Pediatric Type 2 Diabetes Mellitus Treatment & Management
- Author: Alba Morales Pozzo, MD; Chief Editor: Stephen Kemp, MD, PhD more...
Ideally, management of diabetes should involve a pediatric endocrinologist, a diabetes nurse educator, a nutritionist, and a behavioral specialist.
In January 2013, the American Academy of Pediatrics (AAP) issued clinical practice guidelines on the management of type 2 diabetes in children and adolescents. The guidelines recommend insulin treatment in all patients who present with ketosis or extremely high blood glucose levels because it may not be clear initially whether these patients have type 2 or type 1 diabetes. Once a diagnosis of type 2 diabetes is confirmed, lifestyle modification and metformin treatment should be initiated.[41, 42]
The goal of therapy is to achieve and maintain euglycemia, as well as near-normal hemoglobin A1c (HbA1c) levels (≤7%). Patients who are not ill at diagnosis can be treated initially with lifestyle changes (eg, diet, exercise, weight control). However, because few patients can maintain euglycemia with lifestyle changes alone, most children and adolescents require medication.
Hemoglobin A1c (HbA1c) levels should be measured every 3 months and treatment adjusted if goals for both HbA1c and blood glucose are not met. Fingerstick self-glucose monitoring is recommended for all patients receiving insulin or sulfonylureas, those starting or changing therapy, and those who have not met treatment goals or who have intercurrent illness.[41, 42]
Insulin therapy is indicated in symptomatic patients with persistent hyperglycemia, the presence of an HbA1c of more than 9%, or ketoacidosis. After blood glucose levels are normalized, efforts to taper insulin with progressive substitution of an oral agent are undertaken.
Glycemic and nonglycemic goals should be clearly stated and may include the following :
Fasting glycemia of less than 126 mg/dL
Resolution of polyuria, nocturia, and polydipsia
Healthy body weight
Maintenance of cardioprotective levels of lipids and blood pressure - Ie, LDL level of less than 100 mg/dL, triglyceride level of less than 150 mg/dL, HDL level of greater than 35 mg/dL, blood pressure of less than the 95th percentile for age, sex, and height
Participation of the whole family as a unit
Unless an acute complication (eg, recurrent hypoglycemia, persistent ketosis, hyperglycemic hyperosmolar state) occurs or there is poor patient compliance with treatment, type 2 diabetes is usually managed in an outpatient setting.
Recognize that, in patients with PCOS who are receiving metformin, possible resumption of normal ovulation and menstrual cycles increases the risk of pregnancy. Transfer care to an obstetrician when pregnancy is established.
Referral to a nutritionist with experience in pediatric diabetes is necessary. Dietary recommendations should be culturally appropriate, sensitive to family resources, and provided to all caregivers, especially those in charge of cooking the family's meals.
The entire family should be encouraged to adopt healthier lifestyle habits such as participation in daily exercise and decreasing the intake of high-calorie, high-fat foods.
A study by Loimaala et al study showed that long-term endurance and strength training resulted in improved metabolic control of type 2 diabetes compared with standard treatment. However, significant cardiovascular risk reduction and conduit arterial elasticity did not improve.
Because type 2 diabetes in children and adolescents is strongly associated with obesity and sedentary lifestyle, any intervention designed to increase physical activity and improve dietary habits should be encouraged.
Pharmacologic therapy is indicated when the disease is not well controlled with diet and exercise. Metformin should be the first oral agent used in children and teenagers with an HbA1c level of less than 9%. If metformin is unsuccessful as monotherapy, the addition of insulin, a sulfonylurea, or another hypoglycemic agent may be appropriate.
Lipid-lowering agents, such as 3-hydroxy-3-methyl-glutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins), and blood pressure medications (ideally, angiotensin-converting enzyme [ACE] inhibitors) should be used if lifestyle modifications are insufficient in achieving cardioprotective levels of lipids and blood pressure. For example, statins may be needed to treat hyperlipidemia patients with type 2 diabetes if their fasting LDL ̶ level goals are not met after 3-6 months of lifestyle modification.[45, 5] ACE inhibitors are the agents of choice to treat hypertension and microalbuminuria.
