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Diabetes: diagnosis dan pengurusan

Oleh Infomedikini

Pada 28/07/2023

Diabetes: Statistik dan trend

Dalam tahun kebelakangan ini, prevalens penyakit diabetes jenis 2 (T2DM) adalah meningkat secara berterusan. Dianggarkan pada 2045 akan ada seramai 693 juta manusia di serata dunia didiagnosa dengan keadaan ini.

T2DM mendedahkan penghidapnya kepada risiko kesihatan yang signifikan, iaitu peningkatan mortaliti sebanyak dua kali ganda berbanding populasi tanpa diabetes dan juga meni ngkatkan beban ke atas ekonomi global.

Diabetes mellitus type 2 (T2DM) is the most common form of diabetes mellitus, accounting for over 90% of all cases of adult-onset diabetes mellitus in Malaysia.

Pathophysiology

T2DM is characterised by progressive decline in beta-cell function associated with insulin resistance in muscle and adipose tissue.

› The insulin resistant state results in increased hepatic glucose output and reduced utilisation of glucose by various organs contributing to fasting hyperglycaemia and between meal hyperglycaemia.
› Impaired intestinal incretin secretion causes compromised meal-related insulin secretion and glucagon suppression contributing to postprandial hyperglycaemia.
› Excessive renal tubular reabsorption of glucose further contributes to hyperglycaemia.

Carta aliran 2

Bagi individu yang tidak mempunyai simptom/gejala diabetes, saringan paras glukosa darah yang diperlukan bagi menentukan sama ada individu berkenaan menghidapi diabetes atau sebaliknya adalah berpandukan carta aliran tanpa simptom.T2DM

Makna singkatan:

VPG - Venous Plasma Glucose iaitu paras glukosa darah dari saluran vena

FPG - Fasting Plasma Glucose iaitu paras glukosa plasma semasa berpuasa

IFG - Impaired Fasting Glucose iaitu terjejasnya glukosa semasa berpuasa

IGT - Impaired Glucose Tolerance iaitu terjejasnya toleransi terhadap glukosa

OGTT - Oral glucose tolerance tests

Risk factor for other diseases

T2DM is an important risk factor for CVD and microvascular complications such as nephropathy, retinopathy and neuropathy. Other non-vascular complications include infective complications.

Aim of diabetes management

The main aim of management is directed at reducing acute and chronic diabetes-related complications by targeting control of plasma glucose, BP, lipids and body weight concurrently.

Remission possible?

Recently, there is evidence that reversal or remission of T2DM may be possible in some individuals with short duration of disease, following reversal of insulin resistance through significant and sustained weight loss by either caloric restriction or bariatric surgery.

Prevalence

In 2019, there were almost 2 million (1,999,450) adult individuals (9.4% prevalence) with known diabetes in Malaysia.

Prevalence of unknown/undiagnosed diabetes in 2019 (elevated fasting plasma glucose of ≥7.0 mmol/L during survey) for adults age ≥18 years were 8.9%:
42% of those with unknown diabetes are between the age of 18-39 years, and 40% are between the age 40-59 years.

Prevalence of overall diabetes among the major ethnic groups: Indians 31.4%; Malays 22.6% dan Chinese 15.1%.

Prevalence of overall diabetes: lowest between ages 18-19 -- 4.3%; highest between ages 65-69 -- 43.4%.

Comorbidities

Prevalence of hypertension was 80.4%
Prevalence of dyslipidaemia was 74.3%
84.0% of individuals with T2DM are either overweight or obese;
Mean BMI was 27.8 kg/m2;
Mean waist circumference in males was 95.2 cm (>90 cm in 69.6%) and in females was 92.1 cm (>80 cm in 87.8%).

Complications

Hypertension was the most prevalent CV risk factor. Diabetes is 2nd.
Diabetic kidney disease (DKD) was the most common cause of end stage kidney disease (ESKD).

Paras glukosa

Glukometer dan CGM device iaitu alat pengukur berterusan paras glukosa membolehkan paras glukosa darah sendiri diukur dirumah dan tidak perlu hadir di mana-mana ofis.

Flow chart 1

Carta aliran bagi saringan paras glukosa darah bagi menentukan satus diabetes individu yang bergejala.

