5. Stimule la captation de glucose par le foie
Stimule la glycogénogenèse
Inhibe glycogénolyse
Inhibe la néoglucogenèse hépatique
Stimule la captation
de glucose par le muscle
Stimule la captation
de glucose par le T adipeux
25. Mean A1C at Last Visit* (%)
10
9.6%
8.9%
9
8
Combination
oral agents
8.6%
SU or
metformin
Diet and
Exercise
7
ADA Goal
2.5 Years
2.9 Years
2.8 Years
8.2 Years
Initiation
of
insulin therapy
Years Elapsed Since Initial Diagnosis
*Adapted from: Brown JB et al. Diabetes Care. 2004;27:1535-1540.
31. • le choix du patient :
Le patient accepte-t-il le traitement injectable?
Le nombre d’injections ?
• les objectifs glycémiques et la capacité du patient a les atteindre
• l’autonomie du patient :
Peut-il gérer son traitement seul?
Nécessite t il une infirmier(ère) ou une tiers personne ?
• les profils glycémiques : y a-t-il une
hyperglycémie a jeun isolée ou associée a une ou plusieurs hyperglycémies
postprandiales ?
• le mode de vie du patient :
le type d’alimentation
horaires des repas et teneur glucidique
l’activité physique
32.
33. Blood Glucose (mg/dL)
100
90
80
70
60
50
40
Arret de l’insulino secretion
Secretion de Glucagon, Epinephrine,
ACTH, Cortisol, STH
Palpitation, Sueur
Troubles de la conscience du comportment
30
20
10
Mort neuronale
0
Moghissi E, et al. Endocr Pract. 2013;Feb 20:1-33. [Epub ahead of print].
34. Percentage of Patients Treated in 1 Year
6%
Mixtures, Rapid-acting, Basal-bolus
5%
NPH
4%
Basal
3%
2%
1%
0
Sulfonylureas
Meglinitides
DPP-4 inhibitors, GLP-1 receptor agonists,
Metformin, TZDs
Moghissi E, et al. Endocr Pract. 2013;Feb 20:1-33. [Epub ahead of print].
36. ADA-EASD
2012
Les cibles glycémiques
HbA1c <7,0%
Préprandiale PG <1.30 g / l
Postprandiale PG <1.80 g / l
Objectifs plus stricts (de 6,0 à 6,5%)
Sujet jeune bien portant ;diabète récent
Objectifs moins stricts (de 7,5 à 8,0%)
Comorbidités, risque d'hypoglycémie D ancien
Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print]
37. ADA-EASD
2012
Motivation et capacité a se prendre en
charge
Risque d’ hypoglycémie
Durée du diabète
Esperance de vie
Comorbidite associées
Complication vasculaires
Moyens et éducations
Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print]
(Adapted with permission from: Ismail-Beigi F, et al. Ann Intern Med 2011;154:554)
78. Per os
projet de recherche prometteur à
l’Institut Charles Sadron de
Strasbourg.
Trans cutanée
Inhalée
79. L’insuline inhalée : EXUBERA ®
Commercialisée en 2006
Abandonnée en 2008
Complications respiratoires et surtout risque accru de cancer du poumon
80. Les patch pompes
Les patch infusent de l’insuline
sans nécessité de tubulures
La commande de l’infusion d’insuline
(débits de base et bolus) se fait par
l’intermédiaire d’une télécommande.
87. DIABÈTE: Une injection unique de nanoPERSPECTIVES
insuline pour 10 jours de tranquillité
invention du Massachusetts Institute of Technologie (MIT)
nanoparticules , serait capable, avec une injection unique
de maintenir un taux de glycémie normal durant… 10 jours.
ACS Nano May 2, 2013 DOI: 10.1021/nn400630x
Injectable Nano-Network for Glucose-Mediated Insulin Delivery
91. Régime méditerranéen + huile d’olive
7 January 2014 Annals of Internal Medicine Volume 160 • Number 1
Notes de l'éditeur
Depiction of the elements of decision-making used to determine appropriate efforts to achieve glycaemic targets. Greater concerns about a particular domain are represented by increasing height of the ramp. Thus, characteristics/predicaments towards the left justify more stringent efforts to lower HbA1c, whereas those towards the right are compatible with less stringent efforts. Where possible, such decisions should be made in conjunction with the patient, reflecting his or her preferences, needs and values. This ‘scale’ is not designed to be applied rigidly but to be used as a broad construct to help guide clinical decisions. Adapted with permission from Ismail-Beigi et al [ref 20]
Premix insulin is recommended by IDF T2DM treatment algorithm at insulin start and intensification
Basal insulin alone is usually the optimal initial regimen, beginning at 0.1-0.2 U/kg body weight, depending on the degree of hyperglycemia. It is usually prescribed in conjunction with 1-2 non-insulin agents. In patients willing to take >1 injection and who have higher A1c levels (≥9.0%), BID pre-mixed insulin or a more advanced basal plus mealtime insulin regimen could also be considered (curved dashed arrow lines). When basal insulin has been titrated to an acceptable FPG but A1c remains above target, consider proceeding to basal + meal-time insulin, consisting of 1-3 injections of rapid-acting analogues. A less studied alternative—progression from basal insulin to a twice daily pre-mixed insulin—could be also considered (straight dashed arrow line); if this is unsuccessful, move to basal + mealtime insulin. The figure describes the number of injections required at each stage, together with the relative complexity and flexibility. Once a strategy is initiated, titration of the insulin dose is important, with dose adjustments made based on the prevailing BG levels as reported by the patient. Non-insulin agents may be continued, although insulin secretagogues (sulfonylureas, meglitinides) are typically stopped once more complex regimens beyond basal insulin are utilized. Comprehensive education regarding self-monitoring of BG, diet, exercise, and the avoidance of, and response to, hypoglycemia are critical in any patient on insulin therapy.
