PENATALAKSANAAN TINDAKAN KEDOKTERAN GIGI PADA PASIEN
DIABETES MELLITUS
Luthfan Budi PurnomoPERKENI Cabang Jogjakarta
Seminar “AtoZ Tindakan Pencabutan Gigi pada Pasien Medik Compromis (2014)
Diabetes is associated with increased requirement for surgical procedures and increased post-operative morbidity and mortality
The stress response to surgery and resultant hyperglycemia, osmotic diuresis, and hypoinsulinemia can lead to peri-operative ketoacidosis or hyperosmolar syndrome
Introduction
Hyperglycemia impairs leukocyte function and wound healing
The management goal is to optimize metabolic control through close monitoring, adequate fluid and caloric repletion, and judicious use of insulin
Introduction
Type 2 Diabetes Is NOT a Mild Disease
DiabeticRetinopathyLeading causeof blindnessin working ageadults1
DiabeticNephropathyLeading cause of end-stage renal disease2
CardiovascularDisease
Stroke2 to 4 fold increase in cardiovascular mortality and stroke3
DiabeticNeuropathy
Leading cause of non-traumatic lower extremity amputations5
8/10 diabetic patients die from CV events4
1 Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 2Molitch ME, et al. Diabetes Care 2003; 26 (Suppl. 1):S94–S98.
3 Kannel WB, et al. Am Heart J 1990; 120:672–676. 4Gray RP & Yudkin JS. In Textbook of Diabetes 1997.5Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
Microvascular complication
Macrovascular complication
DIABETES IS NOT MILD DISEASE
Increasing DM Prevalence in Indonesia
1985 2007
WHO, Study Group 1985RISKESDAS, 2007
5.7%
1.7%
NATIONAL
Prevalence of DM in Indonesia
1.7%Papua
11.1%Maluku Utara
RISKESDAS, 2007
National
6.2%Lampung
5.7%
KADAR GLUKOSA DARAHDIATUR DAN DIKENDALIKANDALAM RENTANG YANG SEMPIT
Puasa: 80 - <100 mg/dl
2jPP/sesaat: 80 - <140 mg/dl
Hormon Pengendali Homeostasis Bahan Bakar
Insulin
Counter-insulin hormone -glucagon -cathecolamine -growth hormone -glucocorticoids
INSULIN GLUCAGONCATECHOLAMINEGLUCOCORTICOIDGROWTH HORMONE
BLOOD GLUCOSE
BLOOD GLUCOSE
BreakfastLunch
Dinner
Day timeBed time
Fasting blood glucose
Fasting hyperglycemia
Post prandial hyperglycemia
A round the clock hyperglycemia
Fasting
Blood glucose at bed time+
Gluconeogenesis
Pancreatic Islet Cells Dysfunction Leads to Hyperglycemia in T2DM
↑ Glucose
Fewer -Cells
-Cellshypertrophy
Insufficient insulin
Excessive glucagon
–+
↓ Glucose uptake
↑ HGO
+
HGO=hepatic glucose outputAdapted from Ohneda A, et al. J Clin Endocrinol Metab. 1978; 46: 504–510; Gomis R, et al. Diabetes Res Clin Pract. 1989; 6: 191–198.
Kriteria diagnosis diabetes
1. A1c ≥6,5% atau2. Glukosa plasma puasa ≥126 mg/dl atau3. 2-jam setelah TTGO ≥200 mg/dl4. Ada tanda khas DM, glukosa plasma sesaat ≥200 mg/dl
Klasifikasi
Tipe 1 Destruksi sel beta , umumnya menjurus defisiensi insulin absolut•Automun•Idiopatik
Tipe 2 Bervariasi, dominan resistensi insulin disertai defisiensi insulin relatif sampai dominan defek sekresi insulin disertai resistensi insulin
Tipe lain Defek genetik fungsi sel beta; defek genetik kerja insulin; penyakit eksokrin pankreas; endokrinopati; infeksi
Diabetes mellitus gestasional
DIABETIC COMPLICATIONS
Acute
HypoglycemiaDiabetic Ketoacidosis (DKA)Hyperglycemic Hyperosmolar State(HHS)
Chronic
Macrovascular CAD Stroke PADMicrovascular Retinopathy Nephropathy NeuropathyCardiomyopathyDiabetic foot
Slide 17
Updated PERKENI Type 2 Diabetes Treatment Algorithm
Diabetes STEP 1 STEP 2 STEP 3
Healthy life style Healthy life style
+
Mono therapyHealthy life style
+
2 OAD CombinationHealthy life style
+
Combination 2 OAD
+
Basal insulin
Insulin Intensification*
*Intensive Insulin: use of basal insulin together with insulin prandial
Healthy life style
+
3 OAD Combination
Alternative option, if :
• No insulin is available
• The patient is objecting insulin
• Blood glucose is still not optimally controlled
Note:
1. Therapy failed if target of HbA1c < 7% is not achieved within 2-3 months for each step
2. In case of no HbA1c test, the use of blood glucose level is also permitted. Average blood glucose level for a few BG test in one day can be converted to HbA1c (ref: ADA 2010)
Slide 18
OAD’s – a quick summary of the different mechanism of actions
-Glucosidase inhibitorsDelay intestinal carbohydrate absorption
ThiazolidinedionesIncrease glucose uptake in skeletal muscle and decrease lipolysis in adipose tissue
SulfonylureasIncrease insulin secretion from pancreatic -cells
GLP = glucagon-like peptide.Adapted from Cheng and Fantus. CMAJ. 2005;172:213–226.