Aplikasi dan cara guna

Bagi menentukan status paras glukosa darah dan ukuran-ukuran lain yang ada kaitan dengan diabetes, aplikasi di bawah mampu memudahkan diagnosa dilakukan dan seterusnya membantu dalam pengurusan diabetes kendiri.

Hanya perlu isikan petak yang berkaitan dan klik butang diagnosis. Diagnosis dan saranan akan terpapar secara terus ke dalam tetingkap di bawah butang diagnosis.

Aplikasi ini boleh digunakan bagi yang sudah menghidapi diabetes mahupun yang belum. Atau anda boleh saja bermain dengan aplikasi ini dengan memasukkan nilai-nilai hipotetikal.

Sekian dan selamat mencuba. Kalau ada sebarang komen atau pertanyaan, lakukannya dalam link di bawah.

Perokok

Modified Version of the Fagerstrom Tolerance Questionnaire (mFTQ) (Scoring guidelines in parentheses):

How many cigarettes a day do you smoke?
a. Over 26 cigarettes a day (2)
b. About 16-25 cigarettes a day (1)
c. About 1-15 cigarettes a day (0)
d. Less than 1 a day (0)
Do you inhale?
a. Always (2)
b. Quite often (1)
c. Seldom (1)
d. Never (0)
How soon after you wake up do you smoke your first cigarette?
a. Within the first 30 minutes (1)
b. More than 30 minutes after waking but before noon (0)
c. In the afternoon (0)
d. In the evening (0)
Which cigarette would you hate to give up?
a. First cigarette in the morning (1)
b. Any other cigarette before noon (0)
c. Any other cigarette afternoon (0)
d. Any other cigarette in the evening (0)
Do you find it difficult to refrain from smoking in places where it is forbidden (shopping mall, library, movies, etc.)?
a. Yes, very difficult (1)
b. Yes, somewhat difficult (1)
c. No, not usually difficult (0)
d. No, not at all difficult (0)
Do you smoke if you are so ill that you are in bed most of the day?
a. Yes, always (1)
b. Yes, quite often (1)
c. No, not usually (0)
d. No, never (0)
Do you smoke more during the first 2 hours than during the rest of the day?
a. Yes (1)
b. No (0)

Score:
1 - 2 = low dependence
3 - 4 = low to moderate dependence
5 - 7 = moderate dependence
8+ = high dependence

Offer pharmacotherapy to all smokers who are attempting to quit, unless contraindicated.

If selected, use nicotine replacement therapy (NRT) for at least eight to twelve weeks, whereas varenicline should be used for at least twelve weeks.

Combination therapy (e.g. two NRTs, a non-NRT, e.g. bupropion with an NRT) is better than monotherapy in smoking cessation treatment and may be most useful for those smokers at highest risk of relapse.

Nota Kaki

BMI -- Body Mass Index.

T2DM -- Diabetes jenis 2.

RBG -- Random Blood Glucose.

FBG -- Fasting Blood Glucose.

PPG -- postprandial glucose.

HDL -- kolesterol jenis high-density lipoprotein.

LDL-C -- low density lipoprotein cholesterol

HbA1c -- haemoglobin A1c

TG -- lemak triglycerides

BMI: body mass index.

Limitasi:

1. Untuk diagnosis paras glukosa darah individu dewasa;

2. Bukan untuk diagnosis diabetes gestasional.

Rujukan:

MANAGEMENT OF TYPE 2 DIABETES MELLITUS 6th edition, Malaysian Endocrine and Metabolic Society (MEMS);

CVOTS

Cardiovascular outcome trials (CVOTS): CVD is the leading cause of mortality and morbidity in patients with T2D [2,3,4], and more than 30% of patients with T2D are diagnosed with CVD [4]. The most common CVD manifestations in patients with T2D are peripheral arterial disease, ischaemic stroke, stable angina, heart failure (HF) and nonfatal myocardial infarction (MI) [3, 5]. A recent meta-analysis showed that patients with coexisting diabetes and HF have an increased risk of all-cause death, cardiovascular (CV) death and hospitalisation [6]. Moreover, one in six patients with newly diagnosed T2D have evidence of silent MI associated with an increased risk of all-cause mortality (HR 1.26, 95% CI 1.06–1.50) and fatal MI (HR 1.49, 95% CI 1.15–1.94) [7]. Reducing CV risk is a key part of T2D disease management [3]

