Q&A: Managing Pediatric and Adolescent Patients with T2DM

Course Director

Chhavi Agarwal, MD

Chhavi Agarwal, MD
Assistant Professor of Pediatrics
Albert Einstein College of Medicine
Bronx, New York


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Part 2 of a 2-part series

Dr. Agarwal provides expert feedback to the questions submitted by your peers during a recent survey on this topic.

Overview

The American Academy of Pediatrics, in collaboration with the American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians, and the Academy of Nutrition and Dietetics, has published its first ever guidelines for managing type 2 diabetes in children aged 10 to 18 years. Until recently, type 2 diabetes was considered primarily a disorder that occurred in adults ≥40 years of age. Now, however, up to 30% of children diagnosed with diabetes have type 2 diabetes. This finding reflects the higher prevalence of obesity in children. Yet many physicians who treat pediatric patients with type 2 diabetes will not have had training in this area. In this activity, Dr. Chhavi Agarwal provides practical insights on the management of pediatric patients with type 2 diabetes.


Disclosures

This activity is supported by an educational grant from Lilly USA, LLC.
Additional support provided by Penn State College of Medicine and Answers in CME.

Course Director
Chhavi Agarwal, MD, has no financial interests/relationships or affiliations in relation to this activity.
Medical Director
Annette Wiggins
Answers in CME, Inc.
Annette Wiggins has no financial interests/relationships or affiliations in relation to this activity.

Answers in CME staff who may potentially review content for this activity have disclosed no relevant financial relationships.

Penn State College of Medicine staff and faculty involved in the development and review of this activity have disclosed no relevant financial relationships.

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Your patient is a 15-year-old Hispanic female with a history of irregular menstrual cycles. Her weight is 220 lb; her height is 60 in, for a BMI of 42. Her blood pressure is 130/80 mmHg. Other relevant factors in her medical history include presence of acanthosis nigricans. Blood work showed an HbA1c of 7.2%, fasting plasma glucose of 136 mg/dL, and hypercholesterolemia. On previous visits you advised the patient and her parents to make lifestyle changes—to be more active and eat right—which she did not follow. What would be your next step in the management of this patient?

Dr. Agarwal: She definitely is an overweight girl with risk factors for type 2. She comes from a high-risk Hispanic ethnicity. She has features of insulin resistance in the form of acanthosis nigricans, and clinical features suggestive of polycystic ovary syndrome. And looking at the glycemic criteria, she does fit into the category of diabetes, with a fasting glucose of >126 mg/dL and an HbA1c of 7.2%.

So she needs to be treated both for hyperglycemia as well as comorbidities like dyslipidemia, hypertension, and proteinuria. Further lab testing may be necessary to differentiate between type 1 and type 2.

And the management goals for her will include normalizing glycemia and HbA1c, increasing diabetes self-management skills, with an aim to decrease weight and improve nutrition and increase exercise; [and] at the same time, managing the comorbidities to prevent complications of diabetes. She really needs a team approach that includes herself, her family members, her healthcare providers, her registered dietitian or social worker, as well as a psychologist. We need to intensify her lifestyle modification program, and we also need to add metformin once the diagnosis is confirmed by negative antibody titers, if possible. And then she needs to be reevaluated every three months to adjust medications and reinforce adherence.1

Weight management should ideally be done using a medical nutrition therapy and using a registered dietitian. And behavioral intervention really helps in adherence to the lifestyle intervention plan.

As I mentioned, she should also receive metformin. The US FDA has approved metformin in children above ten years of age, and various randomized controlled trials have shown that metformin can reduce HbA1c by almost 1% to 2%.2

So now how about insulin? If we want to bring her HbA1c of <7%, or we want to bring the fasting plasma glucose of <130 mg/dL or postprandial glucose of <180 mg/dL, and if these goals are not achieved in three to six months, then you would have to add insulin, which could be either added as a long-acting analog, which comes as glargine or detemir, at a dose of 0.3 to 0.4 units/kg at bedtime. If the combination therapy with basal-only fails, then you can go for bolus insulin three times a day. But keep in mind that the adherence rate to multiple daily injections in an adolescent population is very dismal.1

The current range of oral therapies used in adults has a very limited role in children. The sulfonylureas, the thiazolidinediones, the glucagon-like peptide 1 [GLP-1] receptor agonists, like exenatide, or DPP-4 inhibitors, like sitagliptin or linagliptin, all have similar outcomes in lowering HbA1c, but the side-effect profile is not favorable. The side-effect profile and limited safety data in children limit their use in this population, and all of these medications are not yet approved for children <18 years of age.1 In certain individual cases you do end up using thiazolidinediones or incretins very occasionally. But again, that use is still off-label. The FDA has not yet approved its use.