MeglitinidesIncrease insulin secretion from pancreatic -cells
Biguanide (metformin)Decreases hepatic glucose production and increases uptake
Incretins :GLP-1 analogue(exen- atide)/DPP-4 inhibitors Improves glucose-dependent insulin secretion from pancreatic β-cells, suppresses glucagon secretion from -cells, slows gastric emptying
Incretins :GLP-1 analogue(exen- atide)/DPP-4 inhibitors Improves glucose-dependent insulin secretion from pancreatic β-cells, suppresses glucagon secretion from -cells, slows gastric emptying
Oral Diabetes Drugs in Indonesia
Class Generic Mg/tabDaily dose (mg)
Duration of action
(hr)
Freq/day
TimeA1C
reductionFBG vs.
PPG
Sulfonylureas
Glibinclamide 2.5-5 2.5-15 12-24 1-2 Before meals
1.5 FBG
Glipizid 5-10 5-20 12-16 1
Gliklazid 30,60,80 30-320
24 1-2
Glikuidon 30 30-120
6-8 2-3
Glimepiride 1,2,3,4 0.5-6 24 1
Glinid
Repaglinid 1 1.5-6 3 1-1.5 Both
Nateglinid 120 360 3 0.5-0.8 PPG
TZD
Pioglitazone 15-30 15-45 18-24 1 Indep of meals
0.5-1.4 FBG
α-glucosidase inhibitor
Acarbose 50-100 100-300
3 With 1st food
0.5-0.8 PPG
PERKENI Guidelines 2012
Oral Diabetes Drugs in IndonesiaClass Generic Mg/tab
Daily dose (mg)
Duration of action
(hr)
Freq/day
TimeA1C
reduction
FBG vs. PPG
Biguanides
Metformin 500-850 500-3000 6-8 1-3 With or after meals
1.5 FBG
Metformin XR 500-750 500-2000 24 1
DPP-IV inhibitors
Vildagliptin 50 50-100 12-24 1-2 Indep of meals
0.6-0.8 Both
Sitagliptin 25,50,100
25-100 24 1
Saxagliptin 5 5 24 1
Fixed dose combination drug
Metformin+ Glibenclamide
25-500/1.25-5
Glib max 20 mg/day
12-24 1-2 With or after meals
Glimepiride + metformin
1-2/250-500
2-4/500-1000
2
Pioglitazone+ metformin
15-30/500-850
Piog max 45 mg/day
18-24 1
Sitagliptin + metformin
50/500-1000
Sita max 100 mg/day
1
Vildagliptin + metformin
50/500-1000
Vilda max 100 mg/day
12-24 2
PERKENI Guidelines 2012
Insulin in Indonesia
PERKENI Consensus Guidelines, 2011.
Type of Insulin Onset of Action
Peak of Action
Duration of Action Presentation
Insulin Prandial (Meal-Related)
Insulin Short-Acting
Regular (Actrapid®, Humulin® R) 30-60 min 120-180 min 5-8 hourVial,
Pen/Cartridge
Insulin Analog Rapid-Acting
Insulin Lispro (Humalog®) 5-15 min 30-90 min 3-5 hour Pen/Cartridge
Insulin Glulisine (Apidra®) 5-15 min 30-90 min 3-5 hour Pen
Insulin Aspart (Novorapid®) 5-15 min 30-90 min 3-5 hour Pen, Vial
Insulin in Indonesia (Cont’d)
Type of Insulin Onset of Action
Peak of Action
Duration of Action Presentation
Insulin Intermediate-Acting
NPH (Insulatard®, Humulin® N) 2-4 hour 4-10 hour 10-16 hour Vial, Pen/Cartridge
Insulin Long-Acting
Insulin Glargine (Lantus®) 2-4 hour No Peak 20-24 hour Pen
Insulin Detemir (Levemir®) 2-4 hour No Peak 16-24 hour Pen
Insulin Campuran
70% NPH 30% Regular(Mixtard®, Humulin® 30/70)
30-60 min Dual 10-16 hour Pen/Cartridge
70% Insulin Aspart Protamin 30% Insulin Aspart (Novomix® 30)
10-20 min Dual 15-18 hour Pen
75% Insulin Lispro Protamin25% Insulin Lispro (HumalogMix® 25)
5-15 min Dual 16-18 hour Pen/Cartridge
PERKENI Consensus Guidelines, 2011.