Fibrosis index

T2DM:
Elevated ALT and/or AST

US to diagnose fatty liver and exclude focal liver lesion
Exclude other causes of elevated ALT/ AST

Calculating Fibrosis 4 index:
FIB-4 = Age (years) x AST (U/L) divided by Platelet count (x 109 /L) x ALT (U/L)

Resuilt:
FIB-4 below 1.3 -- Unlikely to have advanced liver fibrosis
FIB-4 1.3 and higher -- Intermediate to high risk for advanced fibrosis; proceed with liver stiffness measurement

Result:
Below 10 kPa:
Unlikely to have advanced liver fibrosis

10-15 kPa:
May have advanced liver fibrosis
Requires monitoring
Consider referral to Gastroenterologist/ Hepatologist

15 - 20 kPa:
Likely to have advanced liver fibrosis
Consider referral to Gastroenterologist/ Hepatologist
Consider HCC surveillance

20-25 kPa:
Likely to have clinically significant portal hypertension
Should refer to Gastroenterologist/ Hepatologist
Consider variceal screening

Rujukan

Bagi menentukan status paras glukosa darah dan ukuran-ukuran lain yang ada kaitan dengan pengurusan diabetes, aplikasi di bawah dibina yang dibina berpandukan maklumat daripada MANAGEMENT OF TYPE 2 DIABETES MELLITUS 6th edition, Malaysian Endocrine and Metabolic Society (MEMS), aplikasi di bawah ini mampu memudahkan diagnosis dan pengurusan diabetes secara umumnya.

App Diabetes

Cara guna

Input:
Hanya perlu tekan butang pilihan yang diberikan atau masukkan angka yang diminta sekiranya berkaitan.
Klik butang diagnosis
Output:
Diagnosis dan saranan akan otomatik terpapar pada skrin.
Diagnosis dan saranannya boleh disalin ke dalam clipboard dengan menekan butang copy
Padam/ulang:
Klik butang reset untuk padamkan semua input dan output

Fakta Diri

Jantina

Kenapa Jantina?

Lelaki dan wanita berbeza dari segi julat-julat normal bagi berikut:

Tekanan darah (BP)
Indeks Jisism Badan (BMI)
Saiz pinggang
Faktor risiko mendapat Diabetes Jenis 2 (T2DM)
Paras kolesterol, dsbnya.

Umur

Kenapa Umur?

Berikut berbeza berdasarkan kumpulan umur:

Paras glukosa normal
Tekanan darah (BP)
Faktor risiko mendapat diabetes
Rawatan diabetes

Prediabetes

Makna dan cara input

"Plasma glucose abnormalities may span a progressive continuum ranging from prediabetes, consisting of impaired fasting glycaemia (IFG) and impaired glucose tolerance (IGT), to overt diabetes mellitus.

Prediabetes usually does not cause symptoms and is characterised by elevated plasma glucose levels that fall below the threshold to diagnose diabetes. Prediabetes is an important risk factor for future diabetes and cardiovascular disease (CVD). It is a potentially reversible condition with lifestyle modification.

The National Health and Morbidity Survey (NHMS) 20191 reported a prevalence of 23.6% for those with abnormal fasting plasma glucose (FPG) in non-diabetic range (FPG 5.6 mmol/L-6.9 mmol/L) at the time of the survey. This estimates approximately 5 million (5,019,359) adult individuals in Malaysia with probable prediabetes in 2019 and future risk of diabetes."

Tatacara Input

Diabetes

Input diabetes

Klik "Ya" kalau sudah ada diabetes
Klik "Tiada" kalau belum ada diabetes
Tak perlu klik kalau sudah ada prediabetes

T2DM pada remaja

Criteria for testing

Screening should be performed in adolescents* who are overweight (85th percentile) or obese (95th percentile), and who have one or more additional risk factors such as:

maternal history of diabetes or GDM during the child’s gestation
family history of T2DM in a 1° relative
recurrent abscess and/or pruritus genitalia
signs of insulin resistance or conditions associated with insulin resistance (dyslipidaemia, hypertension, polycystic ovary syndrome, acanthosis nigricans or small for gestational age birth weight)

If tests are normal, repeat screening at a minimum of 3-year intervals, or more frequently if BMI is increasing.

