New Hope for Diabetic Patient in

INA Medicare Era 2014

Pradana Soewondo
Division of Metabolism and
Endocrinology, Department of Internal
Medicine Faculty of Medicine University
of Indonesia / Cipto Mangunkusumo
National Referral Hospital Jakarta,
Indonesia

Agenda

of
Type 2 Diabetes in Indonesia

Population : 230 million

GDP/capita +3000 USD

Known DM

Undiagnosed DM

Total DM

IGT

1,5 %

4,2 %

5,7 %

10,2 %

National Health Survey 2007

24.417 subjects, >15 years old, from 33 provinces in Indonesia.

List of South East Asia Countries with The

Estimated Cases of Diabetes (WHO)

Atlas IDF, 2010

Cause of Deaths
No.

Diseases (2007)

1.

Stroke

15.4

2.

Tuberculosis

7.5

3.

Hypertension

6.8

4.

Trauma

6.5

5.

Perinatal diseases

6.0

6.

Diabetes mellitus

5.7

7.

Malignancy

5.7

8.

Liver diseases

5.1

9.

Coronary Artery Diseases

5.1

10. Lower Respiratory Tract Infection

5.1

Ministry of Health, Republic of Indonesia. 2007.

Diabetes Evidence Framework

Blood Glucose Lowering Treatment
Undesirable Effects
- Hypoglycaemia
- Weight gain
- Specific side effects

Intermediate
Outcome (HbA1c)

Clinical Outcome
Premature Mortality
Microvascular
Macrovascular

Other
Considerations
- Cost
- Availability

Perkeni
Perspective

Patient Demographic and Characteristics

Variable
Age (Years)* (n=1719)
Gender** (n=1803) Male/ Female
Age at Onset (Years)* (n=1686)
Duration of Diabetes (Years)*
(n=1704)
Type of Diabetes**
Type 1
Type 2
Others
BMI (Kg/m2)14 * (n=1646)
<23 / 23 (%)
Duration of Treatment (Years)*
(n=1817)
Duration of OADs (Years)* (n=1727)
Duration of Insulin (Years)**
(n=1176)
Smoking (Yes)** (n=1831)

Data
58.939.57
793 (43.3) / 1010
(55.16)
49.686.8
8.615.97
17 (0.9)
1785 (97.5)
2 (0.1)
25.23.6
28.7 / 71.3
8.57.0
8.46.8
2.83.0
178 (9.7)

* Data expressed as Mean SD; ** Data expressed as n (%); Percentage are calculated out of total cohort (n=1832) except for BMI.

Diabetes Management - The DiabCare

Indonesia 2008

Diabetes management variable

Type of Management
Diet
Insulin monotherapy
Insulin and OAD combination
OAD monotherapy
Herbal
None
Type of OAD Therapy
Biguanides
Sulphonylureas
Meglitinides
Alpha Glucosidase inhibitors
Thiazolidinediones
Other OADs
Traditional Herbal medicines
Double drug fixed dose combination
Triple drug fixed dose combination

Data, n (%)
317 (17.3)
356 (19.4)
1133 (61.9)
5 (0.3)
20 (1.1)
1085(59.3)
1036(56.6)
8(0.4)
461(25.2)
51(2.8)
48 (2.6)
5(0.3)
88 (4.8)
5 (0.3)

Use of OADs Decreased at Duration of Diabetes

10 Years
Number of patients (%)
92

--

90

--

88

--

86

--

84

--

82

--

80

--

78

--

76

--

74

--

72

--

89.71
86.67

86.86

86.83

84.27

77.71

70
<1
<10

1 and <3
10

3 and <5

5 and <7

7 and

Duration of diabetes (years)

DiabCare Indonesia
2008

Glycemic Control In The Study

Population

Fasting

Postprandial

A1c

143.6 mg%

207.7 mg%

8.1 %
DiabCare Indonesia 2008

Country

A1c
measurem
ent per
year

A1c (%)

A1c >7%
(%)

