Скачать презентацию Reducing Risk in Type 1 Diabetes A Скачать презентацию Reducing Risk in Type 1 Diabetes A

cd4a45bb3f03fc92abc323e78860394a.ppt

  • Количество слайдов: 48

Reducing Risk in Type 1 Diabetes – A Practical Approach Jay S Skyler on Reducing Risk in Type 1 Diabetes – A Practical Approach Jay S Skyler on behalf of the Global Partnership for Effective Diabetes Management This slideset was developed in 2009 with support from Glaxo. Smith. Kline

Global Partnership for Effective Diabetes Management: Identifying and addressing gaps in T 1 DM Global Partnership for Effective Diabetes Management: Identifying and addressing gaps in T 1 DM care • There are considerable gaps in care of adults with T 1 DM: – High proportion continue to develop complications – Majority do not achieve glycemic goals – Patients face many challenges e. g. insulin dose adjustment, hypoglycaemia, impact on daily life Aschner P, et al. Int J Clin Pract 2009: in press.

Global Partnership for Effective Diabetes Management: Identifying and addressing gaps in T 1 DM Global Partnership for Effective Diabetes Management: Identifying and addressing gaps in T 1 DM care • The Global Partnership has developed practical guidance to improve care in T 1 DM by addressing: – management of hyperglycemia – insulin therapy – management of CV risk factors – psychological aspects – team approach to care Aschner P, et al. Int J Clin Pract 2009: in press.

Importance of management of hyperglycemia Importance of management of hyperglycemia

DCCT: Early intensive therapy reduced the incidence of retinopathy and microalbuminuria in T 1 DCCT: Early intensive therapy reduced the incidence of retinopathy and microalbuminuria in T 1 DM Cumulative incidence of retinopathy progression Cumulative incidence of microalbuminuria 54% risk reduction* 60 50 40 Patients (%) 50 Patients (%) 39% risk reduction* 60 Conventional 30 20 Intensive 10 40 Conventional 30 20 Intensive 10 0 1 2 3 4 5 6 7 Time (years) 8 9 *Intensive vs conventional treatment Median Hb. A 1 c during 6. 5 year follow-up period: intensive group, 7. 3%; conventional group, 9. 1%. N = 1441 DCCT Research Group. N Engl J Med 1993; 329: 977– 986. Copyright 1993 Massachusetts Medical Society. All rights reserved.

Cumulative incidence of retinopathy over 10 years in EDIC following DCCT: the ‘legacy effect’ Cumulative incidence of retinopathy over 10 years in EDIC following DCCT: the ‘legacy effect’ Cumulative incidence, % 60 Conventional Intensive 53% risk reduction with intensive therapy, 95% CI, 43%– 61%; P <. 001 50 40 30 20 10 0 0 1 2 3 4 5 6 7 8 9 10 Hb. A 1 c (%) 12 10 8 6 + + P <. 001 ++ ++ ++ <. 001 DCCT 1 closeout 2 . 002 . 08 . 12 . 64 . 84 . 36 . 01 3 4 5 6 7 8 9 Conventional Intensive 10 EDIC study year Error bars are 95% CI. N = 1211 White NH, et al. Arch Ophthalmol 2008; 126: 1707– 1715. Copyright © 2008 American Medical Association. All rights reserved.

Cumulative incidence of non-fatal MI, stroke or death from CVD DCCT/EDIC: glycemic control reduces Cumulative incidence of non-fatal MI, stroke or death from CVD DCCT/EDIC: glycemic control reduces macrovascular complications in T 1 DM 0. 06 57% risk reduction in non-fatal MI, stroke or CVD death* Conventional treatment 0. 04 0. 02 Intensive treatment 0. 00 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 DCCT (intervention period) EDIC (observational follow-up) Years *Intensive vs conventional treatment. N = 1441 DCCT/EDIC Study Research Group. N Engl J Med 2005; 353: 2643– 2653. Copyright 2005 Massachusetts Medical Society. All rights reserved.