*After the onset of puberty or after 10 years of age, whichever occurs earlier.

Risiko

Faktor risiko

Berikut adalah faktor-faktor berisiko diabetes.

A - Wanita dengan sejarah gestational diabetes -- GDM.

B - Dewasa yang terlebih berat dan obes (BMI ≥23 kg/m2 atau wanita dengan ukur lilit pinggang ≥80 sm dan lelaki ≥90 sm dengan mana-mana satu daripada yang berikut:

Sejarah penyakit kardiovaskular.
Ahli keluarga terdekat (1° relatives) menghidapi 'type 2 diabetes' -- T2DM.
Hypertensi dengan BP ≥140/90 mmHg atau menerima rawatan untuk hipertensi
Kolesterol jenis HDL-C kurang dari 0.9 mmol/L atau jenis trigliserida -- TG >2.8 mmol/L.
Wanita yang melahirkan bayi dengan berat ≥4 kg atau sesiapa yang lahir daripada ibu yang menghidapi GDM
Lain-lain kondisi endokrina yang berasosiasi dengan rintangan insulin seperti:
PCOS, Cushing’s syndrome, Acromegaly, Phaeochromocytoma, acanthosis nigricans.
Kurang aktiviti fizikal dan kehidupan yang banyak duduk serta berbaring
Mereka yang menerima rawatan jangka panjang dari mana-mana berikut:
corticosteroids, rawatan anti-retroviral, atypical anti-psychotic drugs, thiazide diuretics, β-adrenergic blockers, 3-Hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase inhibitors [statins].
Saringan diabetes diperlukan bagi yabg positif risiko dan meskipun tiada simptom diabetes.

Risk-based screening for pre-diabetes and/or T2DM in adults should be performed in individuals >30 years of age and repeated annually.

C - Kesemua mereka yang menghidapi prediabetes (HbA1c ≥5.7%-6.2% [39 mmol/mol44 mmol/mol], IGT, or IGF) harus diuji setiap tahun.

Simptom

Symptomatic or asymptomatic

Simptom diabetes adalah:

Kencing lebih kerap dari kebiasaan terutama waktu malam (poliuria, nokturia)
Dahaga berlebihan, kerap lapar dan makan berlebihan.
Terasa sangat letih, hilang berat badan, kegempalan otot merosot
Penglihatan kabur
Luka/lebam lambat sembuh.
Turun berat badan meskipun makan lebih (diabetes jenis 1)
Kebas dan rasa seperti cucukan jarum di tangan/kaki (diabetes jenis 2)
Gatal pada alat sulit (balanitis).

Any individual who has symptoms suggestive of T2DM should be investigated to confirm diagnosis of T2DM.

From our National Health and Morbidity Survey (NHMS) data, 48.6% of individuals with diabetes were undiagnosed at time of screening. Recognising that up to 50% of individuals with diabetes are asymptomatic makes the case for screening when specific risk factors are present.

Criteria for testing for T2DM or prediabetes in asymptomatic adults:

1. Women with history of GDM

2. Adults who are overweight or obese (Body mass index [BMI] ≥23 kg/m2 or waist circumference ≥80 cm for women and ≥90 cm for men) with ANY of the following:

History of CVD
1° relatives with T2DM
Hypertension (BP ≥140/90 mmHg or on therapy for hypertension)
HDL-C over 0.9 mmol/L or TG over 2.8 mmol/L
Women who have delivered a baby weighing ≥4 kg
Those who were born from mothers with GDM
Other endocrine conditions associated with insulin resistance e.g.; › PCOS,
› Cushing’s syndrome,
› Acromegaly,
› Phaeochromocytoma,
› Presence of acanthosis nigricans
Physical inactivity and sedentary lifestyle
Those receiving long-term treatment with any of the following: › corticosteroids,
› anti-retroviral therapy,
› atypical anti-psychotic drugs,
› thiazide diuretics,
› β-adrenergic blockers,
› 3-Hydroxy-3-methyl-glutaryl-CoA (HMG-CoA) reductase inhibitors [statins]

Note: In those without the above risk factors, testing should begin at the age of 30 years. If tests are normal, screening should be performed annually

3. All individuals with prediabetes (HbA1c ≥5.7%-6.2% [39 mmol/mol44 mmol/mol], IGT, or IGF) should be tested yearly

In symptomatic individuals, 1 abnormal result (either plasma glucose/ HbA1c) is diagnostic while in asymptomatic individuals, 2 abnormal test results from the same sample (e.g. plasma glucose + HbA1c) or from 2 separate test samples are accepted for diagnosis.

