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Diabete
Claudio Maffeis
UOC Pediatria Indirizzo Diabetologico e Malattie del Metabolismo
Centro Regionale Diabetologia Pediatrica
Centro di Riferimento Europeo per la Diabetologia Pediatrica
Università e Azienda Ospedaliera Universitaria Integrata - Verona
IPERTENSIONE
DISLIPIDEMIA
ICTUS
DIABETE
INFARTO
MIOCARDIO
OBESITA’
TUMORI
Survey on etiological diagnosis of diabetes in 1244
Italian diabetic children and adolescents:
Impact of access to genetic testing
0,2
4,9
prevalence (%)
91,8
T1DM
T2DM
Monogenic diabetes
Mozzillo E, Maffeis C, et al. Diabetes Res Clin Pract. 2015;107(3):e15-8
Incidenza di DMT1 Regione Veneto (2008-2012)
Incidenza media di DMT1 in Veneto 2008-2012:
16,5 nuovi casi per 100.000 soggetti per anno
Marigliano M, Maffeis C, et al. Diabetes Res Clin Pract. 2015
Prevalenza di DMT1 Regione Veneto
Prevalenza media di DMT1 in Veneto 2008-2013:
1,26 casi per 1.000 soggetti di età 0-18 anni
Marigliano M, Maffeis C, et al. Diabetes Res Clin Pract. 2015
Estimated 2002 incidence of T1DM (A) and T2DM (B) among
U.S. individuals aged <20 years by age and race/ethnicity.
Imperatore G et al. Diab Care 2012
The Time Is Right for a New Classification System for Diabetes:
Rationale and Implications of the β-Cell–Centric Classification Schema
Schwartz SS, et al. Diabetes 2016
Schwartz SS, et al. Diabetes 2016
A unified model of the relationship between environmental factors,
beta-cell endoplasmic reticulum stress, generation of neoautoantigesns
(HIPs), and loss of immune tolerance that triggers islet autoimmunity
Rewers & Ludvigsson Lancet 2016
Environmental triggers and protective factors for islet autoimmunity and promoters
of progression to type 1 diabetes for which an association has been suggested
What are the fundamental
determinants of metabolic control?
Insulin regimen
Diet
Exercise
Structure of clinical care teams
Motivation
Family support
Mental health
Access to care
Goal setting
Family function
Cameron & Wherrett. Lancet 2015;385:2096-106.
obiettivi di trattamento
• Variabilità glicemica
• Ipoglicemia
• Iperglicemia
Malik FS & Taplin CE Pediatr Drugs 2014;16:141-50
•
•
•
•
•
•
Automonitoraggio
CGM
CSII
Pancreas artificiale
(CHC)
insulina
Evidence of a Strong Association
Between
Frequency
of
SelfMonitoring of Blood Glucose and
Hemoglobin A1c Levels in T1D
Exchange Clinic Registry Participants
13 – 26 years
1 – 13 years
Pumps
13 – 26 years
1 – 13 years
13 – 26 years
Injections
1 – 13 years
Means are adjusted for potential
confounders
Conclusions
There is a strong association between higher
SMBG frequency and lower HbA1c levels.
It is important for insurers to consider that
reducing restrictions on the number of test strips
provided per month may lead to improved
glycemic control for some patients with type 1
diabetes.
Miller KM, et al. Diabetes Care 2013;36:2009-14
CGM
HbA1c according to insulin modality/CGM use
status.
CGM No CGM
CGM No CGM
CGM No CGM
Injection
Pump
Foster NC, et al. Diabetes Care 2016;39
Microinfusore di insulina
Long-term outcome of insulin pump therapy in children with T1D
assessed in a large population-based case–control study
Non pump therapy
Pump therapy
Johnson SR, et al. Diabetologia 2013;56:2392–2400
Closed-loop system for type 1 diabetes therapy (artificial pancreas)
Atkinson MA et al. Lancet 2014
Algoritmo di controllo:
prime applicazioni in uso oggi.
Threshold-Based Insulin-Pump Interruption for Reduction of Hypoglycemia
Bergenstal RM, et al. NEJM 2013;369:224-32
Efficacia del Pancreas Artificiale durante la notte
Effect of Sensor-Augmented Insulin Pump Therapy and Automated
Insulin Suspension vs Standard Insulin Pump Therapy on Hypoglycemia
in Patients With T1D: a Randomized Clinical Trial.
Ly TT, et al. JAMA. 2013;310:1240-1247.
Nocturnal Glucose Control with an Artificial Pancreas at a Diabetes Camp
Artificial
Pancreas
Phillip M, et al NEJM 2013;368:824-33
Control
Systematically In Silico Comparison of Unihormonal
and Bihormonal Artificial Pancreas Systems
Glucose management results of
the standard subject under 4
algorithms, where the whole
testing duration is 24 h
Gao X, et al. Computat Math Met Med, 2013
Systematically In Silico Comparison of Unihormonal
and Bihormonal Artificial Pancreas Systems
The blood glucose curves of ten virtual subjects under two proposed therapies
P-type therapy
PD-type therapy
Gao X, et al. Computat Math Met Med, 2013
Pancreas Artificiale: il progetto italiano in età
pediatrica (Bardonecchia 2015).
Gruppo di Ricerca:
Diabetologia Pediatrica di:
1.Verona;
2.Milano;
3.Torino;
4.Roma;
5.Napoli.
Università di Padova: Diabetologia dell’adulto e Ingegneria
Medica
Università di Pavia: Ingegneria Medica.
Del Favero S et al. Diab Care 2016
Microinfusore
Sensore
per la glicemia
DiAS (pancreas artificiale)
32 bambini (età 5-9 anni)  randomizzati in due gruppi
A
B
3 giorni
3 giorni
SAP
SAP
(microinfusore + sensore)
(microinfusore + sensore
DiAS
DiAS
(pancreas artificiale)
(pancreas artificiale)
TeleMonitoraggio
Take home message
La tecnologia consentirà a breve di disporre di strumenti
dotati di intelligenza artificiale che potranno migliorare
ulteriormente il controllo metabolico del diabete del
bambino e dell’adolescente.
Il pediatra insieme al paziente e alla sua famiglia dovrà
quindi acquisire nuove competenze per assicurare un
livello di cura ottimale del diabete.
The use and efficacy of continuous glucose monitoring in T1D
treated with insulin pump therapy: a randomised controlled trial
Battelino T, et al. Diabetologia 2012;55:3155-62