Clinic vs ‘real-world’ data: incidence of proliferative retinopathy (DCCT-EDIC/EDC) EDC DCCT – Conventional therapy Clinic vs ‘real-world’ data: incidence of proliferative retinopathy (DCCT-EDIC/EDC) EDC DCCT – Conventional therapy 70 Cumulative incidence, % 60 DCCT – Intensive therapy 50 40 30 20 10 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 Diabetes duration, years Cumulative incidence of proliferative retinopathy or worse DCCT/EDIC Research Group. Arch Intern Med 2009; 169: 1307– 1316. Copyright © 2009 American Medical Association. All rights reserved.

Clinic vs ‘real-world’ data: incidence of nephropathy (DCCT-EDIC/EDC) 40 EDC DCCT – Conventional therapy Clinic vs ‘real-world’ data: incidence of nephropathy (DCCT-EDIC/EDC) 40 EDC DCCT – Conventional therapy Cumulative incidence, % 35 DCCT – Intensive therapy 30 25 20 15 10 5 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 Diabetes duration, years Nephropathy was defined as albumin excretion rate ≥ 300 mg/24 h, serum creatinine ≥ 2 mg/dl, or dialysis or renal transplant DCCT/EDIC Research Group. Arch Intern Med 2009; 169: 1307– 1316. Copyright © 2009 American Medical Association. All rights reserved.

Clinic vs ‘real-world’ data: incidence of CVD (DCCT-EDIC/EDC) 20 EDC DCCT – Conventional therapy Clinic vs ‘real-world’ data: incidence of CVD (DCCT-EDIC/EDC) 20 EDC DCCT – Conventional therapy Cumulative incidence, % 18 DCCT – Intensive therapy 15 13 10 8 5 3 0 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 Diabetes duration, years CVD was defined as: non-fatal myocardial infarction or stroke, CVD death, subclinical MI, angina, angioplasty or coronary artery bypass DCCT/EDIC Research Group. Arch Intern Med 2009; 169: 1307– 1316. Copyright © 2009 American Medical Association. All rights reserved.

Management of hyperglycemia Management of hyperglycemia

Glycemic targets for individuals with T 1 DM Characteristic ADA CDA IDF NICE (UK) Glycemic targets for individuals with T 1 DM Characteristic ADA CDA IDF NICE (UK) < 7. 0% ≤ 7. 0% 6. 2– 7. 5% ≤ 6. 5– 7. 5% Fasting⁄ preprandial glucose, mg⁄dl (mmol/l) 70– 130 (3. 9– 7. 2) 72– 126 (4. 0– 7. 0) 91– 120 (5. 1– 6. 5) 72– 144 (4. 0– 8. 0) Postprandial glucose, mg⁄dl (mmol/l) < 180* (< 10. 0) 90– 180† (5. 0– 10. 0) 136– 160‡ (7. 6– 9. 0) < 180‡ (< 10. 0) Hb. A 1 c ADA = American Diabetes Association; CDA = Canadian Diabetes Association; IDF = International Diabetes Federation; NICE = National Institute for Health and Clinical Excellence The CDA guidelines note that Hb. A 1 c goals and strategies must be tailored to the individual with diabetes, with consideration given to individual risk factors. ADA and CDA glycaemic targets are for type 1 and type 2 diabetes. * Peak postprandial capillary plasma glucose. † 90– 144 mg/dl (5. 0– 8. 0 mmol/l) if Hb. A 1 c target not being met. ‡ Capillary postprandial glucose 1– 2 h after meal. ADA. Diabetes Care 2009; 32(Suppl. 1): S 13–S 61. CDA. Can J Diabetes 2008; 32(Suppl. 1): S 1–S 201. IDF. Desktop guide to Type 1 (insulin-dependent) diabetes, 1998; Brussels: IDF. NICE. Clinical Guideline 15. 2004; London, UK: NICE.

Percentage not reaching Hb. A 1 c target (%) Majority of patients with T Percentage not reaching Hb. A 1 c target (%) Majority of patients with T 1 DM do not reach glycemic targets 74% UK 1 Hb. A 1 c > 7. 5% 81% DCCT-EDIC Intensive 83% EDC 87% DCCT-EDIC Conventional US 2 Hb. A 1 c > 7. 0% 1. Calvert M, et al. BMJ 2009; 338: b 1870. 2. DCCT/EDIC Study Research Group. Arch Intern Med 2009; 169: 1307– 1316.