Indonesia

2.3

8.1

67.7

Bangladesh

1.4

8.6

76.9

Singapore

3.3

7.8

65.4

Malaysia

1.1

8.6

76.5

Taiwan

3.8

7.9

69.7

Thailand

2.9

8.2

74.3

Philippines

2.6

31.8
DiabCare Asia - 2008

Diabetic Complications
60

Microangiopathy >>
Macroangiopathy

54

50

Re nopathy
Neuropathy
Proteinuria

40
30

Dialysis

33.4

Foot Ulcer
26.5

Amputa on
Angina
MCI

20
10.9

8.7
10
0.5
0

7.4
1.3

5.3

2.7

5.3

Heart Failure
Stroke
PAD

IDMPS Indonesia, 2007

Comorbidities and
Complications Type 2
Variable
Hypertension
Yes with treatment
Yes but no treatment
No hypertension
Dislipidemia
Yes with treatment
Yes but no treatment
No dislipidemia
Late complication
At least one
No complication

Lifestyle

OGLD

Insulin +

Total

8 (38.1)
0
13 (61.9)

230 (44.2)
17 (3.3)
273 (52.5)

59 (45.4)
5 (3.8)
66 (50.8)

297 (44.3)
22 (3.3)
352 (52.5)

8 (40.0)
4 (20.0)
8 (40.0)

179 (42.6)
36 (8.6)
205 (48.8)

53 (50.0)
12 (11.3)
41 (38.7)

240 (44.0)
52 (9.5)
254 (46.5)

9 (69.2)
4 (30.8)

290 (70.6)
121 (29.4)

97 (85.8)
16 (14.2)

396 (73.7)
141 (26.3)

Most diabetic patients have at least one late diabetic complication

The Cost of Diabetes

Direct Costs Personal
Drugs, supplies,
insurance
Direct Costs healthcare
System
Treatment and
rehabilitation
Hospital and healthcare
professional services
Products, supplies, tests
Hospital admissions

Indirect Costs
Loss of productivity
Premature
retirement
Premature mortality
Pain, anxiety and
inconvenience
decrease quality of life
Work discrimination
Negative effect on
relationships, mobility
and leisure activities
WHO Fact Sheet 2012

126.104 pts

258.208 pts

ASKES Data
Annual cost for each diabetes patient
Without Complications + 40 US$
With Complications + 900 US$

384.312 pts

Indirect Cost
Variable
Working productivity
Unemployed
Normal work
Sick leave
Unable to work
Hospitalized
Yes
No
Mean (SD)
Median

Type 2 DM
359 (53.3)
234 (34.8)
64 (9.5)
16 (2.4)
69 (15.8)
369 (84.2)
1.1 (0.5)
1.0

Only 34.8% of diabetic patients had normal work

IDMPS Indonesia,2007

Treating diabetes reduces risks of

complications and costs of
diabetes

Reduction in incidence risk

per 1% reduction in HbA1c

Risk reduction by lowering

HbA1c with 1%

Diabetesrelated
death

Myocardial
infarction

Microvascular
complications

Costs related to type 2 diabetes

Peripheral
vascular
disease

Diabetes drugs only constitute 7%

7%

10

14%*

20
30
40
50

Other drugs

18%

Ambulatory
Hospitalization

37%*
*p<0.0001

Source: UKPDS, Stratton et al. BMJ 2000;321:40512

Date

20%
55%

21%*

Antidiabetic drugs

43%*
Source: Revealing the cost of Type II diabetes in
Europe, B. Jnsson in Diabetologia (2002)

Restructuring of Health Sevices

ru

ed
m
Pri

ar y

re
Ca

ru
St

l
Se

ur
ct

ed

Tertiary
Secondary

e
ar
fC

Se
c
da on
r
Ca y
re

st
n
U

r
tu

Rujukan Kewenangan

Primary Care
Tertiary Care
RS/PUSKESMAS
DAERAH

INTERVENSI 3 :

GATE KEEPER

Self Care

PRAKTEK SWASTA

RS/PUSKESMAS
DAERAH

PUSKESMA
S
RAKSASA

UA
RIB
N
ien
pas

RIB
UA
N
Pas
ie
n

PRAKTEK SWAST

PUSAT RUJUKAN

DOKTER KELUARGA

18

Personal Healthcare Service

Flow *

*Diambil dari alur pelayanan kesehatan PT. Askes

BPJS Personal Health Benefit

Primary care services
Secondary and tertiary care services
Drug Services
Cathastrophic disease:
Heart disease
Cancer
Dialysis
Thallasemia & Haemofilia

ERA BPJS: Managig The Health Care System

GATE KEEPER CONCEPT PROMOTIF PREVENTIF
Strengthen its position as primary service door to tiered health
care refferal system

