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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