Managing hyperglycemia in type 1 diabetes The Global Partnership recommends: Aim for as good Managing hyperglycemia in type 1 diabetes The Global Partnership recommends: Aim for as good glycemic control as possible while minimizing the risk of hypoglycemia Ensure regular and appropriate monitoring for complications Aschner P, et al. Int J Clin Pract 2009: in press.

Insulin therapy Insulin therapy

Intensive insulin therapy using a basal-bolus approach: considered best treatment in T 1 DM Intensive insulin therapy using a basal-bolus approach: considered best treatment in T 1 DM • Intensive insulin therapy using a basal-bolus approach, whether as multiple daily injections or pump therapy, is considered best treatment for individuals with T 1 DM regardless of age – Provides greater glycemic control, reduces risk of complications, preserves β-cell function (DCCT)1 -3 • Choice of insulin/mode of delivery should be guided by factors such as: – hypoglycemia, age, lifestyle, general health, motivation, ability for self-management and diet, availability/accessibility 1. DCCT Research Study Group. N Engl J Med 1993; 329: 977– 986. 2. DCCT/EDIC Research Study Group. N Engl J Med 2005; 353: 2643– 2653. 3. DCCT Research Study Group. Ann Intern Med 1998; 128: 517– 523.

DCCT: C-peptide levels decrease with increasing duration of T 1 DM 0. 6 Basal DCCT: C-peptide levels decrease with increasing duration of T 1 DM 0. 6 Basal C-peptide Stimulated C-peptide (nmol/L) 0. 5 0. 4 0. 3 0. 2 0. 1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Duration of T 1 DM (years) Mean ± SEM basal (solid) and stimulated (stripes) C-peptide levels shown for 610 patients, mean age 25 years (range 13– 39 years). C-peptide levels measured following meal challenge Reproduced with permission from DCCT Research Study Group. J Clin Endocrinol Metab 1987; 65: 30– 36.

DCCT: Intensive therapy preserves residual β-cell function 1 Probability of maintaining C-peptide > 0. DCCT: Intensive therapy preserves residual β-cell function 1 Probability of maintaining C-peptide > 0. 2 pmol/m. L 0. 9 0. 8 0. 7 0. 6 0. 5 0. 4 0. 3 Intensive therapy 0. 2 0. 1 Conventional therapy 0 Eligibility Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Number of patients in each treatment group who were evaluated Intensive 138 131 80 53 32 8 2 Conventional 165 150 63 32 22 3 0 DCCT Research Study Group. Ann Intern Med 1998; 128: 517– 523. Copyright © 1998 American Medical Association. All rights reserved.

Hb. A 1 c in T 1 DM is better with continuous subcutaneous insulin Hb. A 1 c in T 1 DM is better with continuous subcutaneous insulin infusion (CSII) Study SMD (random (95% CI) Weight (%) SMD (95% CI) Berg 1998 Ciavarella 1985 De. Vries 2002 Ziegler 1990 Oslo Study 1985– 1988 Chiasson 1984 Hanaire-Broutin 2000 Home 1982 Hoogma 2006 Saurbrey 1988 Schiffrin 1982 Scmitz 1989 7. 90 4. 46 10. 17 9. 67 7. 90 7. 21 10. 41 6. 62 12. 35 8. 60 8. 10 6. 62 -0. 92 (-1. 64, -0. 20) -3. 19 (-4. 43, -1. 95) -0. 81 (-1. 28, -0. 35) 0. 16 (-0. 36, 0. 68) -0. 29 (-1. 01, 0. 42) 0. 33 (-0. 47, 1. 13) -0. 56 (-1. 00, -0. 12) -0. 84 (-1. 72, 0. 04) -0. 22 (-0. 40, -0. 04) 0. 00 (-0. 64, 0. 64) -0. 41 (-1. 10, 0. 28) -1. 36 (-2. 24, -0. 48) Total (95% CI) 100. 00 -0. 55 (-0. 87, -0. 22) -5. 00 -4. 00 -3. 00 -2. 00 -1. 00 Favors CSII 0 1. 00 2. 00 Favors MDI Jeitler K, et al. Diabetologia 2008; 51: 941– 951.