Persentase Biaya Pelkes

Askes

NHS
England

28 %

INA CBGs

76 %

56 %

Kapitasi

Gate Keeper
15 %

BPJS Kesehatan

24 %

Petunj
uk
Teknis

Surat Edaran Direktur

Pelayanan BPJS Kesehatan
Nomor 0038/Ed/0114

Penjelasan Poin 2 Obat Penyakit

Kronis
a. Yang dimaksud penyakit kronis adalah penyakit yang membutuhkan
obat untuk pemakaian rutin selama 30 hari setiap bulan sesuai
indikasi medis, diluar yang sudah diatur dalam poin 3 Surat Edaran
Menkes Nomor HK/Menkes/32/I/2014 tahun 2014 yaitu tentang Program
Rujuk Balik (DM, Hipertensi,jantung,asma,PPOK,epilepsi,skizofren,sirosis
hepatis,stroke,SLE). Pasien yang tidak memerlukan pengobatan rutin
selama 30 hari setiap bulan tidak termasuk dalam ketentuan ini dan
keseluruhan obat sudah termasuk dalam paket INA CBG
b. Dalam hal dokter Spesialis/Sub Spesialis menyatakan pasien dengan
penyakit kronis tersebut dalam kondisi stabil maka pasien dirujuk balik
ke faskes tingkat pertama. Pengobatan selanjutnya diteruskan oleh
faskes tingkat pertama sesuai dengan rekomendasi Dokter Spesialis/Sub
Spesialis.
c. Peserta yang menderita penyakit kronis yang belum stabil diberikan
resep obat untuk kebutuhan 30 hari sesuai indikasi medis :
i. Kebutuhan obat untuk sekurang-kurangnya 7 (tujuh) hari
disediakan oleh Rumah Sakit, biaya sudah termasuk dalam
komponen paket INA CBG
ii. Kebutuhan obat untuk sebanyak-banyaknya 23 (dua puluh tiga)
hari dapat diambil di Instalasi Farmasi Rumah Sakit. Biaya obat
ditagihkan sesuai ketentuan yang berlaku secara fee for service
dengan software/aplikasi khusus obat.

Penjelasan Poin 2
Obat Penyakit
Kronis
e. Pelayanan obat mengacu kepada Formularium Nasional baik nama
generik, jenis, kekuatan maupun restriksinya. Brand obat dan
peresepan maksimal mengacu kepada DPHO PT. Askes (Persero) Tahun
2013
f. Dalam hal obat yang diresepkan tidak tercantum dalam Formularium
Nasional, maka biaya obat tersebut sudah termasuk dalam komponen
paket INA CBG
g. Obat yang diresepkan pada poin 5.d hanya untuk obat kronis. Apabila
pasien membutuhkan obat akut maka obat tersebut disediakan oleh
Rumah Sakit dan biaya sudah termasuk dalam komponen paket INA
CBG
h. Obat pada poin 5.d.ii. dibayar oleh BPJS Kesehatan mengacu pada ecatalogue obat Tahun 2014 ditambah dengan faktor pelayanan dan
embalage sesuai SE Menteri Kesehatan RI Nomor HK/31/Menkes/I/2014.
Sebelum adanya ketetapan e-catalogue obat Tahun 2014, maka harga
obat mengacu pada DPHO PT Askes (Persero) Tahun 2013 dan/atau ecatalogue obat Tahun 2013.

Poin 3 Chronic Disease Drugs

Can be provided by primary care provider
Refer Back Program (PROGRAM RUJUK BALIK
PRB)

DM, hipertensi,
jantung,asma,PPOK,epilepsi,skizofren,sirosi
s hepatis,stroke,SLE

Health Care Services Flow

Members

Captiation

Primary Care
Provider

Referral

Hospital

Emergency

Claim Ina
CBG

BPJS Center

Drug Prescription

Apotek

BPJS
Branch Office

Primary Care Provider as a Gate Keeper

Whats Benefit for Diabetic

Patients

BASIC CONCEPT

Gate Keeper Concept (Primary Care

Provider)

Referral system
Selected Provider (Credentialling)
Provider Payment System
Utilization Review
Preventive & Promotive
Drugs Formulary Fornas and Refer Back Program

quality assurance and cost

containment

Disease Management Program (DM Type2)

