diabetes en la adolescencia - fundación redgdps curso avanzado_valencia_2010... · • dermatitis...

Dr. F. Javier Ampudia-BlascoUnidad de Referencia de Diabetes

Hospital Clínico Universitario de Valencia

1er Curso Práctico Avanzado en Diabetes

Diabetes en la adolescencia

Valencia, 5 de Junio 2010

La adolescencia

“La adolescencia es la fase del desarrollo que ocurre entre la infancia y la vida adulta, y que incorpora los cambios fisiológicos y psicológicos de la pubertad”

Ampu

dia-

Blas

co F

J, M

D

Periodo de transición en muchos aspectos

• De la infancia pasa a la vida adulta

• De la Pediatría a la Medicina del adulto

• Del tratamiento controlado por los padres al control propio del tratamiento

• De la educación al trabajo

Ampu

dia-

Blas

co F

J, M

D

Aspectos a desarrollar

• Diabetes tipo 2 en la adolescencia.

• Enfermedades asociadas a la diabetes en la adolescencia

• Trastornos psicológicos en el paciente diabético adolescente

Ampu

dia-

Blas

co F

J, M

D

Diabetes tipo 1

Obesidad“Doublediabetes”

Diabetes tipo 2

Diabetes monogénica:

• Neonatal

• MODY

Clasificación de la Diabetes en la edad pediátrica (ADA)

Diabetes Care 2006; 25: 731-6

Ampu

dia-

Blas

co F

J, M

D

Prevalence of Diabetes and IFG in US Adolescents – NHANES 1999-2002

• Type 2 Diabetes

– 0.5% of adolescents have diabetes

– 71% type 1 and 29% type 2

• Determined by insulin use vs. no insulin use

– 39,005 US teens with type 2 diabetes

• Impaired Fasting Glucose (IFG)

– 11% had IFG

– 2,769,736 teens with IFG

• Diabetes increased 41% from 4.9 to 6.9/1000 from 1997 to 2003 - adults

Duncan. Arch Pediatr Adolesc Med 2006;160:523; Geiss. Am J Prevent Med 2006;30:371

Ampu

dia-

Blas

co F

J, M

D

¿Cuándo debe sospecharse una diabetes tipo 2 en la adolescencia ?

Ampu

dia-

Blas

co F

J, M

D

Type 1 diabetes Type 2 diabetes

Weight

Course

DKA

Relative with DM

Comorbid

C-peptide

Antibody

Ethnicity

20% may be overweight / obese Virtually all BMI > 85%th percentile

RapidFrom DPT-1 can be indolent

IndolentVirtually none found on screening

35%-40%Ketonuria (33%)Mild DKA (5%-25%)

5% with T1DM Up to 30% may have with T2DMFH of T2 2-3Xs in person with T1

74%-100% - 1st –2nd degree with T2DM

Thyroid, adrenal, vitiligo, celiacIncrease in polycystic ovary syndromeAcanthosis nigricans

C-peptide can be preserved at DX Normal or increased

85%

Whites predominate

15% (reported as high as 30%)

NA, AA, HA, Asian, Pacific Islander

Type 1 vs. type 2 diabetes in youth?

Kaufman. Endocrinol Metab Clin North Am 2005; 34:659-76

Ampu

dia-

Blas

co F

J, M

D

Autoantibody testing and C-Peptide when diagnosing and treating T2DM

• In all pediatric patients with the clinical diagnosis of T2DM:

– As indication of earlier need for Insulin

– As a need to check for other associated autoimmune disorders

• Should be considered in overweight/obese children > 13 years of age with a clinical picture of T1DM (weight loss, ketosis/ketoacidosis)

• C–peptide should be measured in overweight/obese children > 13 years of age, who have worsening on oral agents to confirm requiring insulin therapy

Rosenbloom AL et al. Pediatric Diabetes 2009: 10 (Suppl. 12): 17–32

Ampu

dia-

Blas

co F

J, M

D

¿Cómo debe de enfocarse este problema ?