Incidence of severe hypoglycemia is reduced with CSII Study Severe hypoglycemia rate ratio Weight Incidence of severe hypoglycemia is reduced with CSII Study Severe hypoglycemia rate ratio Weight (%) 5. 84 4. 66 5. 11 3. 34 3. 26 2. 19 5. 23 5. 07 5. 87 5. 13 2. 04 5. 75 3. 04 6. 03 5. 60 2. 17 3. 58 5. 40 3. 61 5. 75 5. 61 5. 73 100. 00 Bode (poor control) Bode (good control) Kaderman Maniatis Rizvi Litton Linkeschova Bruttomesso Rudolph, Hirsch Plotnik Cohen Hunger-Dathe Weintrob Weinzimer Mc. Mahon Siegel-Czarkowski Alemzadeh Mack-Fogg Sciaffini Rodrigues Lepore Hoogma Overall (l 2 = 84. 2%, P = 0. 00) 0. 5 Favors MDI 1. 0 2. 0 5. 0 10 Favors CSII SMD (95% CI) 5. 55 (3. 57, 8. 61) 10. 50 (4. 24, 26. 01) 6. 47 (3. 09, 13. 55) 1. 29 (0. 31, 5. 42) 8. 00 (1. 84, 34. 79) 5. 75 (0. 72, 45. 97) 13. 92 (6. 95, 27. 86) 3. 44 (1. 62, 7. 33) 3. 81 (2. 49, 5. 84) 2. 18 (1. 05, 4. 52) 4. 69 (0. 52, 41. 98) 3. 62 (2. 23, 5. 85) 3. 00 (0. 62, 14. 44) 2. 11 (1. 50, 2. 96) 2. 89 (1. 67, 4. 98) 7. 07 (0. 87, 57. 46) 2. 51 (0. 67, 9. 47) 2. 09 (1. 12, 3. 92) 1. 25 (0. 34, 4. 65) 35. 41 (29. 94, 57. 15) 3. 50 (2. 04, 6. 01) 2. 50 (1. 53, 4. 08) 4. 19 (2. 86, 6. 13) 25 Pickup JC & Sutton AJ. Diabet Med 2008; 25: 765– 774. Reprinted by permission of John Wiley & Sons, Inc.

Initiation of insulin The Global Partnership recommends: Initiate basal-bolus regimen as early as possible Initiation of insulin The Global Partnership recommends: Initiate basal-bolus regimen as early as possible Provide all patients with a structured educational programme at initiation of insulin and thereafter Aschner P, et al. Int J Clin Pract 2009: in press.

Adjusting insulin dosages: practical barriers facing individuals with T 1 DM • Patients must Adjusting insulin dosages: practical barriers facing individuals with T 1 DM • Patients must adjust insulin doses in response to many factors to minimize risk of hypo- or hyperglycemia: – carbohydrate intake, lifestyle, exercise, intercurrent illness • Modification of insulin dosages based on diet and exercise should be considered an essential part of patient education – adapted to local diet and lifestyle • Patients may not know the effect of factors such as exercise or alcohol on glucose levels and need for appropriate adjustment of insulin therapy – 64% of patients with T 1 DM do not achieve recommended physical activity levels due to barriers such as fear of hypoglycaemia 1, 2 1. Brazeau AS, et al. Diabetes Care 2008; 31: 2108– 2109. 2. Plotnikoff RC, et al. Med Sci Sports Exerc 2006; 38: 1526– 1534.

Modification of insulin dosages based on diet and exercise: DTTP study Hb. A 1 Modification of insulin dosages based on diet and exercise: DTTP study Hb. A 1 c Severe hypoglycemic episodes (events per patient-year) 10 Hb. A 1 c (%) Severe hypoglycemia 9 8 7 6 5 Baseline 0. 7 0. 6 0. 5 0. 4 0. 3 0. 2 0. 1 1 year Mean difference: – 0. 7% (95% CI – 0. 9 to – 0. 6%, P < 0. 0001) 0 Baseline 1 year Mean difference: − 0. 21 events per patient-year (95% CI − 0. 32 to − 0. 11, P = 0. 0001) Dusseldorf Diabetes Treatment and Teaching Programme (DTTP): N = 9, 583. Samann A, et al. Diabetologia 2005; 48: 1965– 1970.