Why DM Type 2:
big trigger for other
chronic
Hospital
Start from June 2010
(Medical Specialist)
- Members Database
- Reminder activity
- Health Promote
(Media)
- Club Chronic for
Members

PT Askes
(Persero)

Members
Chronic Disease
DM Tipe2
(individual
treatment)

Referral
- Comprehensive & Continued Care
control
(Guidelines Evidence Based) Mentor &
- Referral to the advanced level consultant for
- Health Education
GPs
- Health Status Monitoring
- Prescription chronic
drugs

- Health status evaluation and

feedback
- Health care cost
- Workshop for family Physician (DM
Family Physician
Type2)
by endokrin specialist

DM Guidelines
MEDICAL PROFESIONAL ORGANIZATION
PERHIMPUNAN ENDOKRINOLOGI INDONESIA (PERKENI)

Primary Care
for Members Diagnosed DM Type 2
Members
Diagnosed
DM Type 2

Register to Primary
Care
Family Physician

Primary Care for Members of PT.Askes (Persero):

Individual Physician
500 to 2.000 members
Group Physicians
with maximum 50 members
Clinics
Community Health Center (Puskesmas) diagnosed DM Type 2

Ensure that members are to be handled directly by the doctor

and the certainty of the service time
Members in DM Type2 program (per Aug 2011): 8.858 person
Managed by 668 Primary Care Providers

7 PILAR PPDM 2

31

Update on
PERKENI
Guidelines

PERKENI Guideline 2011

Lifestyle
Modification

Lifestyle
Modification
+
OAD Monotherapy

Lifestyle
Modification
+
2 OADs
Combination

Alternative :
Insulin not available
Patient preference
Glucose control not
optimal

Notes :
Fail : not achieving A1c target <7% after 2-3
months of treatment.
(A1c = average blood glucose conversion, ADA
2010)

Lifestyle
Modification
+
3 OADs
Combination

Lifestyle
Modification
+
2 OADs
Combination
+
Basal insulin

Intensive Insulin

HbA1c Level
7-8%

Lifestyle
Modification

Lifestyle
Modification

PERKENI Guideline 2011

<7%

+
Monotherapy
Met, SU, AGI,
Glinid, TZD,
DPP-IV

8-9%

>9%

9-10%

>10%

Lifestyle
Modification
+
2 OADs
Combination
Met, SU, AGI,
Glinid, TZD,
DPP-IV

Notes :
Fail : not achieving A1c target <7% after 23 months of treatment.
(A1c = average blood glucose conversion,
ADA 2010)

Lifestyle
Modification
+
3 OADs
Combination
Met, SU, AGI,
Glinid, TZD,
DPP-IV

Lifestyle
Modification
+
2 OADs
Combination
Met, SU, AGI,
Glinid, TZD
+

Lifestyle
Modification

Basal Insulin

+
Intensive
Insulin

Target of Treatment
Risk CVD (-)

Risk CVD (+)

Blood Glucose
-

FPG (mg/dL)

< 100

< 100

Post Prandial BG(mg/dL)

< 140

< 140

< 7,0

< 7,0

A1C (%)
BMI (kg/m2)
Blood Pressure

18,5

- < 23

18,5

- < 23

< 130/80

< 130/80

Total Cholesterol(mg/dL)

<200

<200

Triglyceride (mg/dL)

<150

<150

HDL cholesterol (mg/dL)

>40/>50

>40/>50

LDL cholesterol (mg/dL)

< 100

< 70

Lipid

PERKENI Guidelines 2011

Health Status Monitoring For Type 2 DM

Spesialistic Provider
Item
Periode

Primary Care Provider

Item

Periode
EKG
ECHO

Blood
Glucose
Test

1 per
Month

Sistole /
Diastole

1 per
Month

Body Mass
Index

1 per
Month

Albumin

HBA1C

1 per 6
Month

SGPT

Rontgen Thoraks
Funduscopy
ABI
Ureum
Creatinin
SGOT
Protein Kualitatif
Cholesterol Total
Choleterol LDL
Cholesterol HDL
Trigliserida

1 per
Year

Drug for Refer Back Programe

NO.

URAIAN

BPJS KESEHATAN

1.

Landasan Hukum

Peraturan BPJS

2.