Proposed Management Algorithm
Diabetes education is indicated, including lifestyle changes to achieve healthy weight goals. First-line therapy is metformin at 1000-2000 mg/d. Goals include a fasting glucose level goal of less than 126 mg/dL and/or an HbA1c level of less than 7%. If goals in step 1 are achieved, continue therapy.
If goals in step 1 not achieved after 3 months (fasting glucose level >126 mg/dL or HbA1c level >7%), add 0.4-0.6 U/kg of 24-hour insulin at bedtime (Glargine or Levemir). If combination therapy is adequate, continue therapy. If combination therapy is inadequate after 3 months, intensify insulin therapy until the fasting plasma glucose level is less than 126 mg/dL and the HbA1c level is less than 7%.
In 2010, the American Heart Association-American Stroke Association released updated guidelines for the primary prevention of stroke. Specific recommendations for patients with diabetes are incorporated in these.
Regular blood pressure screening, lifestyle modification, and drug therapy are recommended. A lower risk of stroke and cardiovascular events are seen when systolic blood pressure levels are less than 140 mm Hg and diastolic blood pressure is less than 90 mm Hg. In patients who have hypertension with diabetes or renal disease, the blood pressure goal is less than 130/80 mm Hg.
Blood pressure control is recommended in type 1 and 2 diabetes. Hypertensives agents that are useful in the diabetic population include ACE inhibitors and angiotensin receptor blockers (ARBs). Treating adults with diabetes with statin therapy, especially patients with other risk factors, is recommended, and monotherapy with fibrates may also be considered to lower stroke risk. Taking aspirin is reasonable in patients who are at high cardiovascular disease risk; however, the benefit of taking aspirin in diabetic patients for the reduction of stroke risk has not been fully demonstrated.
Treating patients with statins is recommended in patients with coronary heart disease or certain high-risk conditions, for the primary prevention of ischemic stroke. In addition to statin therapy, therapeutic lifestyle changes and LDL-cholesterol goals are recommended. Niacin may be used in patients with low HDL cholesterol or elevated lipoprotein (a), but its efficacy in preventing ischemic stroke is not established.
Fibric-acid derivatives, niacin, bile acid sequestrants, and ezetimibe may be useful in patients who have not achieved target LDL levels with statin therapy or who cannot tolerate statins. However, their effectiveness in reducing the risk of stroke has not been established.
A diet that is low in sodium and high in potassium is recommended to reduce blood pressure. Diets that promote the consumption of fruits, vegetables, and low-fat dairy products, such as the DASH (Dietary Approaches to Stop Hypertension)-style diet, help to lower blood pressure and may lower risk of stroke.
Increasing physical activity is associated with a reduction in the risk of stroke. The goal is to engage in at least 30 minutes of moderate intensity activity on a daily basis.
Prevention and treatment of hyperlipidemia and hypertension in individuals with type 2 diabetes are necessary in order to protect these patients from future cardiovascular disease. (The risk for vascular complications and cardiovascular mortality in patients with diabetes mellitus is increased by poor glucose control.) Treatment of type 2 diabetes should target the improvement of glycemia, dyslipidemia, and hypertension, as well as weight management and the prevention of short- and long-term complications. Blood sugar monitoring should be performed 2-3 times daily, and more often than this when insulin treatment is being adjusted.
The patient should be seen every 3 months at the diabetes clinic, and more often, as necessary, when treatment is being adjusted.
HbA1c values should be monitored at each quarterly visit. An international expert committee composed of appointed representatives of the American Diabetes Association, the European Association for the Study of Diabetes, and others, recommended HbA1c assay for the diagnosis of diabetes mellitus in nonpregnant adults. The committee’s recommendation to diagnose diabetes is an HbA1c level of 6.5% or higher, with confirmation from repeat testing (unless clinical symptoms are present and the glucose level is >200 mg/dL). Glucose measurement should remain the choice for diagnosing pregnant women or should be used if HbA1c assay is unavailable. The committee listed the following advantages of HbA1c testing over glucose measurement:
Captures long-term glucose exposure
Has less biologic variability
Does not require fasting or timed samples
Is currently used to guide management decisions
Additional monitoring should be performed as follows:
Microalbuminuria and fasting lipid profile - Should be checked yearly
Dilated eye examination - Should be done annually
Blood pressure evaluation and careful neurologic - Should be performed at each clinic visit
Weight loss, increased physical activity, and better food choices should be encouraged because they improve fasting lipid profile. Growth assessment is important.
