATMENT DIABETES MELLITUS
 MULA KERJA DAN MASA KERJA INSULIN
 TREATMENT DIABETES MELLITUS
 GRAFIK WAKTU KERJA INSULIN
 TREATMENT DIABETES MELLITUS
 INSULIN
• PILIHAN TERAPI INSULIN:
 Neutral protamineHagedorn (NPH)

 Regular

 Basal analogues (glargine, detemir)

 Rapid analogues (lispro, aspart, glulisine)

 Pre-mixed varieties
KOMPLIKASI DIABETES
MACROVASCULAR MICROVASCULAR

PENYAKIT
JANTUNG NEUROPATHY
KORONER

PENYAKIT
PEMBULUH RETINOPATHY
DARAH PERIFER

PENYAKIT
PEMBULUH NEPHROPATHY
DARAH OTAK
KOMPLIKASI AKUT DIABETES

DIABETES HYPEROSMOLAR
KETOACIDOSIS HYPERGLYCEMIA