Transcript Type 2 Diabetes Guidelines: AAP - American Academy of Pediatrics

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Prepared for your next patient.
AAP Clinical Practice Guideline:
Management of Newly Diagnosed
Type 2 Diabetes Mellitus in
Children and Adolescents
Janet Silverstein, MD
University of Florida
Kenneth C. Copeland, MD
University of Oklahoma
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AAP Resources on Diabetes
Enjoy a 20% DISCOUNT through April 12, 2013 on new orders
of the following AAP resources! Go to the AAP Bookstore at
www.aap.org/bookstore and use promo code T2WEB.
 Pediatric Clinical Practice Guidelines & Policies, 13th Edition [MA0663]
 AM:STARS – Asthma and Diabetes in the Adolescent [MA0523]
 Type 2 Diabetes: Tips for Healthy Living [HE50527]
 Pediatric Care Online [PCO]
 Patient Education Online [ONPE]
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Disclaimers
 Statements and opinions expressed are those of the
authors and not necessarily those of the American
Academy of Pediatrics.
 All clinical practice guidelines from the American
Academy of Pediatrics automatically expire five years
after publication unless reaffirmed, revised, or
retired at or before that time.
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Disclaimers (continued)



The guidelines discussed today emerged through the work of the AAP
Subcommittee on Type 2 Diabetes (with oversight provided by the Steering
Committee on Quality Improvement and Management, 2008–2012).
The recommendations reviewed in this webinar were recently published in the
February issue of Pediatrics (2013;131[2]:364–382). The online version can be
accessed at http://pediatrics.aappublications.org/content/131/2/364.full.
The recommendations do not indicate an exclusive course of treatment or serve as a
standard of medical care. Variations, taking into account individual circumstances,
may be appropriate.
o Co-chair Copeland, KC — AAP Endocrinology and Pediatric Endocrine Society Liaison (Individual
disclaimers: Novo Nordisk, Genentech, Endo, and Daichi Sankyo [National Advisory Groups]; published
research related to type 2 diabetes)
o Co-Chair Silverstein, J — AAP Endocrinology and American Diabetes Association Liaison (Individual
disclaimers: small grants with Pfizer, Novo Nordisk, Sanofi-Aventis, Daichi Sankyo, and Lilly; grant review
committee for Genentech; advisory committees for Sanofi-Aventis, and Abbott; published research
related to type 2 diabetes)

The authors do not intend to discuss an unapproved or investigative use of a
commercial product or device in this presentation.
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Case #1
 A 12-year-old obese Mexican American female has a 3month history of polyuria, polydipsia, and has noted a 3pound weight loss. Her blood glucose (BG) level is 282
mg/dl and she has large ketones on urinalysis. Her A1c
level is 9.2%. Her father and maternal grandmother have
type 2 diabetes (T2DM).
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Point of Care Laboratory Studies
Urine ketones via strip and vial
Blood glucose level via meter
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Questions