Ampu

dia-

Blas

co F

J, M

D

Prevention Treatment–10 10 Years

Diagnosis

MacrovascularMacrovascular complicationscomplications

0

IGT/IFG Type 2 diabetes

Historia natural de la diabetes tipo 2

Blood glucose

Insulin resistance

MicrovascularMicrovascular complicationscomplications

DeFronzo RA. Med Clin N Am 2004; 88:787–835

Β-cell function

Ampu

dia-

Blas

co F

J, M

D

Prior conditions associated with insulin resistance during development

• Conditions associated with insulin resistance:

– premature adrenarche in girls (pubic hair appearing before the age of 8 years)

– small for gestational age

– ovarian hyperandrogenism and PCOS


Ampu

dia-

Blas

co F

J, M

D

Diabetes is only one manifestation of the insulin resistance syndrome

• Obesity

• Hypertension

• Albuminuria may be present at the time of diagnosis

• Hypertriglyceridemia and ↓ HDL cholesterol

• Ovarian hyperandrogenism and premature adrenarche

• Hepatic steatosis: 25–45% of adolescents with T2DM

• Systemic inflammation: ↑ CRP, ↑ inflammatory cytokines, ↑ white blood cell


Ampu

dia-

Blas

co F

J, M

D

Tratamiento de la diabetes tipo 2

Control glucémico:Hábitos dietéticosActividad físicaTx farmacológico

Tx comorbilidades asociadas:DislipemiaHTAObesidad(Enf. Cardiovascular)

Screening/Tx complicaciones:RetinopatíaNefropatíaNeuropatíaEnf. CardiovascularOtras

Principios de la dieta en niños y adolescentes

Número de comidas:

– 3 comidas principales

– 2-3 snacks

– Adaptada a la edad, actividad física y pauta de insulina

Ingesta calórica:

– 1000 kcal + 100 kcal/año de edad (máximo de 2.200 kcal en chicas/ 2.600 kcal en chicos, que se incrementará o disminuirá en función de actividad física y peso)

– 50–55% en carbohidratos

– 30% en grasas

– 15–20% en proteínas

Ampu

dia-

Blas

co F

J, M

D

Treatment decision tree for type 2 diabetes in children and adolescents


Ampu

dia-

Blas

co F

J, M

D

Key messagesand follow-up

Ampu

dia-

Blas

co F

J, M

D

Recommendation for initial medical treatment of type 2 diabetes

• Preadolescent children are unlikely to have T2DM, even if obese

• Overweight adolescents may have both T1DM and T2DM. Antibody determination is the only way to definitively differentiate both entities.

• Initial treatment modality is determined by symptoms, severity of hyperglycemia, and presence or absence of ketosis/ketoacidosis.

• Lifestyle changes in diet and exercise are essential and should be recommended for all individuals with T2DM


Ampu

dia-

Blas

co F

J, M

D

Associated diseases testing, specific to T2DM in young people

• Testing for microalbuminuria at the time of diagnosis and annually thereafter

• BP should be monitored at every visit

• Testing for dyslipidemia should be performed soon after diagnosis when BG control has been achieved and annually thereafter

• Evaluation for NAFLD should be done at diagnosis and annually thereafter

• Examination for retinopathy should be performed at diagnosis and annually thereafter


Ampu

dia-

Blas

co F

J, M

D





Ampu

dia-

Blas

co F

J, M

D

Otras patologías asociadas

• Diabetes mal controlada:

– Retraso de crecimiento y alteraciones puberales

• Enfermedades autoinmunes:

– Tiroiditis autoinmune (3-8%, 25% anticuerpos)

– Enf. de Graves-Basedow

– Enfermedad de Addison (2% anticuerpos)

– Enfermedad celíaca (1-10%)

– Vitíligo (6%)

• Necrobiosis lipoídica diabeticorum

• Limitación de la movilidad articular

Ampu

dia-

Blas

co F

J, M

D

Hipotiroidismo primario autoinmune

Ampu

dia-

Blas

co F

J, M

D

Tiredness

Forgetfulness/Slower Thinking

Moodiness/ Irritability

Depression

Inability to Concentrate

Thinning Hair or Hair LossLoss of Body Hair

Dry, Patchy Skin

Muscle Weakness or Cramps

Constipation

Infertility

Menstrual Irregularities/Heavy Period

Slower Heartbeat

Difficulty Swallowing

Persistent Dry or Sore Throat

Hoarseness/Deepening of Voice

Swelling (Goiter)

Puffy Eyes

Weight Gain

Cold Intolerance

Elevated Cholesterol

Signs and Symptoms of Hypothyroidism

Ampu

dia-

Blas

co F

J, M

D

Diagnosing Hypothyroidism

• Family and personal medical history• Hypothyroidism may be

Hereditary

• Physical exam• MD Observes the Patient• Palpates the thyroid• Interviews patient

• Laboratory Tests• TSH Test• Free T4

Ampu

dia-

Blas

co F

J, M

D

Hypothyroidism associated with type 1 diabetes in young people

• Primary hypothyroidism is due to autoimmune thyroiditis(3–8%)

• Antithyroid antibodies (in up to 25%) are predictive for the development of clinical or compensated hypothyroidism

• Thyroid antibodies are observed more frequently in girls than in boys, often emerging along with pubertal maturation

Kordonouri O et al. Pediatric Diabetes 2009: 10 (Suppl. 12): 204–10

Ampu

dia-

Blas

co F

J, M

D

Enfermedad celíacao intolerancia al gluten

Ampu

dia-

Blas

co F

J, M

D

Why screening for celiac disease in type 1 diabetes?