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How often should we monitor and manage pediatric patients with prediabetes?

Dr. Agarwal: In children with blood glucose in the diabetes range, repeat testing should be done annually and lifestyle intervention should be initiated to promote weight loss. And the goal during that time should be to maintain euglycemia as well as to improve insulin sensitivity by stimulating these kids to lose weight and exercise and eat healthy.

There are some randomized controlled trials of lifestyle or medication intervention in adults with prediabetes which have demonstrated that type 2 can be prevented if intervened at this stage.3-5 But there are no real studies in pediatric populations, so the question remains whether we can really prevent diabetes in this age group or not without medication intervention. Metformin use in overweight adolescents not meeting the criteria for type 2 diabetes is still off-label. So at this stage, you basically still have to rely on lifestyle intervention to prevent or delay the onset of type 2 diabetes.

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When do you make the transition to treating an adolescent with type 2 diabetes as an adult? I have 16-year-old patients who weigh more than 200 pounds and have a very adult habitus, but they are clearly still children.

Dr. Agarwal: There's an absolute deficiency of studies on transitioning youth with type 2 diabetes from pediatric to adult care. We start the transitioning of our patients around 18 years of age with the help of a transition coordinator. The goal of an effective transition plan is to provide developmentally appropriate healthcare services to these young adults and make sure that these services continue uninterrupted as the individual moves from adolescence to adulthood. There are no proven strategies to achieve these goals, but using diabetes education or skill training workshops or special transition clinics, does help to improve this transition.6

Although the 16-year-old is not yet ready to be transitioned, he is at this age where we should start preparing him for transition. And the preparation should not only include focus on diabetes self-management skills for the team, but also broadening the responsibilities that go beyond diabetes management, such as making sure that they know how to schedule their appointment. They're taking the responsibility to make sure that they have enough supply of all the medications and things that they need for their diabetes management.

Preparation should also include informing them that there is a difference between the pediatric and adult care providers in their approach to the care of these patients, as well as educating them regarding health insurance options that they have and what they can do to maintain the coverage.

And for the pediatric provider, they should also prepare a detailed written summary that includes an active problem list, a compilation of all the medications that a patient is on, assessment of their diabetes self-care skills, summary of past glycemic control, summary of diabetes-related comorbidities that this patient has during that period, as well as a well-written summary of any mental health problems and referrals during the pediatric care.

The emerging adults with diabetes should also be evaluated and treated for disordered eating behavior and affective disorders. It's very, very important for the diabetes provider to have a mental health referral source who understands the fundamentals of working with these adolescent individuals with diabetes. Also, it's important that they should be given some help during the first appointment with the adult care provider, which should be within three to four months of the final pediatric visit.

And in these cases I personally feel that having a care ambassador or a patient navigator—which could be anyone, a social worker, a certified diabetes educator [CDE], or a nurse practitioner—can really aid this transitional process and make sure that these young adults are going for regular followups and they have all the supplies and help that they need to continue their management of the diabetes.

So for the emerging young adults with diabetes, it's very important to create an effective and translatable process for this transition in care from pediatric to adult care provider in order to optimize the well-being and health of these young adults.

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References

  1. Copeland KC et al. Pediatrics. 2013;131:364-382.
  2. Glucophage (metformin) package insert. http://packageinserts.bms.com/pi/pi_glucophage.pdf. Accessed July 23, 2013.
  3. NIDDK Diabetes Prevention Program Study. http://www.bsc.gwu.edu/dpp/index.htmlvdoc. Accessed July 23, 2013.
  4. NHLBI DASH program. www.nhlbi.nih.gov/health/health-topics/topics/dash/. Accessed July 23, 2013.
  5. DeFronzo RA, Abdul-Ghani M. Diabetes Care. 2011;34(Suppl 2):S202-S209.
  6. Peters A et al. Diabetes Care. 2011;34:2477-2485.

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This activity is supported by an educational grant from Lilly USA, LLC.
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Expert Perspectives: Managing Type 2 Diabetes in Pediatric & Adolescent Patients

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