Kenneth C. Copeland, MD

Milburn Professor and Section Chief Pediatric Diabetes/Endocrinology

OU Children’s Diabetes CenterUniversity of Oklahoma

AAP Clinical Practice Guidelines:

Management of Newly DiagnosedType 2 Diabetes Mellitus inChildren and Adolescents

DISCLOSURE STATEMENT

None for this presentation

Goals for this presentation

• To know the Key Action Statements from the recent AAP report on Evidence-based Guidelines for the Management of type 2 Diabetes in Youth.

• To apply the Guidelines to cases encountered in clinical practice

New Cases of Type 2 Diabetes in Youth %

ne

w o

nse

t p

ati

en

ts w

ith

T2

DM

0

5

10

15

20

25

30

35

87 88 89 90 91 92 93 94 95 96

Journal of Pediatrics 136:664, 2000

AAP Clinical Practice Guidelines:

Management of Newly Diagnosed Type 2 Diabetes Mellitus in Children and Adolescents

Pediatrics, 131(2), 364–382, 2013, PMID: 23359584

Response to the emergence of type 2 diabetes in youth, especially those of ethnic minority background…..

o who may have limited access to medical specialty care,

o who may live in extremely rural locations.

Scarcity of Pediatric Diabetes subspecialists, especially in certain parts of the country.

Less than ideal levels of confidence of pediatricians, and (perhaps) overconfidence of family physicians, in treating these youth.

Rationale for the Guidelines

Primary Goal of the GuidelinesTo better equip the “generalist” (pediatrician or family doctor) to deal with this disease, especially when a pediatric diabetes doctor is not available

TM

Case #1

A 12-year-old obese Mexican American female has a 3-month history of polyuria, polydipsia, and has noted a 3-pound weight loss. Her blood glucose (BG) level is 354 mg/dl and she has moderate ketones on urinalysis. Her A1c level is 9.2%. Her father and maternal grandmother have type 2 diabetes (T2DM).

Questions:

o What type of diabetes does she have?

o Does she need any additional testing?

o What is the proper initial therapy for her?

o After BG levels return to normal, whatwould you treat her with?

Ketone Strips

Ketone strip with vial and BG meter with high BG level

TM

AAP Key Action Statement #1

Clinicians must ensure that insulin therapy is initiated for children and adolescents with T2DM

o Who are ketotic or in diabetic ketoacidosis,

o Who have venous or plasma BG levels >250 mg/dl

o Who have hemoglobin A1c >9 percent; or

o In whom the distinction between type 1 and type 2 diabetes is unclear.

TM

So….for Case #1

A 12-year-old obese Mexican American female has a 3-month history of polyuria, polydipsia, and has noted a 3-pound weight loss. Her blood glucose (BG) level is 354 mg/dl and she has moderate ketones on urinalysis. Her A1c level is 9.2%. Her father and maternal grandmother have type 2 diabetes (T2DM).

Questions:

o What type of diabetes does she have?

o Does she need any additional testing?

o What is the proper initial therapy for her?

o After BG levels return to normal, whatwould you treat her with?

TM

Case #2

A 16-year-old obese Native American female has a 6-month history of polyuria and polydipsia, coincident with a 56-pound weight gain over the last year and profound darkening of her skin beneath her neck and under her arms. Her weight is 228 pounds. Her BG is 226 mg/dl and her A1c is 7.4%. She has no ketones on urinalysis.

Questions:o Does she have diabetes?

o What type of diabetes doesshe have?

o What is the proper initialtherapy for her?

TM

AAP Key Action Statement #2

In all other instances, clinicians should:

Initiate a lifestyle modification program, including nutrition and physical activity,

AND

Start metformin as first-line therapy for children and adolescents at the time of diagnosis with T2DM.

Barriers to Accurate Classification

20–25% of patients newly diagnosed with type 1 diabetes mellitus (T1DM) are obese.

≥15% of minority populations have a +FH of T2DM.

3X increase in FH of T2DM among patients with T1DM.

Overlap of C-Peptide measurements at onset and first year.

~10% of typical pediatric T2DM cases have diabetes-specific autoimmunity markers.