Waknine Y. Diabetes rates rocket in US tweens and teens. Medscape Medical News. May 6, 2014. [Full Text].
Dabelea D, Mayer-Davis EJ, Saydah S, Imperatore G, Linder B, Divers J, et al. Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009. JAMA. 2014 May 7. 311(17):1778-86. [Medline].
[Guideline] Diagnosis and classification of diabetes mellitus. Diabetes Care. 2004 Jan. 27 Suppl 1:S5-S10. [Medline].
American Diabetes Association. Type 2 diabetes in children and adolescents. Diabetes Care. 2000 Mar. 23(3):381-9. [Medline].
Management of dyslipidemia in children and adolescents with diabetes. Diabetes Care. 2003 Jul. 26(7):2194-7. [Medline].
Bennett WL, Maruthur NM, Singh S, et al. Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations. Ann Intern Med. 2011 May 3. 154(9):602-13. [Medline].
Alberti G, Zimmet P, Shaw J, Bloomgarden Z, Kaufman F, Silink M. Type 2 diabetes in the young: the evolving epidemic: the international diabetes federation consensus workshop. Diabetes Care. 2004 Jul. 27(7):1798-811. [Medline].
Morales AE, Rosenbloom AL. Death caused by hyperglycemic hyperosmolar state at the onset of type 2 diabetes. J Pediatr. 2004 Feb. 144(2):270-3. [Medline].
Ten S, Maclaren N. Insulin resistance syndrome in children. J Clin Endocrinol Metab. 2004 Jun. 89(6):2526-39. [Medline].
Hillier TA, Pedula KL. Complications in young adults with early-onset type 2 diabetes: losing the relative protection of youth. Diabetes Care. 2003 Nov. 26(11):2999-3005. [Medline].
Weyer C, Bogardus C, Mott DM, Pratley RE. The natural history of insulin secretory dysfunction and insulin resistance in the pathogenesis of type 2 diabetes mellitus. J Clin Invest. 1999 Sep. 104(6):787-94. [Medline].
Matthews DR, Cull CA, Stratton IM, Holman RR, Turner RC. UKPDS 26: Sulphonylurea failure in non-insulin-dependent diabetic patients over six years. UK Prospective Diabetes Study (UKPDS) Group. Diabet Med. 1998 Apr. 15(4):297-303. [Medline].
Gungor N, Arslanian S. Progressive beta cell failure in type 2 diabetes mellitus of youth. J Pediatr. 2004 May. 144(5):656-9. [Medline].
Rosenbloom AL, Joe JR, Young RS, Winter WE. Emerging epidemic of type 2 diabetes in youth. Diabetes Care. 1999 Feb. 22(2):345-54. [Medline].
Wei JN, Sung FC, Li CY, et al. Low birth weight and high birth weight infants are both at an increased risk to have type 2 diabetes among schoolchildren in taiwan. Diabetes Care. 2003 Feb. 26(2):343-8. [Medline].
Silverman BL, Metzger BE, Cho NH, Loeb CA. Impaired glucose tolerance in adolescent offspring of diabetic mothers. Relationship to fetal hyperinsulinism. Diabetes Care. May 1995. 18(5):611-7. [Medline].
Young TK, Martens PJ, Taback SP, et al. Type 2 diabetes mellitus in children: prenatal and early infancy risk factors among native canadians. Arch Pediatr Adolesc Med. 2002 Jul. 156(7):651-5. [Medline].
Mayer-Davis EJ, Dabelea D, Lamichhane AP, D'Agostino RB Jr, Liese AD, Thomas J. Breast-feeding and type 2 diabetes in the youth of three ethnic groups: the SEARCh for diabetes in youth case-control study. Diabetes Care. 2008 Mar. 31(3):470-5. [Medline].
Brauser D. More Proof Antipsychotics Boost Kids' Diabetes Risk. Medscape Medical News. Available at http://www.medscape.com/viewarticle/809942. Accessed: August 27, 2013.
Bobo WV, Cooper WO, Stein CM, Olfson M, Graham D, Daugherty J, et al. Antipsychotics and the Risk of Type 2 Diabetes Mellitus in Children and Youth. JAMA Psychiatry. 2013 Aug 21. [Medline].
