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Dr. G. KRZENTOWSKI, Diabétologue ISPPC – CHU Charleroi President Association Belge du Diabète Diabetes.

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Présentation au sujet: "Dr. G. KRZENTOWSKI, Diabétologue ISPPC – CHU Charleroi President Association Belge du Diabète Diabetes."— Transcription de la présentation:

1 Dr. G. KRZENTOWSKI, Diabétologue ISPPC – CHU Charleroi President Association Belge du Diabète Diabetes

2 Diabetes Estimates and Projection Type million 18.1 million 23.7 million Type million157.3 million215.6 million TOTAL110.4 million175.4 million239.3 million

3 Source: Mokdad et al., Diabetes Care 2000;23: Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 1990 No Data 10%

4 Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS Source: Mokdad et al., Diabetes Care 2000;23: No Data 10%

5 Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS Source: Mokdad et al., Diabetes Care 2000;23: No Data 10%

6 Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS Source: Mokdad et al., Diabetes Care 2000;23: No Data 10%

7 Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 1995 Source: Mokdad et al., Diabetes Care 2000;23: No Data 10%

8 Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS Source: Mokdad et al., Diabetes Care 2000;23: No Data 10%

9 Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 1999 Source: Mokdad et al., Diabetes Care 2001;24:412. No Data 10%

10 Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 2000 Source: Mokdad et al., J Am Med Assoc 2001;286:10. No Data 10%

11 Diabetes Trends* Among Adults in the U.S., (Includes Gestational Diabetes) BRFSS 2001 Source: Mokdad et al., J Am Med Assoc 2001;286:10. No Data 10%

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14 Diabète de type 1 Temps Cell.  0 % 10 % 100 % Hérédité Environnement Auto-immunité

15 Diabète de type 2 HEREDITE ENVIRONNEMENT Cell.B R. INS.  Pro. Ins./Ins. Glucotoxicité M Foie ADIP Stockage Utilisation

16 126 mg / dl

17 TYPE 1 TYPE 2 GESTATIONNEL AUTRES OMS Classification ADA 1997

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19 20 ans de diabète de type 255 ans de diabète de type 1 Un petit diabète ?

20 Reduction in life expectancy in type 2 diabetes Age at Diagnostis Marks & Krall 1971 Goodkin 1975 Panzram & Zabel- Langhennig / 15(17) – 1916 – – 2912 – – 3910 – – 498 – 9107 – 8 50 – 596 – 765 – 6 60 – 694 – 553 –

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23 OBESITY LDL HDL Smoking BP Sedentarity

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25 –Amélioration du contrôle glycémique :  12 à 76 % de réduction des complications. –Amélioration du contrôle de la tension artérielle :  24 à 56 % des risques des complications. –Amélioration du contrôle des lipides :  33 à 62 % de réduction des complications. Reduction du Risque des Complications chez les Patients Diabétiques

26 Risk reductions from intervention studies in type 2 diabetes Clinical OutcomesUKPDS Metformine n = 753 UKPDS SU/Ins n = 3867 UKPDS Captopril Atenolol n = 1148 HOT Felodipine Aspirin n = S Simvastatine n = 202 HOPE Ramipril n = 3577 Diabetes-related deaths (%) All-cause mortality (%) All MI (%) Fatal MI (%) All stroke (%)41(+) Fatal stroke (%)25(+) Follow-up (years)

27 Myocardial infarction StrokeDiabetes deaths  42%  39%  41% Median dose = 2550 mg/day Clinical outcomes for metformin in the UKPDS

28 STENO II Study Multifactorial intervention and cardiovascular disease in patients with type 2 diabetes. P. Gaede et al. N.E.J.M. 348 (5) : , 2003

29 315 type 2 diabetic patients with microalbuminuria 160 randomised IntensiveConventional 12 deceased 7 CVD 2 cancer 3 other 15 deceased 7 CHD 5 cancer 3 other 67 patients63 patients Mean follow up 7.8 years

30 Treatment objectives ConventionalIntensive Systolic BP (mmHg)< 160< 135< 140< 130 HbA1c (%)< 7.5< 6.5 Cholesterol (mmol/l)< 6.5< 4.9 < 4.5 Tryglycerides (mmol/l)< 2.2< 2.0< 1.7 ACE-I independent of BPNoYes Aspririn Known ischemiaYes Inferior limb Arteriopathy No Yes No peripheral or central ischemic disease No yes

31 Dietary –< 30 % calorie intake as fat –< 10 % calorie intake as saturated fat –Vitamin supplements Vit C 250 mg/d D-alpha-tocopherol 100 mg/d Folate 400  g/d Chromium 100  g/d Exercise –30 minutes brisk walk 3 to 5 days/week Intensive Intervention Modalities

32 Smoking cessation ACE-I (captopril 50 mg x 2/d) or AT-II if contraindication Statine and/or fibrate Aspirin (150 mg/d) OAD, mixed schema (bedtime NPH) or intensive insulin Follow up every 3 months Intensive Intervention Modalities (Ctd)

33 Number of Patients reaching the Objectives (%) IntensiveConventional HbA1c < 6.5 %15 %< 5 % Cholesterol < 4.5 mmol/l75 %25 % Triglycérides < 1.7 mmol/l 60 %45 % Systolic BP < 130 mmHg47 %20 % Diastolic BP < 80 mmhg75 %60 %

34 Added benefit of intensive treatment at the end of the study : Systolic BP : - 11 mmHg Total cholesterol : mmol/l LDL : mmol/l HbA1c : % Estimated differences between Groups at the End of the Study

35 Primary objective : Cardiovascular events (death, MI, CABG, PTCA, percutaneous angioplasty, peripheral vascular surgery) –24 % vs 44 % –Adjusted relative risk : 0.45 (0.23 – 0.91) NNT in 7.8 years to prevent ONE accident : 5 Secondary objectives : Nephropathy : RR 0.39 (0.17 – 0.87) Retinopathy : RR 0.42 (0.21 – 0.86) Autonomic neuropathy : RR 0.37 (0.18 – 0.79) Peripheral neuropathy : RR 1.09 (0.54 – 2.22) Results

36 A multifactorial approach targeting multiple risk factors at once in microalbuminuric type 2 diabetic patients Results in a reduction of cardiovascular and microvascular events by approximately 50 % Conclusion

37 Prévention primaire du diabète de type 2 EtudesNombresInterventionsDurée (ans) Résultats MALMO6 956 (260 IGT)Lifestyle5RR Diabetes 0.37 DA QING (530 IGT) Lifestyle 6  Diabetes – 42 % FINNISH522 IGTLifestyle 4  Diabetes – 58 % DPP3 234 (IGT ; IFG) Lifestyle and Metformine 3  Diabetes – 58 %  Diabetes – 31 % TRIPOD266 (Previous gestational diabetes) TrogIitazone 2.5  Diabetes : Placebo 12,1 % Troglitazone 5,4 STOP-NIDDM1 429 IGTAcarbose 4 RR Diabetes 0.75 XENDOS3 304 Obèses (21 % IGT) Orlistat 4  Diabetes – 37 %

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41 ADO : – Biguanide – Acarbose – Sulfonylurées – Glinides – Glitazones Traitement du diabète EDUCATIONTHERAPEUTIQUEEDUCATIONTHERAPEUTIQUE

42 INSULINE : – Rapides – Retards – Mélanges – Analogues EDUCATIONTHERAPEUTIQUEEDUCATIONTHERAPEUTIQUE

43 And on the belgian field…


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