Achmad Rudijanto

Divisi Endokrin MetabolikDepartemen Ilmu Penyakit Dalam

Fakultas Kedokteran Universitas BrawijayaRSUD dr. Saiful Anwar Malang

2010

2

Diabetes is an increasing healthcare epidemic throughout the world

Global projections for the number of people with diabetes (20–79 age group), 2007–2025 (millions)

AfricaEastern Mediterraneanand Middle EastEurope

North America

South and Central America

South-East Asia

Western Pacific

28.340.5+43%

16.232.7+102%

10.418.7+80%

24.544.5+81%

53.264.1+21%

67.099.4+48%

46.580.3+73%

IDF. Diabetes Atlas 3rd Edition – 2006

Worldwide:246 million people in 2007380 million projected for 202555% increase

RiskesdasRiskesdas, 2008:, 2008:-- Prevalence 5.7%Prevalence 5.7%-- Pre DM Pre DM 11.0% 11.0%

PrediabetesPrediabetes

Pasien terdiagnosisDM

Pasien terdiagnosisDM

Pasien DM belumterdiagnosis

Pasien DM belumterdiagnosis

RISDKESDAS, 2007

Diagnosed DM = 1,5%Undiagnosed DM = 4,2%

Total DM = 5,7%GTG = 10,2 %

RISDKESDAS, 2007

Diagnosed DM = 1,5%Undiagnosed DM = 4,2%

Total DM = 5,7%GTG = 10,2 %

List of countries with the highest numbers of estimated cases of diabetes for 2000 and 2030List of countries with the highest numbers of estimated cases of diabetes for 2000 and 2030

2000 2030

Ranking Country

People withDiabetes(millions) Country

People withDiabetes(millions)

1 India 31.7 India 79.4

2 China 20.8 China 42.3

3 U.S. 17.7 U.S. 30.3

4 Indonesia 8.4 Indonesia 21.3

5 Japan 6.8 Pakistan 13.9

6 Asian 5.2 Brazil 11.3

7 Russian Federation 4.6 Bangladesh 11.1

8 Brazil 4.6 Japan 8.9

9 Italy 4.3 Philippines 7.8

10 Bangladesh 3.2 Egypt 6.7

Sarah Wild. Diabetes Care 27, 2004

KriteriaKriteria Diagnosis Diagnosis HiperglikemiHiperglikemi

TIPE 2 DIABETES PADA SAAT DIAGNOSISTIPE 2 DIABETES PADA SAAT DIAGNOSIS

20% 20% RETINOPATIRETINOPATI

9% NEUROPATI

UP TO 50% PENYAKIT

JANTUNG / PEMB. DARAH

8% NEFROPATI

Wild S. Diabetes Care 29, 2006

TakTerdiagnosis

tipe 2 diabetes ~

7 juta

Teriagnosedtipe2 2 diabetes

~ 23 juta

GTG ~ 70 juta

TH2030

KOMPLIKASI AKUT HIPERGLKEMIA

Diabetic KetoacidosisHyperglycemic Hyperosmoler State

HIPOGLIKEMIA

KOMPLIKASI KRONIK Kaki DMGagal ginjaldll

KOMPLIKASI AKUT HIPERGLKEMIA

Diabetic KetoacidosisHyperglycemic Hyperosmoler State

HIPOGLIKEMIA

KOMPLIKASI KRONIK Kaki DMGagal ginjaldll

PROBLEMA KAKI DIABETES

Setiap 30 detik, terdapat kehilangan satu kaki akibat diabetes diseluruh dunia.70% amputasi kaki diseluruh dunia disebabkanoleh diabetes.Sebagian besar amputasi dimulai oleh adanyaulkus kaki.Berita baik: sekitar 85% amputasi akibat ulkusdiabetes dapat dicegah.