~30% T2DM cases have ketosis at disease onset.

Classification of Diabetes

Laboratory Teststhat might help distinguish type 1 from type 2 diabetes

Islet autoantibodies Islet antibodies (ICA)

Glutamic acid decarboxylase (GAD)

Insulin-associated protein-2 (IA-2)

Insulin autoantibodies (IAA)

Zinc transporter autoantibodies (ZnT8)

C-Peptide / insulin levels After 1st year

Lipid profile

AAP Key Action Statement #3

The committee suggests that clinicians monitor A1c levels every three months and intensify* treatment if treatment goals for BG and A1c levels are not being met.

*Intensification might include: Increase frequency of clinic visits

Engage in more frequent BG monitoring

Add one or more “anti-diabetic” medications

Adjust dose of current medication

Meet with dietitian or diabetes educators

Meet with psychologist or social worker

Increase attention to diet and exercise regimens

A1c and BG Targets

A1c

o Ideal <7%

o Must individualize with realistic goals

Blood Glucose

o Fasting blood glucose 70–130 mg/dL

AAP Key Action Statement #4

The committee suggests that clinicians advise patients to monitor finger-stick BG levels in those who:o Are taking insulin or other medications with a risk of

hypoglycemia; or

o Are initiating or changing their diabetes treatment regimen; or

o Have not met treatment goals; or

o Have intercurrent illnesses.

Monitoring frequency may be modified once BG levels are at target for patients who are not on insulin and whose A1c is <7%.

The committee suggests that clinicians incorporate the Academy of Nutrition and Dietetics’ Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines in their dietary or nutrition counseling:

• At the time of diagnosis

• As part of on-going management

AAP Key Action Statement #5

AAP Key Action Statement #6

The committee suggests that clinicians encourage children with T2DM to:

o Engage in moderate to vigorous activity for at least 60 minutes daily,

AND

o limit non-academic screen time to less than two hours a day.

American Diabetes Association (ADA) Recommendations for Co-morbidity Screening

At diagnosis:o Blood pressure (BP)o Fasting lipidso Urine microalbumin / creatinineo Dilated eye examination

Follow-up:o BP at each visito Fasting lipids annually (if abnormal) or every five years (if

low-density lipoprotein cholesterol [LDL-C] >100)o Spot urine microalbumin / creatinine annually

• Need two confirmatory specimens if >30 mg/gm creatinine

o Dilated eye examination annually

ADA Recommendations for Managementof Co-morbidities

Hypertension / microalbuminuriao If sBP or dBP >90 percentile, initiate diet and exercise to attempt

weight control.

o If sBP or dBP >90 percentile persistently for three to six months despite diet/exercise, consider angiotensin-converting enzyme (ACE) inhibitor.

o If sBP or dBP >95 percentile persistently, treat with an ACE inhibitor.

Treatment with ACE inhibitor helps reverse microalbuminuria (>30 mg/gm creatinine on three occasions).

ADA Recommendations for Managementof Co-morbidities (continued)

Dyslipidemiao Medical nutrition therapy with step 2 American Heart

Association diet* and optimization of BG

o Add statin if:

• LDL-C >160 mg/dL; or

• LDL-C >130 mg/dL if ≥1 CV risk factor

• If LDL-C 130–160 mg/dL after three to six months lifestyle modification

* AHA Step 2 diet = <30% of total calories as fat, <7% saturated fat, 55% carbohydrate, and < 200 mg cholesterol daily)

The emergence of type 2 diabetes in youth has presented us with substantial diagnostic dilemmas and treatment challenges.

Because types 1 and 2 diabetes in youth initially may appear similar or identical, certain factors (ketosis, ketoacidosis, or extreme hyperglycemia) dictate the use of insulin at the outset.

Metformin, along with dietary and activity counseling, is the first line treatment in all others. However:o Failure rates are high, especially in blacks, and intensification may be

required (including the use of insulin) early in the course of the disease.

Newer and better pharmacologic agents are desperately needed for treatment of type 2 diabetes in youth.

Summary and Conclusions

Thanks!