Precipitating causes of DKA Precipitating factor Percentage of cases Infection 28– 43% Omission/reduction of Precipitating causes of DKA Precipitating factor Percentage of cases Infection 28– 43% Omission/reduction of insulin dose 13– 45% First presentation of diabetes 10– 20% Myocardial infarction No cause identified 1% <40% Wallace TM & Matthews DR. QJM 2004; 97: 773– 780. Reprinted by permission of Oxford University Press.

Self-monitoring blood glucose (SMBG): a fundamental aspect of insulin therapy • SMBG is so Self-monitoring blood glucose (SMBG): a fundamental aspect of insulin therapy • SMBG is so fundamental that insulin therapy should always comprise insulin therapy plus SMBG • Despite clear benefits, up to 64% of patients do not regularly self-monitor 1 • Barriers include patient motivation, psychological barriers, cost, socioeconomic status, education • Patients should receive appropriate training in SMBG when insulin therapy is initiated and periodically thereafter 1. DCCT/EDIC Research Study Group. Arch Intern Med 2009; 169: 1307– 1316.

SMBG ≥ 3 -times per day associated with better glycemic control in T 1 SMBG ≥ 3 -times per day associated with better glycemic control in T 1 DM Estimated Hb. A 1 c (%) 9. 5 9. 0 8. 5 8. 0 7. 5 7. 0 No utilization Less than daily Daily At least 3 x daily Adjusted Hb. A 1 c by strip use (average strips per day) Reproduced from Karter AJ, et al. Am J Med 2001; 111: 1– 9. Copyright 2001 with permission from Elsevier.

Hb. A 1 c (%) JDRF study: Sustained Hb. A 1 c lowering in Hb. A 1 c (%) JDRF study: Sustained Hb. A 1 c lowering in T 1 DM patients with Hb. A 1 c >7. 0% using CGM Treatment time (months) JDRF CGM Study Group. Diabetes Care 2009; 32: 2047– 2049.

Hb. A 1 c (%) JDRF study: Maintained Hb. A 1 c with less Hb. A 1 c (%) JDRF study: Maintained Hb. A 1 c with less hypoglycemia in T 1 DM patients with Hb. A 1 c < 7. 0% using CGM Treatment time (months) JDRF CGM Study Group. Diabetes Care 2009; 32: 2047– 2049.

Self-monitoring of blood glucose The Global Partnership recommends: Ensure that self-monitoring is universally adopted Self-monitoring of blood glucose The Global Partnership recommends: Ensure that self-monitoring is universally adopted as an integral part of insulin therapy Aschner P, et al. Int J Clin Pract 2009: in press.

Hypoglycemia: can affect many aspects of care in T 1 DM • In DCCT, Hypoglycemia: can affect many aspects of care in T 1 DM • In DCCT, severe hypoglycemia three times higher with intensive vs conventional therapy 1, 2 • Almost one-third of patients who experience severe hypoglycemia have a second episode within 4 months 2 • Almost half of severe hypoglycemic episodes occur at night 1 • Risk factors include strict glycemic control, prior episode of severe hypoglycemia, longer duration of diabetes, autonomic neuropathy, hypoglycemia unawareness • In the DCCT, intensively treated patients with greater residual β-cell function had a significantly lower rate of hypoglycemia vs those with less/no residual β-cell function 3 1. DCCT Research Study Group. Am J Med 1991; 90: 450– 459. 2. DCCT Research Group. Diabetes 1997; 46: 271– 286. 3. Steffes M, et al. Diabetes Care 2003; 26: 832– 836.