Patomekanisme kaki diabetes

Kelainan pembuluh darah

Kerusakan syaraf

PROBLEMA KAKI DIABETES

Risk Factors for UlcerationRisk Factors for Ulceration

General or Systemic Contributions:• Uncontrolled hyperglycemia• Duration of diabetes• Peripheral vascular disease• Blindness or visual loss• Chronic renal disease• Older age

General or Systemic Contributions:• Uncontrolled hyperglycemia• Duration of diabetes• Peripheral vascular disease• Blindness or visual loss• Chronic renal disease• Older age

Local Issuues:• Peripheral neuropathy• Structural foot deformity• Trauma and improperly fitted shoes• Callus• History of prior ulcer/amputation• Prolonged elevated pressure• Limited joint mobility

Local Issuues:• Peripheral neuropathy• Structural foot deformity• Trauma and improperly fitted shoes• Callus• History of prior ulcer/amputation• Prolonged elevated pressure• Limited joint mobility

HIGHHIGH

MODERATEMODERATE

LOWLOW

ACTIVEACTIVE

DIABETIC FOOT RISK STRATIFICATION AND TRIAGEDIABETIC FOOT RISK STRATIFICATION AND TRIAGEPresence of active ulceration, spreading infection, critical ischemia, gangrene or unexplained hot, red, swollen foot with or without the presence of pain

Previous ulceration or amputation or more than one risk factor present e.g. loss of sensation or sign of peripheral vascular disease with callus or deformity

One risk factor present e.g. loss of sensation or signs of peripheral vascular disease without callus or deformity

No risk factors present e.g. no loss of sensation, no sign of peripheral vascular disease and no other risk factors

Annual screening by a suitably trained Health Care Professional Agreed self management plan. Provide written and verbal education with emergency contact numbers. Appropriate access to podatrist when required

Annual assessment by podatrist. Agreed and tailored management/ treatment plan by podatrist according to patient needs. Provide written and verbal education with emergency contact members

Annual assessment by specialist podatrist. Agreed and tailored management / treatment plan by specialist podatrist according to patient needs. Provide written and verbal education with emergency contact numbers. Referral fro specialist intervention if/when requred

Rapid referral to and management by a member of a Multidisciplinary Foot Team. Agreed and tailored management/treatment plan according to patient needs. Provide written and verbal education with emergency contact number. Referral for specialist intervention when required

ACTIONACTION

ACTIONACTION

ACTIONACTION

ACTIONACTION

Definition Definition

Definition Definition

Definition Definition

Definition Definition

These risk categories relate to the use of the SCI-DC foot risk startification tool

RIS

IKO

AM

PU

TAS

IR

ISIK

O A

MP

UTA

SI

PENCEGAHAN PRIMERPENCEGAHAN PRIMER

Tujuan Utama: mengidentifikasi risikp terjadinya ulkus kaki

Skor Risiko Karakteristik3 •Ada neropati

•Terjadu ulkus sebelumnya•Ada penyakit pembuluh darah tepi

2 •Ada neropati•Tanpa adanya ulkus sebelumnya•Ada deformitas

1 •Ada neropati•Tanpa adany ulkus sebelumnya•Tanpa deformitas

0 •Tanpa neropati•Tanpa adanya ulkus sebelumnay•Tanpa deformitas

ApakahApakah kitakita telahtelah ““benarbenar”” dalamdalammengklasifikasimengklasifikasi risikorisiko terjadinyaterjadinya ulkusulkus kaki kaki diabetes?diabetes?

Apa manfaat pencegahan?

Keuntungan untuk masa mendatang:

• Penurunan terjadinya ulkus kaki sampai 50-70%• Penurunan nagka kejadian amputasi• Penurunan biaya kesehatan dan sosial• Perbaikan kualitas hidup terkait derajat kesehatan

Pencegahan Primer Kaki Diabetic :

dimulai dengan pengobatan DM

PencegahanPencegahan Primer Kaki Diabetic :Primer Kaki Diabetic :

dimulaidimulai dengandengan pengobatanpengobatan DM DM

MenejemenMenejemen DiabetesDiabetes

Kontrol glukosa:• Diet/life style• Latihan• Obat oral/insulin

Penyakitpenyerta:• Dislipidemia• Hipertentsi• Obesita• CHD• Problem Nutrisi

Komplikasipenyerta:• Retinopati• CVD• Nefropati• Neuropati• Infeksi• Komplikasi yg lain