Rawatan

Rawatan diabetes

"Rawatan diabetes dibahagikan kepada A) Rawatan konvensional dan B) Rawatan CAM -- komplimentari dan alternatif.

Rawatan konvensional: 83% ambil Biguanides (Metformin). 44% ambil Sulphonylureas dan 30.3% ambil insulin.

Sulphonylureas: tingkatkan rembesan insulin, berisiko hipoglisemia, jangan guna glibenclamide sekiranya usia lebih 60 tahun.
Meglitinides: Untuk mengawal paras glukosa post-prandial (PPG).
Alpha-glucosidase inhibitors (AGIs). Contoh: acarbose menurunkan PPG tanpa menyebabkan hipoglisemia.
Thiazolidinediones (TZD): beraksi terumanya meningkatkan sensitiviti insulin dalam otot, tisu adipos dan hepar.
Incretins – Dipeptidyl peptidase 4 inhibitor (DPP4-i) and glucagon-like peptide-1 (GLP-1) analogue. Berkesan dan selamat buat warga tua dan semua peringkat 'diabetic kidney disease' -- DKD.

Rawatan CAM:
Kajian menunjukkan olive oil boleh meningkatkan kawalan glisemik sebanyak 0.27%. Insufficient evidence to recommend the daily use of supplements such as chromium, vitamin D, cinnamon or herbs/supplement".

Rawatan pradiabetes

In addition to lifestyle intervention, metformin should be considered for those at very high risk. These include those with:
combined IFG and IGT,
IGT + obesity (BMI >35 kg/m2 ),
IGT + less 60 years old,
FPG >6.1 mmol/L,
HbA1c more 6%,
previous history of GDM; or
for those who failed lifestyle therapy after 6 months.

• Metformin reduces progression from prediabetes to T2DM by ~30% with persistent benefit, especially in women with previous GDM (overall risk reduction 18%) over the 10 years of the DPP/DPPOS program.
• Metformin is the only drug that has received endorsement by our Malaysian Regulatory authority as well as by other national guidelines for the prevention of T2DM.

Hipertensi

End organ damage

EOD

"End organ damage (EOD) adalah kerosakan organ seperti hati dan ginjal akibat daripada diabetes.

Perokok

Rokok

"End organ damage (EOD) adalah kerosakan organ seperti hati dan ginjal akibat daripada diabetes.

Puasa

Baru/hujung

Puasa yang dimaksudkan adalah sama ada puasa wajib atau puasa sunat. 1. Baru puasa bermaksud baru 1-2 jam berpuasa.
2. Hampir berbuka bermaksud telah berpuasa lebih 8 jam atau hampir kepada waktu berbuka puasa.

IDF-DAR RISK CATEGORIES FOR PATIENTS WITH T2DM WHO FAST DURING RAMADAN

Category 1: Very high risk

*1 or more of the following:

1. Severe hypoglycaemia within the 3 months prior to Ramadan
2. DKA within the 3 months prior to Ramadan
3. Hyperosmolar hyperglycaemic coma within the 3 months prior to Ramadan
4. History of recurrent hypoglycaemia
5. History of hypoglycaemia unawareness
6. Acute illness
7. Pregnancy in pre-existing diabetes, or GDM treated with insulin or SUs
8. Chronic dialysis or DKD stage 4 & 5
9. Advanced macrovascular complications
10. Old age with ill health

Category 2: High risk

*1 or more of the following:

1. T2DM with sustained poor glycaemic control
2. Well-controlled T2DM on MDI or mixed insulin
3. Pregnant T2DM or GDM controlled by diet only or metformin
4. DKD stage 3
5. Stable macrovascular complications
6. Patients with comorbid conditions that present additional risk factors
7. People with diabetes performing intense physical labour
8. Treatment with drugs that may affect cognitive function

