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Objectif du traitement. Recherche du meilleur équilibe glycémique possible. Prévention des complications à long terme. 70. 60. 50. 40. Cumulative percent of subjects with a 3.step progression. 30. 20. p = 0.048. 10. 0. Year of study. 0. 1. 2. 3. 4. 5. 6. 7. 8. 9. - PowerPoint PPT Presentation
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Objectif du traitement
Recherche du meilleur équilibe glycémique possible.Prévention des complications à long terme.
0 1 65432 7 8 9
10
0
20
50
30
40
70
60
Conventional (N) : 70 44 2920
Intensive (N) : 52 34 2318
Year of study
p = 0.048
Cu
mu
lati
ve p
erce
nt
of
sub
ject
sw
ith
a 3
.ste
p p
rog
ress
ion
DCCT : retinopathy in adolescents
J Pediatr 1994,125:1776-88
5.0 5.5 6.56.0 7.57.0 8.58.0 9.59.0 10.510.0
0
2
4
6
8
10
12
14
16
Glycosylated hemoglobin (%)
Rat
e o
f p
rog
ress
ion
of
reti
no
pat
hy
(per
100
pat
ien
t-ye
ars)
DCCT : retinopathy vs HbA1c
DCCT-EDIC
« … intensive treatment of diabetes has extended benefit in delaying progression of complications… »
JAMA 2003,290:2159-67
« …provide further support for the recommendation that adolescents receive therapy aimed at achieving glycemic control as close to normal as possible to reduce the risk of microvascular complications. »
J Pediatr 2001,39:804-12
N Engl J Med 1993,329:977-86. J Pediatr 1994,125:176-88
Intensive
Conventional
Year of study
Gly
co
sy
late
d H
em
og
lob
in (
%)
Year of study
Glycosylated hemoglobin in adult (left) and adolescent (right) patientswith IDDM receiving intensive or conventional therapy
DCCT
Belgium - Canada - Denmark - Finland – France
Germany - Ireland - Italy - Japan – Macedonia
Netherlands - Norway - Portugal - Spain
Sweden - Switzerland - UK – USA
The Hvidoere Study Groupon Childhood Diabetes
HbA1c per cent
Nu
mb
er
of
ch
ild
ren
(p
er
ce
nt
of
tota
l)
Percentage distribution of HbA1C values in 1,443 boys and 1,430 girls with IDDM
Diabetes Care 1997,20:714-20
The Hvidoere Study Group
Age (years)
Hb
A1c
pe
r c
en
t
Age specific mean values for HbA1C values in 1,443 boys and 1,430 girls with IDDM
**
The Hvidoere Study Group
Diabetes Care 1997,20:714-20
Linköping Diabetes Complications Study
Declining incidence of nephropathy
Duration of Diabetes (yr)
Cum
ula
tive
inci
denc
e (%
)
Onset of diabetes1961-65 (n = 57)1966-70 (n = 50)1971-75 (n= 55)1976-80 (n = 51)
30
20
10
00
10 20 30
N Engl J Med 1994,330:15-8
Microangiopathy in adolescents
The risk of complications is:
- decreasing
DCCT, Hvidoere Study Group …
- high in adolescence
Linköping Diabetes Complications Study …
- « …predicted by potentially modifiable factors. »
Diabetologia 2006,49:2281-90
Prise en charge globale du diabète
- Insulinothérapie.- Alimentation.- Surveillance glycémique.- Adaptation des doses
d’insuline.- Suivi médical.- Education.
Réveil Soir Réveil
Les besoins en insuline
Fast-acting insulin analogues
Morning Evening Morning
Continuous subcutaneous insulin infusion
Morning Evening Morning
Continuous subcutaneous insulin infusion
Morning Evening Morning
Evening Morning Evening
Morning Evening Morning
CSII vs MDI
Diabetes Care 2004,27:1554-8
CSII vs MDI
Diabetes Care 2004,27:1554-8
Insulin injection regimen and HbA1Cin young Danish type 1 patients
Diabet Med 1192,9:834-9
Center rank at baseline
The HvidØre Study Group
Persistent differencesamong centers over 3 years
in glycemic control.
Diabetes Care 2001,24:1342-7
The HvidØre Study Group Persistent differences among centers over 3 years
Diabetes Care 2001,24:1342-7
DCCTLe rôle du comportement alimentaire
Adherence to diet
Excess food to treat hypoglycemia
Snacking behavior
Food intake/insulin dose adjustment
Timing insulin/meals
Diabetes Care 1993,16:1453- 8
Le rôle des troubles du comportement alimentaire
The incidence of bulimia nervosa and sub-threshold eating disorders is increased in female adolescents with type 1 diabetes
… an increased level of retinopathy.
The incidence of insulin omission or misuse in females with type 1 diabetes is 12-15 %.
… poor glycemic control and an increased risk of complications.
Australian Clinical Practice Guidelines: Type 1 diabetes in children and adolescents
Autres facteurs de risque
Non-adherence with treatment regimens is common when:
- the parents or child have a low level of education;
- there is a low level of cohesion within the family;
- self-care autonomy is promoted or impeded at an inappropirate time;
- an underlying psychiatric disorder is present.
Australian Clinical Practice Guidelines: Type 1 diabetes in children and adolescents
"...Every patient can benefit from psychological support"
"Patient motivation is perhaps the determining factorin treatment success or failure"
Hirsch IB et al, Diabetes Care 1990,13:1265-83
Chez l'enfant et l'adolescent
Les facteurs alimentaires,
psychologiques et culturels ont plus de
poids sur l'HbA1c que le nombre des
injections.
Education is the keystone
of diabetes care and management.
ISPAD Consensus Guidelines 2000
Recommended