Type 2 diabetes in children and adolescents. American Diabetes Association. Pediatrics. 2000 Mar. 105(3 Pt 1):671-80. [Medline].
Dabelea D, Bell RA, D'Agostino RB Jr, et al. Incidence of diabetes in youth in the United States. JAMA. 2007 Jun 27. 297(24):2716-24. [Medline].
Urakami T, Kubota S, Nitadori Y, Harada K, Owada M, Kitagawa T. Annual incidence and clinical characteristics of type 2 diabetes in children as detected by urine glucose screening in the Tokyo metropolitan area. Diabetes Care. 2005 Aug. 28(8):1876-81. [Medline].
Ehtisham S, Hattersley AT, Dunger DB, Barrett TG,. First UK survey of paediatric type 2 diabetes and MODY. Arch Dis Child. 2004 Jun. 89(6):526-9. [Medline].
Kadiki OA, Reddy MR, Marzouk AA. Incidence of insulin-dependent diabetes (IDDM) and non-insulin-dependent diabetes (NIDDM) (0-34 years at onset) in Benghazi, Libya. Diabetes Res Clin Pract. 1996 May. 32(3):165-73. [Medline].
Chan JC, Cheung CK, Swaminathan R, Nicholls MG, Cockram CS. Obesity, albuminuria and hypertension among Hong Kong Chinese with non-insulin-dependent diabetes mellitus (NIDDM). Postgrad Med J. 1993 Mar. 69(809):204-10. [Medline]. [Full Text].
Ramachandran A, Snehalatha C, Satyavani K, Sivasankari S, Vijay V. Type 2 diabetes in Asian-Indian urban children. Diabetes Care. 2003 Apr. 26(4):1022-5. [Medline].
Sayeed MA, Hussain MZ, Banu A, Rumi MA, Azad Khan AK. Prevalence of diabetes in a suburban population of Bangladesh. Diabetes Res Clin Pract. 1997 Jan. 34(3):149-55. [Medline].
Braun B, Zimmermann MB, Kretchmer N, Spargo RM, Smith RM, Gracey M. Risk factors for diabetes and cardiovascular disease in young Australian aborigines. A 5-year follow-up study. Diabetes Care. 1996 May. 19(5):472-9. [Medline].
McGrath NM, Parker GN, Dawson P. Early presentation of type 2 diabetes mellitus in young New Zealand Maori. Diabetes Res Clin Pract. 1999 Mar. 43(3):205-9. [Medline].
Eppens MC, Craig ME, Jones TW, Silink M, Ong S, Ping YJ. Type 2 diabetes in youth from the Western Pacific region: glycaemic control, diabetes care and complications. Curr Med Res Opin. 2006 May. 22(5):1013-20. [Medline].
Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al. Type 2 diabetes among North American children and adolescents: an epidemiologic review and a public health perspective. J Pediatr. May 2000. 136(5):664-72. [Medline].
Grinstein G, Muzumdar R, Aponte L, et al. Presentation and 5-year follow-up of type 2 diabetes mellitus in African-American and Caribbean-Hispanic adolescents. Horm Res. 2003. 60(3):121-6. [Medline].
Pavkov ME, Bennett PH, Knowler WC, Krakoff J, Sievers ML, Nelson RG. Effect of youth-onset type 2 diabetes mellitus on incidence of end-stage renal disease and mortality in young and middle-aged Pima Indians. JAMA. 2006 Jul 26. 296(4):421-6. [Medline].
Yokoyama H, Okudaira M, Otani T, et al. Higher incidence of diabetic nephropathy in type 2 than in type 1 diabetes in early-onset diabetes in Japan. Kidney Int. 2000 Jul. 58(1):302-11. [Medline].
Maahs DM, Snively BM, Bell RA, Dolan L, Hirsch I, Imperatore G. Higher prevalence of elevated albumin excretion in youth with type 2 than type 1 diabetes: the SEARCH for Diabetes in Youth study. Diabetes Care. 2007 Oct. 30(10):2593-8. [Medline].