For category 1 and 2, If patients insist on fasting then they should:
√ Receive structured education
√ Be followed by a qualified diabetes team
√ Check their blood glucose regularly (SMBG)
√ Adjust medication dose as per recommendations
√ Be prepared to break the fast in case of hypo- or hyperglycaemia
√ Be prepared to stop the fast in case of frequent hypo- or hyperglycaemia or worsening of other related medical conditions

Category 3: Moderate/low risk Well-controlled T2DM treated with one or more of the following:
1. Lifestyle therapy
2. Metformin
3. Acarbose
4. TZDs
5. Second-generation SUs
6. Incretin-based therapy
7. SGLT2-i
8. Basal insulin

For category 3, patients who fast should:
√ Receive structured education
√ Check their blood glucose regularly (SMBG)
√ Adjust medication dose as per recommendations

DKA: diabetic ketoacidosis; GDM: gestational diabetes mellitus; SU: sulphonylurea; DKD: diabetic kidney disease; T2DM: type 2 diabetes mellitus; MDI: mixed dose insulin; TZD: thiazolidinediones; SGLT2-i: sodium-glucose transport protein 2 inhibitors; SMBG: self-monitoring blood glucose.

Adapted from the International Diabetes Federation–Diabetes and Ramadan International Alliance. Diabetes and Ramadan: Practical Guidelines. 2016.

Ukuran dan aktiviti fizikal

Pinggang

Cara ukur

Untuk mendapatkan ukuran saiz pinggang yang betul, dalam posisi berdiri, lilitkan pita ukur mengelilingi perut pada paras hampir di atas tulang pinggul. Ambil ukuran sejurus selepas nafas dihembus.

BMI

Kira BMI

Body mass index (BMI) adalah ukuran berat badan (kg) di bahagikan dengan tinggi (meter) kuasa dua. Gunakan link dalaman ini yang akan membawa kepada kalkulator BMI pintar.

Senaman

Durasi senaman/minggu

1. Input yang dimaksudkan adalah jumlah jam atau minit senaman per minggu.
2. Senaman sederhanaBerjalan deras (3-4.5 mph)
Kayuh basikal 5 to 9 mph melalui permukaan tanah yang rata atau sedikit berbukit.
Berkebun, mencakar rumput atau tanam pokok.
Buat kerja rumah sederhana, turun naik tangga, cuci pakaian, berus lantai dan bilik air secara melutut.
Senaman aerobik (impak rendah).

Tekanan Darah

Sistolik

Diastolik

Kaedah ukur

Clinic BP or Home BP:
The potential advantages of having patients take their own blood pressure (BP) are twofold: the distortion produced by the white coat effect is eliminated, and multiple readings can be taken over prolonged periods.

Technical aspects with measurement from the arm:

Effects of posture -- no consensus as to whether blood pressure should be routinely measured while seated or supine
Arm position: horizontal not vertical
Support patient’s back
Make the cuff size relative to the diameter of the arm

Cuff sizes recommended by the American Heart Association:

Arm circumference: 22-26 cm
BP Cuff width: 10 cm
BP Cuff length:24 cm
Arm circumference: 27-34 cm
BP Cuff width: 13 cm
BP Cuff length: 30 cm
Arm circumference: 35-44 cm
BP Cuff width: 16 cm
BP Cuff length: 38 cm

Paras Glukosa darah

Ujian saringan

In circumstances where facilities for venous plasma glucose measurements are not readily available, preliminary screening can be performed by measuring capillary plasma glucose using standard glucometers.

Tatacara

Pengambilan sampel dan cara guna glukometer:

Pasang lancet (label 1) pada lancing device (label 2)
Pasang test strip (label 3)pada glucometer (label 4)
Sapu alkohol/sanitizer pada hujung jari dan biarkan 30 saat
Cucuk jari dengan lancing device agar berdarah.
Sentuh titisan darah pada hujung test strip
Tunggu 5 saat untuk bacaan paras glukosa

RPG(C)

RPG capillary

Random capillary plasma glucose testing can be done irrespective of timing of prior meals.

If random capillary plasma glucose is done for screening and the result ≥7.8 mmol/L, a confirmatory test needs to be performed by one of the following methods:

Fasting Plasma Glucose (FPG)--venous blood
Oral Glucose Tolerance Test (OGTT)
HbA1c

RPG(V)

RPG vena

Random vena plasma glucose testing can be done irrespective of timing of prior meals.