Pemberi Layanan

Apotek atau depo farmasi Fasilitas

Kesehatan tingkat pertama yang
bekerja sama dengan BPJS
Kesehatan untuk Program Rujuk
Balik

3.

Cakupan PRB

4.

Acuan Daftar Obat Daftar Obat Fornas untuk Program

PRB

5.

Sistem
pembiayaan Obat
PRB

6.

Acuan Harga Obat E-Catalog (HNA + Ppn) + Faktor

Pelayanan + Embalage

DM dan HT
Fee For Service langsung kepada
Apotek

PT. Askes (Persero)

Drug List for Diabetes and

Hypertention
Nama Generik

Sediaan dan
Kekuatan

OPR
B

Keterangan:

Acarbose

Tab 50, tab 100

Diberikan pada pelayanan

Tingkat lanjut saja

Glibenklamid

Ta 2,5 , 5 mg

Glicazid

Tab MR 30 mg

Glikuidon

30 mg

Glimepirid

Tab 1, 2 ,3,4 mg

Glipizide

Tab 5, 10 mg

Metformin

Tab 500 dan 850

mg

Pio Glitazon

Tab 5 dan 10 mg

Antidiabetes
Oral

Antidiabetes parenteral
Human Insulin

Diberikan pada pelayanan

Tingkat lanjut saja

Diberikan pada pelayanan

Tingkat lanjut saja

Drug List for Diabetes and

Hypertention
Nama Generik
Antihipertensi Oral
amlodipin
atenolol
beraprost sodium
bisoprolol
diltiazem
doksazosin
hidroklortiazid
imidapril
irbesartan
kandesartan
kaptopril
klonidin

Sediaan dan
Kekuatan
tab 5, 10 mg
tab 50 , 100 mg
tab 20 mg
tab 5 mg
Tab 30 mg, kaps SR
100 mg, kaps 200
mg
tab 1 dan 2 mg
tab 25 mg
tab 5 dan 10 mg
Tab 150 dan 300
mg
Tab 8 mg dan 16
mg
tab 12,5 dan 25 mg
Tab 0,15 mg

OPR
B

Keterangan:

v
v
x
v
v
v
v
v
v
v
v
v

Diberikan pada pelayanan

Tingkat lanjut saja

Drug List for Diabetes and

Hypertention
Nama Generik

Antihipertensi
oral
klortalidon
lisinopril

Sediaan dan
Kekuatan

tab 50 mg
Tab 5, 10 dan 20
mg
metildopa
Tab 250 mg
nifedipin
kap 10 mg, tab
20 mg SR, tab 30
mg oros
perindoprilarginin tab 5 mg
propranolol
tab 10 mg
ramipril
tab 2,5 ; 5 dan
10 mg
telmisartan
tab 40 ; 80 mg
valsartan
tab 80 ; 160 mg
verapamil
tab 80, 240 mg

OPRB

X
v
v
v
v
v
v
v
v
v

Keterangan:

Orphan Drugs

Drug List for Diabetes and

Hypertention
Obat Tambahan
tiamin (vitamin B1)

tab 50 mg
v

vitamin B kompleks

Tab

piridoksin (vitamin B6)

Tab 10 mg dan 25 mg

Members Education Activity

Members Fitness Activity

Reimbursment System
Primary Care

Health Care + Drugs Capitation

Health Education for Members Education Fee
Health Status Monitoring package for service

Specialist Care
Health Care Inpatient & Out Patient (Contract to Hospital)
Health Status Monitoring package for service
Health Education for Primary Care Consultant Fee

Supporting Activity by BPJS

Workshop for Primary Care & for Members

Club Activity
Health Promotion Media
Information System, Reminder & Communication

Conclusion
Diabetic cost is increasing
High rate of undiagnosed diabetes
High rate of uncontrolled blood glucose
High rate of complications
Efficacy of treatment depends not only on
medication but also on patients
compliance and healthcare system
The need of health care restructurization to
fit the management of chronic diseases
Improving the quality of care may increase
the cost efectiveness of diabetes
management

Comparison of 2003 and 2008 DiabCare study

Parameter

2003

2008

Age (Yrs)

58.79.3

58.99.5

Duration of diabetes (Yrs)

9.26.6

9.27.2

42.9/57.1

44/56

98.2

97.4

Mean BMI (kg/m2)

24.13.5

25.13.6

Mean A1c (%)