DCCT: Risk of severe hypoglycemia versus Hb. A 1 c in intensive and conventional DCCT: Risk of severe hypoglycemia versus Hb. A 1 c in intensive and conventional groups 100 Rate per 100 years 80 60 40 20 Intensive Conventional 0 5 6 7 8 9 10 11 12 13 14 Hb. A 1 c (%) during study N = 1, 441 DCCT Research Study Group. Diabetes 1997; 46: 271– 286. Copyright 1997 American Diabetes Association. Reprinted with permission from The American Diabetes Association.

Incidence of hypoglycemia in the DCCT Rate of hypoglycemia ± SE per 100 participant-years* Incidence of hypoglycemia in the DCCT Rate of hypoglycemia ± SE per 100 participant-years* 14. 0 12. 0 10. 0 8. 0 6. 0 4. 0 2. 0 0 Undetectable Minimal Baseline-only Sustained Stimulated C-peptide group *Both treatment groups (intensive and conventional therapy). Undetectable 0. 03 nmol/L; minimal 0. 04– 0. 20 nmol/L; baseline-only (> 0. 2 nmol/L at baseline, < 0. 2 nmol/L thereafter); sustained (> 0. 2 nmol/L at baseline and 1 year later). Rates were compared (horizontally) between stimulated C-peptide groups. Rates between all groups were significantly different (P < 0. 05), except comparison between minimal and baseline-only group Steffes M, et al. Diabetes Care 2003; 26: 832– 836. Copyright 2003 American Diabetes Association. Reprinted with permission from The American Diabetes Association.

Effect of impaired awareness of hypoglycemia in T 1 DM Awareness of hypoglycemia: Normal Effect of impaired awareness of hypoglycemia in T 1 DM Awareness of hypoglycemia: Normal Impaired 80 Subjects (%) 2. 5 2. 0 60 1. 5 40 1. 0 20 0. 5 0 0. 0 Percentage Number of events per year 100 Events Geddes J, et al. Diabetic Med 2008; 25: 501– 504.

Hypoglycemia The Global Partnership recommends: Provide education about prevention, recognition and treatment of hypoglycemia Hypoglycemia The Global Partnership recommends: Provide education about prevention, recognition and treatment of hypoglycemia at initiation of insulin therapy and thereafter Aschner P, et al. Int J Clin Pract 2009: in press.

Management of CV risk factors Management of CV risk factors

Higher absolute risk of CVD in T 1 DM at younger age in men Higher absolute risk of CVD in T 1 DM at younger age in men and women MEN WOMEN Absolute CVD risk per 1000 person-years T 1 DM Without diabetes ≤ 35 years 0. 8 (0. 4 -1. 6) 0. 07 (0. 02 -0. 2) 0. 5 (0. 2 -1. 3) 0. 05 (0. 01 -0. 2) 35 -45 years 4. 8 (3. 2 -7. 1) 1. 1 (0. 8 -1. 6) 3. 5 (2. 1 -6. 1) 0. 2 (0. 09 -0. 6) 45 -55 years 10. 6 (7. 3 -15. 2) 3. 6 (2. 8 -4. 7) 10. 2 (6. 7 -15. 5) 1. 1 (0. 6 -1. 9) 65 -75 years 35. 2 (21. 6 -57. 5) 15. 3 (11. 3 -20. 8) 38. 7 (24. 1 -62. 3) 4. 9 (2. 8 -8. 4) 122. 2 (69. 4 -215. 2) 34. 2 (23. 1 -50. 6) 87. 3 (39. 2 -194. 3) 28. 2 (18. 0 -44. 2) >75 years Soedamah-Muthu SS, et al. Diabetes Care 2006; 29: 798– 804. Copyright 2006 American Diabetes Association. Reprinted with permission from The American Diabetes Association.