Significant health problem, multi-organ morbidity:

– Intestinal: diarrhea, distention, vomiting, abdominal pain, weight loss

– Extra-intestinal: pubertal/growth delay, anemia, osteopenia, etc.

– In type 1 diabetes: unexplained hypoglycemia, poor HbA1c

Ampu

dia-

Blas

co F

J, M

D

T T cell

ab TCR

APC

HLA-DQ2or -DQ8

Pathomechanism of Celiac Disease

TG

Gluten

Transaminatedgluten peptides

T

T T

T T

T

TG

Old paradigm Celiac disease as a disease of small intestine

Celiac disease• villous atrophy • malnutrition

London, year 1938

Ampu

dia-

Blas

co F

J, M

D

New paradigm: multi-organ autoimmune disease

Celiac disease• villous athrophy• malnutrition• malignancies

Bone• osteoporosis, fractures• arthritis• dental anomalies

HepatitisCholangitis

Skin & mucosa• dermatitis herpetiformis• aphtous stomatitis• hair loss

Reproductive• miscarriage, infertility• delayed puberty

Central nervous system• ataxia, seizures• depression

Carditis, cardiomyopathy

Anemia

Ampu

dia-

Blas

co F

J, M

D

Dermatitis Herpetiformis

• Erythematous macule > urticarial papule > tense vesicles

• Severe pruritus

• Symmetric distribution

• 90% no GI symptoms

• 75% villous atrophy

• Gluten sensitive

Ampu

dia-

Blas

co F

J, M

D

Involve the secondary dentition

Dental Enamel DefectsAm

pudi

a-Bl

asco

FJ,

MD

Aphtous StomatitisAm

pudi

a-Bl

asco

FJ,

MD

Osteopenia/OsteoporosisLow bone mineral density by DEXA in a child with untreated CD

Ampu

dia-

Blas

co F

J, M

D

Entheropathy-Associated T-cell Lymphoma

Ampu

dia-

Blas

co F

J, M

D

Prevalence of TG IgA Autoantibodies

in 2,949 T1D Patients

0%

2%

4%

6%

8%

10%

12%

14%

0-4 5-9 10-14 15-19 20-24 25-29 30-39 40+

TG IgA+

TG IgA 0.05-0.5TG IgA >0.5

Age

Rewers M et al. 2004

Ampu

dia-

Blas

co F

J, M

D

Histology of intestinal biopsy in celiac disease

Ampu

dia-

Blas

co F

J, M

D

Recommendations for celiac disease

• All patients with type 1 diabetes should be screened for TG IgA at onset and at least bi-annually until age 10, or if symptomatic

• In asymptomatic cases, intestinal biopsy should be recommended if TG levels are positive (predictive in over 90%)

• Biopsy should be done after at least 1-2 weeks on a high-wheat diet

• Persistent TG IgA and HLA-DQA1*0501/B1*0201 predict progression to celiac disease even if the initial biopsy is negative

• Gluten-free diet should be recommended to all Bx+ patients

• Insulin dose usually needs to be increased when gluten-free diet is started

Ampu

dia-

Blas

co F

J, M

D

Screening and diagnosis of CD in diabetic patients and their relatives

Biopsy negative:Biopsy positive: GFD monitor TG,

repeat biopsy

Biopsyrecommended

TG IgA > 0.5

or symptoms

Biopsy likely negrepeat TG in 6-12 months

TG IgA < 0.5 and

asymptomatic

TG Positive > 0.05

TG negative, no symptomsrepeat every 1-2 yrs if HLA-DQB1*0201

until age 10?

Biopsyrecommended

IgA <10 mg/dl

TG negative, symptomaticrepeat in 3-6 months

check IgA levels, HLA,other causes?

All patients TG IgA

Rewers et al. EMCNA 2004

Ampu

dia-

Blas

co F

J, M

D

A girl that refuses pasta and breadFemale Type 1 diabetes diagnosed by age 3.9 yr HLA-DR3/4 DQB1*0201/0302

Height Weight

GFD ?

