Objectif du traitement

1
Objectif du traitement

• Recherche du meilleur équilibe glycémique
  possible.
• Prévention des complications à long terme.

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DCCT retinopathy in adolescents
J Pediatr 1994,1251776-88
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DCCT retinopathy vs HbA1c
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DCCT-EDIC

•   intensive treatment of diabetes has extended
  benefit in delaying progression of
  complications 
• JAMA 2003,2902159-67
•  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 2001,39804-12

5
DCCT
Glycosylated hemoglobin in adult (left) and
adolescent (right) patientswith IDDM receiving
intensive or conventional therapy
N Engl J Med 1993,329977-86. J Pediatr
1994,125176-88
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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 1997,20714-20
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 1997,20714-20
9
Linköping Diabetes Complications Study Declining
incidence of nephropathy
N Engl J Med 1994,33015-8
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 2006,492281-90

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Prise en charge globale du diabète

• - Insulinothérapie.
• - Alimentation.
• - Surveillance glycémique.
• - Adaptation des doses dinsuline.
• - Suivi médical.
• - Education.

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Les besoins en insuline
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Fast-acting insulin analogues
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Continuous subcutaneous insulin infusion
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Continuous subcutaneous insulin infusion
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CSII vs MDI
Diabetes Care 2004,271554-8
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CSII vs MDI
Diabetes Care 2004,271554-8
20
Insulin injection regimen and HbA1Cin young
Danish type 1 patients
Diabet Med 1192,9834-9
21
The HvidØre Study Group Persistent
differences among centers over 3 years in
glycemic control.
Diabetes Care 2001,241342-7
Center rank at baseline
22
The HvidØre Study Group Persistent differences
among centers over 3 years
Diabetes Care 2001,241342-7
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 1993,161453- 8
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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
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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
1990,131265-83
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Chez l'enfant et l'adolescent

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

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Education is the keystone of diabetes care and
management.

• ISPAD Consensus Guidelines 2000