Blood pressure, lipid and aspirin therapy Study SBP mm. Hg LDL-C mmol/L (mg/d. L) Blood pressure, lipid and aspirin therapy Study SBP mm. Hg LDL-C mmol/L (mg/d. L) On statins, % On aspirin, % ACCORD 1, 4 127/67 2. 35 (91) 88 76 ADVANCE 2, 4 136/74 2. 64 (102) 47 56 VADT 3, 4 127/68 2. 07 (80) 84 87 1. ACCORD Study Group. N Engl J Med 2008; 358: 2545– 2559. 2. ADVANCE Collaborative Group. N Engl J Med 2008; 358: 2560– 2572. 3. Duckworth W, et al. N Engl J Med 2009; 360: 129– 139. SBP = systolic blood pressure; LDL-C = LDL-cholesterol

Managing cardiovascular risk factors Patients with T 1 DM of ≥ 15 years’ duration Managing cardiovascular risk factors Patients with T 1 DM of ≥ 15 years’ duration and aged >30 should be considered at high risk of CVD CDA. Can J Diabetes 2008; 32(Suppl. 1): S 1–S 201.

Other risk factors The Global Partnership recommends: Manage all CV risk factors Aschner P, Other risk factors The Global Partnership recommends: Manage all CV risk factors Aschner P, et al. Int J Clin Pract 2009: in press.

Psychological aspects Psychological aspects

Depressive symptoms significantly related to Hb. A 1 c in T 1 DM Significant Depressive symptoms significantly related to Hb. A 1 c in T 1 DM Significant positive relationship between BDI score and Hb. A 1 c 12 (r = 0. 44, P < 0. 02) Hb. A 1 c (%) 11 10 9 8 7 6 0 5 10 15 20 Beck Depression Inventory (BDI) score BDI score ≥ 16 indicates possible clinical depression Reproduced with permission from Van Tilburg MA, et al. Psychosom Med 2001; 63: 551– 555.

Disordered eating behavior associated with higher risk of retinopathy & nephropathy in young women Disordered eating behavior associated with higher risk of retinopathy & nephropathy in young women with T 1 DM Diabetic retinopathy at follow-up* Abnormal urinary albumin excretion at follow-up 86% (6/7) 43% (3/7) Moderately disordered 43% (6/14) 20% (3/15) Nondisordered 24% (12/50) 18% (9/50) Disordered-eating status at baseline Highly disordered Values are % (n with complications/total n) Mean age at baseline (±SD): 15± 2 years (range 12– 18) Rydall AC, et al. N Engl J Med 1997; 336: 1849– 1854. Copyright 1997 Massachusetts Medical Society. All rights reserved.

Psychological aspects of type 1 diabetes The Global Partnership recommends: Explore psychological issues associated Psychological aspects of type 1 diabetes The Global Partnership recommends: Explore psychological issues associated with type 1 diabetes and treat/refer, as appropriate Aschner P, et al. Int J Clin Pract 2009: in press.

Team approach to care Team approach to care

A multidisciplinary approach to care • Many complexities involved in treating patients with T A multidisciplinary approach to care • Many complexities involved in treating patients with T 1 DM • Adopting a team approach that involves a broad range of disciplines is essential • Where possible, team should include: patient, diabetes specialist, primary care physician, nurse, dietitian, podiatrist and psychologist/psychiatrist, as well as family and friends. • All members of the team should work together to ensure continuity of care Aschner P, et al. Int J Clin Pract 2009: in press.

A team approach to diabetes care The Global Partnership recommends: Adopt a multidisciplinary team A team approach to diabetes care The Global Partnership recommends: Adopt a multidisciplinary team approach with shared goals and recommendations Aschner P, et al. Int J Clin Pract 2009: in press.

Practical recommendations for the management of adults with T 1 DM • Aim for Practical recommendations for the management of adults with T 1 DM • Aim for as good glycemic control as possible while minimizing the risk of hypoglycemia • Ensure regular and appropriate monitoring for complications • Initiate basal-bolus regimen as early as possible • Provide all patients with a structured educational programme at initiation of insulin and thereafter • Ensure that self-monitoring is universally adopted as an integral part of insulin therapy Aschner P, et al. Int J Clin Pract 2009: in press.

Practical recommendations for the management of adults with T 1 DM • Provide education Practical recommendations for the management of adults with T 1 DM • Provide education about prevention, recognition and treatment of hypoglycaemia at initiation of insulin therapy and thereafter • Manage all CV risk factors • Explore psychological issues associated with T 1 DM and treat/refer, as appropriate • Adopt a multidisciplinary team approach with shared goals and recommendations Aschner P, et al. Int J Clin Pract 2009: in press.