M3b

TG>0.5

TG 0.05-0.05

•TG<0.05

Ampu

dia-

Blas

co F

J, M

D

A girl that is trying to catch upFemale Type 1 diabetes diagnosed by age 5.3 yr HLA-DR3/4 DQB1*0201/0302

Height Weight

GFD

M3c

TG>0.5

TG 0.05-0.05

•TG<0.05

Ampu

dia-

Blas

co F

J, M

D

With gluten free diet1 in 10

TG IgA +++

Biopsy

M1

M2

M3

Ampu

dia-

Blas

co F

J, M

D





Ampu

dia-

Blas

co F

J, M

D

Causes of deterioration of metabolic control in adolescents with diabetes

• Erratic meal and exercise patterns

• Poor adherence to treatment regimens

• Hazardous and risk taking behaviours

• Eating disorders

• Endocrine changes associated with puberty, leading to greater insulin resistance

Court JM et al. Pediatric Diabetes 2009: 10 (Suppl. 12): 185–94

Ampu

dia-

Blas

co F

J, M

D

Adolescencia vs. diabetes

¿Qué exige la diabetes?

Grandes cambios físicos, psicológicos y sociales.

Transgresión de las normas

Necesidad de libertad independencia,

Inconstancia

Falta de madurez para asumir responsabilidades totales.

Afirmación con el grupo

Problema de salud

Vida ordenada (horarios, dieta sana...)

Limites

Autocontrol, sobreprotección

Asumir la diabetes para responsabilizarse en el aprendizaje y manejo

Posicionarse ante los demás

¿Cómo es la adolescencia?

Grandes cambios físicos, psicológicos y sociales.

Transgresión de las normas

Necesidad de libertad independencia,

Inconstancia

Falta de madurez para asumir responsabilidades totales.

Afirmación con el grupo

Ampu

dia-

Blas

co F

J, M

D

Eating disorders and diabetes in adolescence

• Insulin omission for weight control has been reported in 12–15% of adolescents

• Rebellion, binges and erratic eating behavior are frequent during adolescence

• Poor glycemic control may reflect insulin omission in association with disordered eating

• Eating disorders in adolescents and young adults with diabetes are associated with poor metabolic control and diabetic complications

Smart C et al. Pediatric Diabetes 2009: 10 (Suppl. 12): 100–17

Ampu

dia-

Blas

co F

J, M

D

Anorexia nerviosa

1. Pérdida deliberada de peso

2. Distorsión de la imagen corporal

Ampu

dia-

Blas

co F

J, M

D

• Negativa a mantener un peso por encima del 85% de su peso ideal.

• Intenso miedo a ganar peso y a la obesidad, a pesar de estar malnutrido.

• Distorsión de la imagen corporal

• En mujeres postmenárquicas, amenorrea durante al menos tres ciclos consecutivos.

Ampu

dia-

Blas

co F

J, M

D

Criterios diagnósticos de anorexia nerviosa

Bulimia nerviosa

Atracones

Preocupación excesiva por el peso

Conductas compensadoras

Ampu

dia-

Blas

co F

J, M

D

1. Episodios recurrentes de atracones caracterizados por la ingesta en un periodo corto de tiempo de una gran cantidad de alimentos con sensación de pérdida de control.

2. Comportamientos compensadores para evitar ganar peso como el uso de diuréticos, laxantes, enemas u otras medicaciones, vómitos autoinducidos, ayuno o ejercicio exagerado.

Criterios diagnósticos de bulimia nerviosa

Ampu

dia-

Blas

co F

J, M

D

3. Tanto los atracones como los comportamientos compensadores ocurren al menos dos veces a la semana durante tres meses.

4. La autovaloración está claramente influenciada por la imagen corporal y el peso.

5. Los alteraciones no ocurren exclusivamente durante los episodios de anorexia nerviosa.

Criterios diagnósticos de bulimia nerviosa (cont.)

Ampu

dia-

Blas

co F

J, M

D

Etiopatogenia de la anorexia y de bulimiaAm

pudi

a-Bl

asco

FJ,

MD

Ampu

dia-

Blas

co F

J, M

D

Recommendations for health care teams dealing with adolescents

• Understand the physiological and psychosocial developmental changes of adolescence

• Develop a consistent trusting and motivating relationship with the adolescent

• Develop communication skills to facilitate teaching and education

• Enable the adolescent to learn from mistakes

• Recognize the signs of mental health problems (depression, eating disorders, illicit drug usage, etc.) and the occasional need for psychiatric treatment

Court JM et al. Pediatric Diabetes 2009: 10 (Suppl. 12): 185–94

Ampu

dia-

Blas

coFJ

, M

D

diabetes en la adolescencia - fundación redgdps curso avanzado_valencia_2010... · • dermatitis...

Documents