dr. g. krzentowski, diabétologue isppc – chu charleroi president association belge du diabète...
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Dr. G. KRZENTOWSKI, Diabétologue ISPPC – CHU CharleroiPresident Association Belge du Diabète
Diabetes Diabetes
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Diabetes Estimates and Projection 1994 - 2010
1994 2000 2010
Type 1 11.5 million 18.1 million 23.7 million
Type 2 98.9 million 157.3 million 215.6 million
TOTAL 110.4 million 175.4 million 239.3 million
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Source: Mokdad et al., Diabetes Care 2000;23:1278-83.
Diabetes Trends* Among Adults in the U.S.,(Includes Gestational Diabetes)
BRFSS 1990
No Data <4% 4%-6% 6%-8% 8%-10% >10%
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Diabetes Trends* Among Adults in the U.S.,(Includes Gestational Diabetes)
BRFSS 1991-92
Source: Mokdad et al., Diabetes Care 2000;23:1278-83.
No Data <4% 4%-6% 6%-8% 8%-10% >10%
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Diabetes Trends* Among Adults in the U.S.,(Includes Gestational Diabetes)
BRFSS 1993-94
Source: Mokdad et al., Diabetes Care 2000;23:1278-83.
No Data <4% 4%-6% 6%-8% 8%-10% >10%
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Diabetes Trends* Among Adults in the U.S.,(Includes Gestational Diabetes)
BRFSS 1995-96
Source: Mokdad et al., Diabetes Care 2000;23:1278-83.
No Data <4% 4%-6% 6%-8% 8%-10% >10%
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Diabetes Trends* Among Adults in the U.S.,(Includes Gestational Diabetes)
BRFSS 1995
Source: Mokdad et al., Diabetes Care 2000;23:1278-83.
No Data <4% 4%-6% 6%-8% 8%-10% >10%
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Diabetes Trends* Among Adults in the U.S.,(Includes Gestational Diabetes)
BRFSS 1997-98
Source: Mokdad et al., Diabetes Care 2000;23:1278-83.
No Data <4% 4%-6% 6%-8% 8%-10% >10%
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Diabetes Trends* Among Adults in the U.S.,(Includes Gestational Diabetes)
BRFSS 1999
Source: Mokdad et al., Diabetes Care 2001;24:412.
No Data <4% 4%-6% 6%-8% 8%-10% >10%
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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 <4% 4%-6% 6%-8% 8%-10% >10%
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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 <4% 4%-6% 6%-8% 8%-10% >10%
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Diabète de type 1
Temps
Cell.
0 %
10 %
100 %
Hérédité
Environnement
Auto-immunité
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Diabète de type 2
HEREDITE
ENVIRONNEMENT
Cell.B
R. INS.
Pro. Ins./Ins.
Glucotoxicité
M
Foie
ADIP
Stockage
Utilisation
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126 mg / dl
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• TYPE 1• TYPE 2• GESTATIONNEL• AUTRES
OMS
Classification ADA 1997
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20 ans de diabète de type 2 55 ans de diabète de type 1
Un petit diabète ?
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Reduction in life expectancy in type 2 diabetes
Age at Diagnostis
Marks & Krall 1971
Goodkin 1975
Panzram & Zabel-Langhennig 1981
10 / 15 (17) 27 -
15 – 19 16 – 17 23 -
20 – 29 12 – 14 16 -
30 – 39 10 – 11 11 -
40 – 49 8 – 9 10 7 – 8
50 – 59 6 – 7 6 5 – 6
60 – 69 4 – 5 5 3 – 4
70 + - - 3
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OBESITY
LDL
HDL
Smoking
BP
Sedentarity
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– 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
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Risk reductions from intervention studies in type 2 diabetes
Clinical Outcomes UKPDS Metformine
n = 753
UKPDS
SU/Ins n = 3867
UKPDS
Captopril Atenolol n =
1148
HOT Felodipine Aspirin n = 1501
4S Simvastatine
n = 202
HOPE Ramipril
n = 3577
Diabetes-related deaths (%)
42 10 32 67 36 37
All-cause mortality (%) 36 6 18 43 43 24
All MI (%) 39 16 21 51 55 22
Fatal MI (%) 50 6 28 - - -
All stroke (%) 41 (+) 11 44 30 62 33
Fatal stroke (%) 25 (+) 17 58 - - -
Follow-up (years) 10.7 10.7 8.4 3.8 5.4 4.5
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Myocardialinfarction StrokeDiabetes deaths
42% 39% 41%
Median dose = 2550 mg/day
Clinical outcomes for metformin in the UKPDS
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STENO II Study
Multifactorial intervention and cardiovascular
disease in patients with type 2 diabetes.
P. Gaede et al. N.E.J.M. 348 (5) : 383-393, 2003
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315 type 2 diabetic patients with microalbuminuria
160 randomised
Intensive Conventional
12 deceased
7 CVD
2 cancer
3 other
15 deceased
7 CHD
5 cancer
3 other
67 patients 63 patients
Mean follow up
7.8 years
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Treatment objectives
Conventional Intensive
1993-99 2000-01 1993-99 2000-01
Systolic BP (mmHg) < 160 < 135 < 140 < 130
HbA1c (%) < 7.5 < 6.5 < 6.5 < 6.5
Cholesterol (mmol/l) < 6.5 < 4.9 < 4.9 < 4.5
Tryglycerides (mmol/l) < 2.2 < 2.0 < 1.7 < 1.7
ACE-I independent of BP No Yes Yes Yes
Aspririn
Known ischemia Yes Yes Yes Yes
Inferior limb
Arteriopathy
No No Yes Yes
No peripheral or central ischemic disease
No No No yes
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• 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
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• 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)
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Number of Patients reaching the Objectives (%)
Intensive Conventional
HbA1c < 6.5 % 15 % < 5 %
Cholesterol < 4.5 mmol/l 75 % 25 %
Triglycérides < 1.7 mmol/l
60 % 45 %
Systolic BP < 130 mmHg 47 % 20 %
Diastolic BP < 80 mmhg 75 % 60 %
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Added benefit of intensive treatment at the end of
the study :
• Systolic BP : - 11 mmHg
• Total cholesterol : - 1.21 mmol/l
• LDL : - 0.87 mmol/l
• HbA1c : - 0.7 %
Estimated differences between Groups at the End of the Study
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• 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
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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
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Prévention primaire du diabète de type 2
Etudes Nombres Interventions Durée (ans)
Résultats
MALMO 6 956 (260 IGT) Lifestyle 5 RR Diabetes 0.37
DA QING 110 660 (530 IGT)
Lifestyle 6 Diabetes – 42 %
FINNISH 522 IGT Lifestyle 4 Diabetes – 58 %
DPP 3 234 (IGT ; IFG)
Lifestyle and Metformine
3 Diabetes – 58 %
Diabetes – 31 %
TRIPOD 266 (Previous gestational diabetes)
TrogIitazone 2.5 Diabetes : Placebo 12,1 %
Troglitazone 5,4
STOP-NIDDM 1 429 IGT Acarbose 4 RR Diabetes 0.75
XENDOS 3 304 Obèses (21 % IGT)
Orlistat 4 Diabetes – 37 %
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ADO :
– Biguanide
– Acarbose
– Sulfonylurées
– Glinides
– Glitazones
Traitement du diabète E
D
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A
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Traitement du diabète
INSULINE :
– Rapides
– Retards
– Mélanges
– Analogues
E
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A
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N
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And on the belgian field…