Presse Med
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The 2008-year was full of learning experience and suspense in diabetologia. The past studies, UKPDS in type 2 diabetic patients and DCCT in type 1 diabetic patients have shown that intensive treatment during a short period did reduce the incidence of microvascular events and in the long term, the incidence of macrovascular events linked to diabetes. The conclusions of recent studies quote, from ACCORD, an increased mortality in the type 2 diabetic patients using intensive therapy, from ADVANCE, a reduction of microvascular complications and from VADT, no effect. ⋯ Moreover, to define HbA1c objective, age, duration of diabetes, presence of cardiovascular risk factors, former HbA1c level and potential undesirable effects, such hypoglycaemia, must be considered. The management of type 2 diabetic patients requires an early, not to quick intensive treatment, which avoids hypoglycaemia and is combined with a strict control of cardiovascular risk factors. So, the recent position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) consideres needs and preferences of each patient and individualizes glycemic targets and treatments.
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In France, 2.8 millions of patients have type 2 diabetes, which is a well-established risk factor for cardiovascular disease. In about 15 years, several large clinical trials tried to study the relationship between a tight glycaemic control and the occurrence of micro- and macroangiopathy. Meta-analyses of targeting intensive versus conventional glycaemic control focused on divergent results. ⋯ Worries about the excess of mortality observed in the ACCORD study in the intensive treatment group were not described in other studies. The decrease of mortality was not associated with an intensive glyceamic control. Intensified multifactorial intervention is finally needed to improve microangiopathy.
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Patient education emerged initially as an essential component of the management of type 1 diabetes. Patient education has also been for long an integral part of the recommendations for managing type 2 diabetes. ⋯ However, if we return to the foundations of patient education definition, we cannot summarize the effectiveness of patient education on the only decrease of HbA1c. So, if the aim of patient education is to support patients to take better care of themselves, it might be interesting to use other types of evaluation methodology, including qualitative studies, to reflect the different dimensions of patient education, especially psychosocial.
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Once lifestyle measures implemented, if hyperglycemia persists, above individual HbA1c targets, a medication should be started in type 2 diabetic patients (T2DM). First, unless exception, an oral antidiabetic drug. Except in case of intolerance, the initial monotherapy, metformin remains the strengthening treatment. ⋯ A recommendation that prioritizes the costs of the strategies. An absolutely critical issue, while admitting not to have the tools to measure them in all their dimensions. Finally, we must reconsider every treatment after a maximum of 6 months of use, if the results are deemed inadequate substitute rather than adding drugs.
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Non-adherence is a frequent phenomenon with a major impact in terms of care efficiency and cost. Non-adherence in patients with type 2 diabetes concerns all the tasks of the treatment, including in particular changes of lifestyle. ⋯ It represents a general problem, concerning any chronic disease and which reflects new medical paradigms. The ambition to want "to improve adherence" requires a discussion from an ethical point of view.