7.92.0

8.11.6

Mean FPG (mmol/l)

8.43.4

7.92.4

Mean PPG (mmol/l)

11.63.9

11.53.6

HDL-cholesterol (mmol/l)

1.30.4

1.30.8

Triglycerides (mmol/l)

2.01.1

1.70.6

Sex (M/F) %
Type 2 DM (%)

 715 DM patients
686 met inclusion/exclusion criteria
12 T1DM and 674 T2DM
Location : 85% urban vs 15% rural
Age : mean 55.16 (SD 10.20) years
Sex : female 54.6% vs male 45.4%
BMI : mean 24.78 (SD 4.02) kg/m 2

IDMPS Indonesia

40.6
59.4
A1c Measurements
No A1cMeasurements

HbA1c
Group
<7%

OGLD
OGLD Insulin
+
Insulin
14.3

HbA1c
8.49
Mean (SD) (1.42)

Diet +
Exerci
se

Total

32.9

15.8

44.4

30.5

8.12
(2.12)

8.58
(2.61)

7.04
(1.18)

8.27
(2.19)

IDMPS Indonesia

Indirect Cost
Variable
Lifestyle
Working productivity
Unemployed
Normal work
Sick leave
Unable to work
Hospitalized
Yes
No
Mean (SD)
Median

Type 2
OGLD
Insulin +

Total

13 (61.9)
8 (38.1)
0
0

283 (54.2)
195 (37.4)
32 (6.1)
12 (2.3)

63 (48.5)
31 (23.8)
32 (24.6)
4 (2.3)

359 (53.3)
234 (34.8)
64 (9.5)
16 (2.4)

2 (12.5)
14 (87.5)
2.5 (2.1)
1.0

41 (12.5)
288 (87.5)
1.2 (0.4)
1.0

26 (28.0)
67 (72.0)
1.0 (0.2)
2.5

69 (15.8)
369 (84.2)
1.1 (0.5)
1.0

Only 34.8% of diabetic patients had normal

work

Resource Use
Type 2

Variable
Specialty
GPs/ internists
Endocrinologists

Lifestyle

OGLD

Insulin +

Total

13 (61.9)
8 (38.1)

387 (74.0)
136 (26.0)

71 (54.6)
59 (45.4)

471 (69.9)
203 (30.1)

105 (60.7)
68 (39.3)

23 (47.9)
25 (52.1)

129 (57.6)
95 (42.4)

332 (95.4)
16 (4.6)

96 (98.0)
2 (2.0)

446 (96.1)
18 (3.9)

Follow up in the last 3 months

By GPs/ internists
Followed up
1 (33.3)
None
2 (66.7)
By endocrinologists
Followed up
13 (100.0)
None
0

Education Session

Variable
Lifestyle
Diabetes education
Given
None
Mean (SD)
Median

8 (40.0)
12 (60.0)
6.8 (4.7)
3.0

Type 2
OGLD
Insulin +
168 (34.6)
317 (65.4)
4.1 (3.3)
3.0

Total

49 (41.2) 225 (36.1)

70 (58.8) 399 (63.9)
4.3 (3.9) 4.2 (3.5)
7.0
3.0

Only 36.1% of diabetic patients had formal

diabetic education session

Expected HbA1c reduction according to

intervention
Intervention

Expected in HbA1c (%)

Lifestyle interventions

1 to 2%

Metformin

1 to 2%

Sulfonylureas

1 to 2%

Insulin
Glinides

1.5 to 3.5%
1 to 1.5%1

Thiazolidinediones

0.5 to 1.4%

-Glucosidase inhibitors

0.5 to 0.8%

GLP-1 agonist

0.5 to 1.0%

Pramlintide

0.5 to 1.0%

DPP-IV inhibitors

0.5 to 0.8%
1. Repaglinide is more effectie than nateglinide
Adapted from Nathan DM, et al. Diabetes Care
2009;32:193-203.

A logical stepwise approach

Basal bolus
Basal plus
Basal plus
Basal insulin

Basal +
2 prandial

Basal +
1 prandial

once daily
(treat-to-target)

Lifestyle
+
Metformin

SU

HbA1c 7.0%

HbA1c 7.0%, FBG on target

PPG 160 mg/dL

Time
54
Adapted from Raccah et al. Diabetes Metab Res Rev 2007;23:257.

Basal +
3 prandial