The responses include Release of catabolic hormones Inhibition of insulin secretion and action Anti-insulin effects of surgical stress Insulin resistance induced by circulating stress hormones Effect of surgical stress on pancreatic β cell function
Stress Response and Glucose Regulation
(Dagogo-Jack & Alberti, 2002;;Marks, 2003; Dhatariya et al., 2011)
The Peri-operative Milieu Hypercatabolism
Poor peri-operative glycaemic control Complications of diabetes: ► Cardiovascular disease ► Microvascular disease
Diabetes Related Patients factors Associated with Worse Outcome
Dhatariya et al., 2011
Cardiovascular autonomic function tests
Blood pressure test Blood pressure response to standing up
(fall in systolic blood pressure): 10 mmHg (normal), 11-29 mmHg (borderline), ≥30 mmHg (abnormal)
Blood pressure response to sustained handgrip (increase in diastolic blood pressure): ≥16 mmHg (normal), 11-15 mmHg (borderline), 10 mmHg (abnormal)
Comprehensive Care Pathway
Primary carereferral
Surgicaloutpatient
Preoperativeassessment
Hospital admission
Theatre andrecovery
Post-operativecare
Discharge
(Dhatariya et al., 2011)
Comprehensive Care Pathway
Primary carereferral
Surgicaloutpatient
Preoperativeassessment
Hospital admission
Theatre andrecovery
Post-operativecare
Discharge
(Dhatariya et al., 2011)
Ensure that potential effects of diabetes and associatedco-morbidities on the outcome of surgery are consideredEnsure that diabetes and co-morbidities are optimallymanaged
A1c <8.5% Blood glucose levels 108-180 mg/dl
(Dhatariya et al., 2011)
Peri-operative glycaemic control
Comprehensive Care PathwayPrimary carereferral
Surgicaloutpatient
Preoperativeassessment
Hospital admission
Theatre andrecovery
Post-operativecare
Discharge
(Dhatariya et al., 2011)
Arrange pre-operative assessmentAvoid overnight pre-operative admission tohospital whenever possible
Comprehensive Care PathwayPrimary carereferral
Surgicaloutpatient
Preoperativeassessment
Hospital admission
Theatre andrecovery
Post-operativecare
Discharge
(Dhatariya et al., 2011)
Ensure that glycaemic control optimized prior tosurgeryEnsure that co-morbidities are recognized andoptimized prior to admission
Comprehensive Care PathwayPrimary carereferral
Surgicaloutpatient
Preoperativeassessment
Hospital admission
Theatre andrecovery
Post-operativecare
Discharge
(Dhatariya et al., 2011)
Minimize the metabolic consequences ofstarvation and surgical stressMaintain optimal blood glucose control throughoutthe admissionPrevent hospital acquired foot pathology
Comprehensive Care PathwayPrimary carereferral
Surgicaloutpatient
Preoperativeassessment
Hospital admission
Theatre andrecovery
Post-operativecare
Discharge
(Dhatariya et al., 2011)
Avoid unnecessary use of VRIII (insulin infusion)Check the blood glucose prior to induction ofanesthesiaMonitor the blood glucose regularlyMaintain the blood glucose in the range 108-180mg/dl
Comprehensive Care PathwayPrimary carereferral
Surgicaloutpatient
Preoperativeassessment
Hospital admission
Theatre andrecovery
Post-operativecare
Discharge
(Dhatariya et al., 2011)
Ensure glycaemic control, fluid and electrolyte balanceare maintainedOptimize pain controlEncourage an early return to normal eating and drinking,facilitating return to the usual diabetes regimen
Comprehensive Care PathwayPrimary carereferral
Surgicaloutpatient
Preoperativeassessment
Hospital admission
Theatre andrecovery
Post-operativecare
Discharge
(Dhatariya et al., 2011)
Ensure early dischargeEnsure that factors likely to delay discharge areidentified at the pre-operative assessment
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