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Objectif du traitement

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.

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Objectif du traitement

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  1. Objectif du traitement Recherche du meilleur équilibe glycémique possible. Prévention des complications à long terme.

  2. 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 Conventional (N) : 70 44 29 20 Intensive (N) : 52 34 23 18 DCCT : retinopathy in adolescents J Pediatr 1994,125:1776-88

  3. 16 14 12 10 Rate of progression of retinopathy (per 100 patient-years) 8 6 4 2 0 5.0 5.5 6.0 6.5 7.0 7.5 8.0 8.5 9.0 9.5 10.0 10.5 Glycosylated hemoglobin (%) DCCT : retinopathy vs HbA1c

  4. 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

  5. Conventional Glycosylated Hemoglobin (%) Intensive Year of study Year of study DCCT Glycosylated hemoglobin in adult (left) and adolescent (right) patientswith IDDM receiving intensive or conventional therapy N Engl J Med 1993,329:977-86. J Pediatr 1994,125:176-88

  6. The Hvidoere Study Groupon Childhood Diabetes Belgium - Canada - Denmark - Finland – France Germany - Ireland - Italy - Japan – Macedonia Netherlands - Norway - Portugal - Spain Sweden - Switzerland - UK – USA

  7. The Hvidoere Study Group Number of children (per cent of total) HbA1c per cent Percentage distribution of HbA1C values in 1,443 boys and 1,430 girls with IDDM Diabetes Care 1997,20:714-20

  8. The Hvidoere Study Group * * HbA1c per cent Age (years) Age specific mean values for HbA1C values in 1,443 boys and 1,430 girls with IDDM Diabetes Care 1997,20:714-20

  9. Onset of diabetes 1961-65 (n = 57) 1966-70 (n = 50) 1971-75 (n= 55) 1976-80 (n = 51) 30 20 Cumulative incidence (%) 10 0 0 10 20 30 Duration of Diabetes (yr) Linköping Diabetes Complications Study Declining incidence of nephropathy N Engl J Med 1994,330:15-8

  10. 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

  11. Prise en charge globale du diabète - Insulinothérapie. - Alimentation. - Surveillance glycémique. - Adaptation des doses d’insuline. - Suivi médical. - Education.

  12. Réveil Soir Réveil Les besoins en insuline

  13. Morning Evening Morning Fast-acting insulin analogues

  14. Morning Evening Morning Continuous subcutaneous insulin infusion

  15. Morning Evening Morning Continuous subcutaneous insulin infusion

  16. Evening Morning Evening

  17. Morning Evening Morning

  18. CSII vs MDI Diabetes Care 2004,27:1554-8

  19. CSII vs MDI Diabetes Care 2004,27:1554-8

  20. Insulin injection regimen and HbA1Cin young Danish type 1 patients Diabet Med 1192,9:834-9

  21. The HvidØre Study Group Persistent differences among centers over 3 years in glycemic control. Diabetes Care 2001,24:1342-7 Center rank at baseline

  22. The HvidØre Study GroupPersistent differences among centers over 3 years Diabetes Care 2001,24:1342-7

  23. 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

  24. 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

  25. 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

  26. "...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

  27. Chez l'enfant et l'adolescent Les facteurs alimentaires, psychologiques et culturels ont plus de poids sur l'HbA1c que le nombre des injections.

  28. Education is the keystone of diabetes care and management. ISPAD Consensus Guidelines 2000

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