If the random vena plasma glucose is for screening purpose and the result ≥ mmol/L, a confirmatory test needs to be performed by one of the following methods:

Fasting Plasma Glucose (FPG)--venous blood
Oral Glucose Tolerance Test (OGTT)
HbA1c

FPG(C)

FPG capillary

This testing can be done prior to meals.

If fasting capillary plasma glucose ≥5.6 mmol/L, a confirmatory test needs to be performed by one of the following methods;

Fasting Plasma Glucose (FPG) -- venous blood
Oral Glucose Tolerance Test (OGTT)
HbA1c

FPG(V)

FPG vena

Fasting vena plasma glucose should be performed following a minimum of an 8-hour overnight fast.

Patient is considered to have prediabetes/IFG if the FPG is between 6.1- 6.9 mmol/L and diabetes if the FPG is ≥7.0 mmol/L

Carta aliran ujian kes bergejala:

Jenis2 kalori

makan

HbA1c
Peratus

HbA1c
mmol/mol

Info HbA1c

HbA1c reflects the average plasma glucose level over the preceding 3

Standardised HbA1c assay has been shown to have the least variability (0.3%-0.4%) compared to fasting and 2-hour plasma glucose levels, 12% and 20% respectively.

Using HbA1c to diagnose is convenient as it does not require the individual to fast or consume oral glucose, and it can be performed at any time of the day.

If HbA1c is used for the diagnosis of prediabetes, it is best that the test is followed by an OGTT to classify individuals into either IFG, IGT or combination of both:
This has prognostic significance in terms of the risk of developing CVD and conversion to frank T2DM.

In patients suspected of having haemoglobinopathies, other screening tests for e.g. another HbA1c methodology should be used

HbA1c is not appropriate for the diagnosis of diabetes in:

Adolescents (<18 years old) since the diagnostic cut-off point was derived in those >18 years
Patients taking medication that may cause rapid glucose rise e.g. steroids, antipsychotics
Patients taking iron supplements (may falsely lower HbA1c levels)
Patients with acute pancreatic damage, including pancreatic surgery
Presence of genetic, haematologic and illness-related factors that influence HbA1c and its measurement (e.g. haemoglobinopathies rheumatoid arthritis, chronic liver disease, post-splenectomy)
Patients with chronic kidney disease (CKD) stages 4 or 5 and those on erythropoietin injections; and
Anaemia due to iron, vitamin B12 or erythropoietin deficiencies.

OGTT 0jam

OGTT 2jam

OGTT

Oral glucose tolerance test (OGTT)

OGTT is done in the fasting state using 75 g of glucose.
Patient should rest throughout the test and only allowed to drink plain water.
A 2-hour plasma glucose of ≥11.1 mmol/L confirms the diagnosis of diabetes.
Patient is considered to have IGT or prediabetes if the 2-hour plasma glucose level is between 7.8-11.0 mmol/L

Diagnostic value for glucose tolerance and T2DM based on OGTT

Category: normal
OGTT 0 hr: below 6.1 mmol/L
OGTT 2 hr: below 7.8 mmol/L

Category: IFG
OGTT 0 hr: 6.1-6.9 mmol/L

Category: IGT
OGTT 0 hr: 7.8-11 mmol/L

Category: T2DM
OGTT 0 hr: 7.0 mmol/L and above
OGTT 2 hr: 11.1 mmol/L and above

IFG -- impaired fasting glucose
IGT -- impaired glucose tolerance

Pre-prandial

PPG

Pre-bed

Pre-exercise

Keterangan

1. RBG: Paras glukosa tanpa mengira masa.
2. FBG: Paras sesudah 8-10jam berpuasa digunakan untuk diagnosis diabetes/pradiabetes.
3. HbA1c -- haemoglobin A1c.
3. Preprandial: Iaitu paras glukosa kapilari biasanya 1 atau 2 jam sebelum makan, digunakan dalam plan rawatan diabetes.
4. Post-prandial: Iaitu paras glukosa kapilari yang sebaiknya 2 jam selepas makan, juga digunakan dalam plan rawatan diabetes.
5. Pre bed: adalah paras glukosa sejurus sebelum tidur malam.

Paras Kolesterol

Jenis2 kolesterol

Alat pengukur tekanan darah digital otomatik bagi anggota atas.

HDL

LDL-C