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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