What type of diabetes does she have?
Does she need any additional testing?
What is the proper initial therapy for her?
After BG levels return to normal, what would you
treat her with?
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Barriers to Accurate Classification
 20–25% of patients newly diagnosed with type 1 diabetes
mellitus (T1DM) are obese.
 ≥15% of minority populations have a  family history (FH)
of a T2DM baseline.
 3X increase FH of T2DM in patients with T1DM.
 Overlap of C-Peptide measurements at onset and first
year.
 10–30% of typical pediatric T2DM have diabetes-specific
autoimmunity markers.
 >30% T2DM have ketosis at disease onset.
Classification of Diabetes
Type 1
Type 2
Not usually overweight
Proportionate to obesity in
general population
85% are overweight
Short course
Indolent course
35–40% present with
ketoacidosis
33% with ketonuria
5–25% may have ketoacidosis
Caucasians predominate
Native American; African American;
Latino; Asian; Pacific Islander
Increased incidence of other Increases in polycystic ovary syndrome,
autoimmune diagnoses:
hypertension, triglyceride (TG), low
thyroid; adrenal; vitiligo;
high-density lipoprotein (HDL)
celiac disease
Acanthosis nigricans (up to 90%)
Does she need any additional testing?
Laboratory Evaluation
 Islet autoantibodies
o
o
o
o
Islet cell antibodies (ICA)
Insulin autoantibodies (IAA)
Glutamic acid decarboxylase (GAD)
Insulin-associated protein-2 (IA-2)
 C-Peptide / insulin levels
o After 1st year
 Lipid profile
What is the proper initial therapy for her?
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AAP Key Action Statement #1
 Clinicians must ensure that insulin therapy is
initiated for children and adolescents with T2DM
o
o
o
o
Who are ketotic or in diabetic ketoacidosis
Who have venous or plasma BG levels >250 mg/dl
Who have hemoglobin A1c >9%; or
In whom the distinction between type 1 and type 2
diabetes is unclear
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Case #2
 A 16-year-old obese Native American female has a 6-month
history of polyuria and polydipsia, coincident with a 56pound weight gain over the last year and profound darkening
of 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 does
she have?
o What is the proper initial
therapy for her?
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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.
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TODAY* Data on the Limitations of Metformin Rx
 Main TODAY results:
o Among metformin (met) alone versus met + rosiglitazone (rosi) versus
met + lifestyle, met alone was inferior to met + rosi, and especially
inferior in African Americans. Among those on met alone who failed to
maintain glycemic control, approximately 50% failed within one year of
treatment (almost 70% of African Americans on met alone failed
within three years of treatment).
o Failure rates of the three treatment arms included:
• 51.7% met alone
• 46.6% met + lifestyle
• 38.6% met + rosi
Take home message: Start on metformin, but be alert to the need to
intensify therapy early.
*TODAY Study Group, Zeitler P, Hirst K, Pyle L, et.al. A clinical trial to maintain glycemic control in youth with type 2 diabetes. N Engl J
Med. 2012;366(24):2247–2256.
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TODAY Data (continued)
 The TODAY cohort was comprised of youth with significant barriers
to good health.
o 41.5% household annual income <$25,000
o 26.3% highest education level of parent/guardian less than a high
school degree
o 38.8% living with both biological parents
o 41.1% Hispanic and 31.5% African American
 Other take home messages:
o Lifestyle changes are exceedingly difficult to effect in youth of this
socio-economic demographic.
o Despite the extraordinary resources and efforts devoted to lifestyle
change, as noted above, weight loss was only modest and short-lived,
even in the met + lifestyle group.
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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
is defined as:
Increase the frequency of BG monitoring and adjust
dose and type of medication in an attempt to decrease
BG.
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A1c and BG Targets
 A1c
o Ideal <7%
o Must individualize with realistic goals
 BG
o Fasting blood glucose 70–130 mg/dL
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Intensification Activities
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Increase frequency of clinic visits.
Engage in more frequent BG monitoring.
Add one or more “anti-diabetic” medications.
Meet with dietitian or diabetes educators.
Meet with psychologist or social worker.
Increase attention to diet and exercise regimens.
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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%.
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AAP Key Action Statement #5
 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:
o At the time of diagnosis
o As part of on-going management
• 900–1200 kcal/day for 6- to 12-year-olds if >120% ideal body
weight
• Restrictions of no less than 1200 kcal/day for 13- to 18-yearolds
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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.
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American Diabetes Association (ADA)
Recommendations for Co-morbidity Screening
 At diagnosis:
o
o
o
o
Blood pressure (BP)
Fasting lipids
Urine microalbumin / creatinine
Dilated eye examination
 Follow-up:
o BP at each visit
o Fasting lipids annually (if abnormal) or every five years (if lowdensity lipoprotein cholesterol [LDL-C] <100)
o Urine microalbumin / creatinine annually
• Need two confirmatory specimens if >30 mg/gm creatinine
o Dilated eye examination annually
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Prevalence of Cardiovascular Risk Factors:
SEARCH for Diabetes in Youth
Population-based study of 2096 diabetic youth 0 to 19 years old.
Cardiovascular (CV) disease risk factors: HDL-C <40 mg/dL; TG >110 mg/d;
waist circumference >90%; systolic BP (sBP) or diastolic BP (dBP) >90 percentile
N
↑TG
%
↓HDL
%
↑WC
%
HTN
%
≥2 CV
risk factors
T1DM
1376
14
9
15
22
14%
T2DM
63
65
60
95
73
92%
Rodriguez BL, Fujimoto WY, Mayer-Davis EJ, et al. Prevalence of cardiovascular disease risk factors in U.S. children and adolescents
with diabetes: the SEARCH for diabetes in youth study. Diabetes Care. 2006;29(8):1891–1896.
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ADA Recommendations for Management
of Co-morbidities
 Hypertension / microalbuminuria
o If sBP or dBP >90 percentile
• Diet and exercise to attempt weight control
o If sBP or dBP >90 percentile persistently for three to six
months despite diet/exercise, consider angiotensinconverting 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).
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ADA Recommendations for Management
of Co-morbidities (continued)
 Dyslipidemia
o 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
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Clinical Management of Statins
 Measure baseline aspartate transaminase (AST) / alanine
transaminase (ALT) before statin use.
o Can continue statins if ALT / AST are <3X upper limits of normal
if monitored closely.
o Discontinue statin if muscle symptoms appear, and measure
creatine phosphokinase (CPK).
o If CPK is within normal limits or <3X normal, can continue statin
and monitor symptoms.
• Consider dose reduction.
o Statin must be discontinued if CPK is >10X normal.
Pasternak RC, Smith SC, Bairey-Merz CN, et al. ACC/AHA/NHLBI clinical advisory on the use and safety of statins12. J Amer Coll Cardiol. 2002;40(3):573–572.
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Additional AAP Resources on Diabetes
Enjoy a 20% DISCOUNT through April 12, 2013 on new orders
of the following AAP resources! Go to the AAP Bookstore at
www.aap.org/bookstore and use promo code T2WEB.
 Pediatric Clinical Practice Guidelines & Policies, 13th Edition [MA0663]
 AM:STARS – Asthma and Diabetes in the Adolescent [MA0523]
 Type 2 Diabetes: Tips for Healthy Living [HE50527]
 Pediatric Care Online [PCO]
 Patient Education Online [ONPE]
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Coming Soon!
AAP Essentials: Type 2 Diabetes App
 Available April 2013
 iTunes App Store ($19.99)
 Quick, on-the-go access to
o Treatment algorithm
o Key Action Statements
o Monitoring and lifestyle management plan tools
For all AAP app information, visit www.aap.org/mobile.