Harrison, 2005

diabetes mellitus treatmentdiabetes mellitus treatment

1. Diet 1. Diet 2. 2. ExcersiceExcersice

4. Drugs / Insulin 4. Drugs / Insulin 3. BW control3. BW control 5. Routine control5. Routine control

BersamaBersamaterasaterasa ringanringan

Pemeriksaan kaki secara berkala

Gunakan alas kaki yang benar

Pemeriksaan pembuluh darah dan syaraf

AnkleAnkle--Brachial Index (ABI)Brachial Index (ABI)

Right ABIHigher right ankle pressureHigher arm pressure

Leftt ABIHigher left ankle pressureHigher arm pressure

- Noncompressible- Normal- Bordeline (equivocal)- Mild-to-moderate peripherral

arterial disease- Severe peripheral arterial

disease

Doppler UltrasonographyDoppler Doppler UltrasonographyUltrasonography

Pencegahan Primer

RIS

IKO

AM

PU

TAS

IR

ISIK

O A

MP

UTA

SI

PENCEGAHAN PRIMERPENCEGAHAN PRIMER

Tujuan Utama: mengidentifikasi risiko terjadinya ulkus kaki

Skor Risiko Karakteristik3 •Ada neropati

•Terjadu ulkus sebelumnya•Ada penyakit pembuluh darah tepi

2 •Ada neropati•Tanpa adanya ulkus sebelumnya•Ada deformitas

1 •Ada neropati•Tanpa adany ulkus sebelumnya•Tanpa deformitas

0 •Tanpa neropati•Tanpa adanya ulkus sebelumnya•Tanpa deformitas

RIS

IKO

AM

PU

TAS

IR

ISIK

O A

MP

UTA

SI

PENCEGAHAN PRIMERPENCEGAHAN PRIMER

Tujuan Utama: mengidentifikasi risiko terjadinya ulkus kaki

Skor Risiko Karakteristik

3•Ada neropati•Terjadu ulkus sebelumnya•Ada penyakit pembuluh darah tepi

2•Ada neropati•Tanpa adanya ulkus sebelumnya•Ada deformitas

1•Ada neropati•Tanpa adany ulkus sebelumnya•Tanpa deformitas

0•Tanpa neropati•Tanpa adanya ulkus sebelumnya•Tanpa deformitas

Bila telah terjadi ulkus, apa yang harusdilakukan?

Pencegahan sekunder: Pemeriksaan harianPencegahanPencegahan sekundersekunder: : PemeriksaanPemeriksaan harianharian

Sol Sol sepatusepatu

Angka kejadian ulang ulkus kaki diabetes

DIABETES DAYDIABETES DAYDIABETES DAY

World Diabetes Day World Diabetes Day 14 November14 November

Indonesian Diabetes Day Indonesian Diabetes Day 12 July12 July

Shift in care approach Shift in care approach Shift in care approach

patients

provider

providerprovider

provider

provider

Patients as provider for himselfPatients as provider for himself

Patient oriented

Provider oriented

Menghadapi hal baruMenyangkal kenyataanTimbul marahTidak siaptidak tahu apa

yang harus dilakukanMerasa tidak amanTakut kehilanganMerasa tidak bergunaPutus asa

Empowering

Did we prepare?

Ringkasan

Prevalensi diabetes semakin tinggiSering disertai komplikasi a.l kaki diabetesKaki diabetes penyebab utama amputasiDimulai dengan timbulnya ulkus85% amputasi dapat dicegahPerhatian dan perawatan harian merupakankunci utama pencegahan

AkuAkuIndo

nesiaIndo

nesia

AkuAkuPER

SADIA

PERSAD

IA

AkuAkubisabisa