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