Clinical Practice Guidelines: Management of

Type 2 Diabetes Mellitus (5th Edition) 2015

Topic 17 Diabetes Mellitus in

Adolescents

Introduction

• T2DM is rapidly increasing among the adolescents (ages 12-

18 years): rising sedentary lifestyles and prevalence of

obesity.

• Commonest form of diabetes in this age group in many

countries • Japan, the incidence rate of T2DM in children <18 years from 1981 to

1990 - 4.1/100,000 person-years versus1.5 to 2.0/100,000 person-

years for T1DM.

• Common in adolescents coinciding with physiologic pubertal

insulin resistance.

Primary Factors Contributing to

Development of T2DM in Children

INSULIN

RESISTANCE

PRENATAL

ENVT.

FEMALE

GENDER

ETHNIC

BACKGROUND

FAMILY

HISTORY

PUBERTY

T2DM

OTHER

GENES

SEDENTARY

LIFESTYLE

OBESITY

• visceral

ACCELERATED

BETA CELL

FAILURE

IFG/IGT

Atherosclerosis begins in Childhood

Berenson GS, et.al. N Engl J Med, 1998

T2DM in childhood predisposes for

earlier onset of nephropathic disease

ESRD IN PIMA INDIANS

Pavkov ME, et.al. JAMA, 2006

A National Database on Children and Adolescent with Diabetes (e-DiCARE):

Results from April 2006 to June 2007

• 15-40% of T2DM patients have T1DM-associated pancreatic

autoantibodies - less overweight, younger, have higher A1c and

more rapid development of insulin dependence (usually by 3

years duration).

• T2DM may be misdiagnosed as T1DM:

• in non-obese adolescents with diabetes.

• when ketosis/ketoacidosis is present at onset.

• when pancreatic autoantibodies are positive.

• Other types of diabetes mellitus may be misdiagnosed as T2DM:

• Obese T1DM

• T1DM with low autoimmunity

• Monogenic diabetes

Introduction

Screening and Diagnosis

• Symptomatic or

• If they are overweight (BMI >85th percentile for age and sex,

or weight >120% of ideal)

• Have two or more of the following risk factors:

• Family history of T2DM in first- or second-degree relative.

• Signs of insulin resistance or conditions associated with insulin

resistance (acanthosis nigricans, hypertension, dyslipidaemia,

PCOS).

• Maternal history of GDM during child’s gestation.

• Screen every two years starting at the age of 10 or at onset of

puberty if puberty occurs at a younger age. A glucose load of

1.75 g/kg body weight (maximum of 75 g) for OGTT is used.

Diagnosis

• Fasting insulin and C-peptide - aid diagnosis.

• Measurement interpreted with caution due to considerable

overlap between T1DM, T2DM and monogenic diabetes at

onset and within two years of diagnosis.

• The overlap is due to initial recovery phase (honeymoon

period) of T1DM, glucotoxicity and lipotoxicity impairing

insulin and C-peptide secretion.

• Such measurements are of little value in the acute phase of

the illness.

Diagnosis

• Persistent elevation of C-peptide would be unusual in T1DM

after 12-24 months from diagnosis.

•

• C-peptide should be measured if there is worsening diabetes

control in overweight/obese adolescents on oral agents, in

order to revise the diabetes classification.

Management

• Management of T2DM in the adolescents - involve the

patient and his/her family, emphasising healthy rearing

patterns and parental modelling of healthy habits.

• Education and recommendations must be age-appropriate

and sensitive to the family’s cultural practices and financial resources.

• Lifestyle changes is the cornerstone of T2DM treatment.

Such changes need to be permanent.

1. All foods and beverages served in schools meet Dietary Guidelines.

2. Increasing access to high-quality, affordable foods through new or improved grocery stores and healthier corner stores and bodegas.

3. Increasing the time, intensity, and duration of physical activity during the school day.

Preventive Measures

4. Increasing physical activity by improving the built environment in communities.

5. Using pricing strategies—both incentives and disincentives—to promote the purchase of healthier foods.

6. Reducing ouths’ e posure to the marketing of unhealthy foods through regulation, policy, and effective industry self-regulation.

• Randomized clinical trial with a pre-randomization run-in period – 704 patients at 15 clinical centers – 3 treatment regimens

• Metformin + Placebo • Metformin + Rosiglitazone • Metformin + Intensive Lifestyle Program • At treatment failure: Standardized approach to

insulin initiation

• Primary outcome: Time to failed glycemic control

• Inclusion criteria – Age 10–17 years – Duration of diabetes <2 years – BMI 85th percentile

Copeland KC, Zeitler P, Geffner M, et al. Characteristics of adolescents and

youth with recent-onset type 2 diabetes: the TODAY cohort at baseline. J Clin

Endocrinol Metab. 2011;96(1):159–167

Treatment T2

TODAY Study

Medications at Presentation

• No medication 11%

• Insulin only 12%

• Metformin only 49%

• Metformin + insulin 25%

• Other medication 4%

Mean ± SD or %

Age (years) 14.3 ± 2.0

Race/Ethnicity

White 19.6%

African American 37.4%

Hispanic 32.2%

Native American 5.5%

Other/Unknown 5.3%

BMI (kg/m2) 36.2 ± 7.9

25 - 71

BMI Z-score +2.3 ± 0.5

Treatment T2: The TODAY Trial

Copeland KC, Zeitler P, Geffner M, et al. Characteristics of adolescents and youth with recent-onset type 2 diabetes: the TODAY cohort at

baseline. J Clin Endocrinol Metab. 2011;96(1):159–167

A Clinical Trial to Maintain

Glycemic Control in Youth with Type 2 Diabetes

TODAY Study Group; Zeitler P, Hirst K, Pyle L, et al. A clinical trial to maintain glycemic control in youth with type 2 diabetes. New Eng J Med.

2012:1–10

Treatment T2: The TODAY Trial Study Results

TODAY Study Group; Zeitler P, Hirst K, Pyle L, et al. A clinical trial to maintain

glycemic control in youth with type 2 diabetes. New Eng J Med. 2012:1–10

Pharmacotherapy

• Treatment of T2DM in adolescents follow the same rationale

as does treatment in adults.

• The safety and efficacy of OADs in adolescents have not

been established.

• Among all the OADs currently used to treat T2DM in adults,

only metformin and insulin are FDA approved for use in

adolescents <18 years of age.

• Metformin should be started with 500 mg daily for 7 days.

Gradual dose increment by 500 mg once a week over 3-4

weeks until the maximal dose of 1000 mg BD is achieved.

Pharmacotherapy

• Insulin may be required for initial metabolic control.

Transition from insulin to metformin can usually be made

when metabolic stability is reached. This may take 2-6

weeks.

• In adolescents, long-acting or intermediate acting insulin may be added at a dose of 0.5 u/kg at bed-time.

Conclusion

• 1. Obesity is on the rise among our children

• 2. As a result type 2 DM is increasing

• 3. Treatment is difficult

• Compliance is poor

• Numerous psychological issues

• Limited studies on existing and new anti-diabetic

agents

• Most end up on insulin with all it’s inherent issue

• Increase rate of complications