Dart AB, Sellers EA, Martens PJ, Rigatto C, Brownell MD, Dean HJ. High Burden of Kidney Disease in Youth-Onset Type 2 Diabetes. Diabetes Care. 2012 Mar 19. [Medline].
Krakoff J, Lindsay RS, Looker HC, et al. Incidence of retinopathy and nephropathy in youth-onset compared with adult-onset type 2 diabetes. Diabetes Care. 2003 Jan. 26(1):76-81. [Medline].
Palmert MR, Gordon CM, Kartashov AI, et al. Screening for abnormal glucose tolerance in adolescents with polycystic ovary syndrome. J Clin Endocrinol Metab. 2002 Mar. 87(3):1017-23. [Medline].
Pinhas-Hamiel O, Standiford D, Hamiel D, et al. The type 2 family: a setting for development and treatment of adolescent type 2 diabetes mellitus. Arch Pediatr Adolesc Med. 1999 Oct. 153(10):1063-7. [Medline].
Tucker ME. New guidelines address type 2 diabetes in youth. Medscape Medical News. Jan 28, 2013. Available at http://www.medscape.com/viewarticle/778330. Accessed: Feb 5, 2013.
Copeland KC, Silverstein J, Moore KR, Prazar GE, Raymer T, et al. Management of Newly Diagnosed Type 2 Diabetes Mellitus (T2DM) in Children and Adolescents. Pediatrics. 2013 Feb. 131(2):364-82. [Medline].
Loimaala A, Groundstroem K, Rinne M, Nenonen A, Huhtala H, Parkkari J, et al. Effect of long-term endurance and strength training on metabolic control and arterial elasticity in patients with type 2 diabetes mellitus. Am J Cardiol. 2009 Apr 1. 103(7):972-7. [Medline].
McGavock J, Sellers E, Dean H. Physical activity for the prevention and management of youth-onset type 2 diabetes mellitus: focus on cardiovascular complications. Diab Vasc Dis Res. 2007 Dec. 4(4):305-10. [Medline].
Kavey RE, Allada V, Daniels SR, Hayman LL, McCrindle BW, Newburger JW, et al. Cardiovascular risk reduction in high-risk pediatric patients: a scientific statement from the American Heart Association Expert Panel on Population and Prevention Science; the Councils on Cardiovascular Disease in the Young, Epidemiology and Prevention, Nutrition, Physical Activity and Metabolism, High Blood Pressure Research, Cardiovascular Nursing, and the Kidney in Heart Disease; and the Interdisciplinary Working Group on Quality of Care and Outcomes Research: endorsed by the American Aca... Circulation. 2006 Dec 12. 114(24):2710-38. [Medline].
The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics. 2004 Aug. 114(2 Suppl 4th Report):555-76. [Medline].
[Guideline] Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et al. Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011 Feb. 42(2):517-84. [Medline].
US Food and Drug Administration. Early Communication About Safety of Lantus (insulin Glargine). [Full Text].
Kooy A, de Jager J, Lehert P, Bets D, Wulffelé MG, Donker AJ, et al. Long-term effects of metformin on metabolism and microvascular and macrovascular disease in patients with type 2 diabetes mellitus. Arch Intern Med. 2009 Mar 23. 169(6):616-25. [Medline].
Home PD, Pocock SJ, Beck-Nielsen H, Gomis R, Hanefeld M, Jones NP, et al. Rosiglitazone evaluated for cardiovascular outcomes--an interim analysis. N Engl J Med. 2007 Jul 5. 357(1):28-38. [Medline].
McAfee AT, Koro C, Landon J, Ziyadeh N, Walker AM. Coronary heart disease outcomes in patients receiving antidiabetic agents. Pharmacoepidemiol Drug Saf. 2007 Jul. 16(7):711-25. [Medline].
Home PD, Pocock SJ, Beck-Nielsen H, Curtis PS, Gomis R, Hanefeld M, et al. Rosiglitazone evaluated for cardiovascular outcomes in oral agent combination therapy for type 2 diabetes (RECORD): a multicentre, randomised, open-label trial. Lancet. 2009 Jun 20. 373(9681):2125-35. [Medline].
Bennett WL, Maruthur NM, Singh S, Segal JB, Wilson LM, Chatterjee R, et al. Comparative effectiveness and safety of medications for type 2 diabetes: an update including new drugs and 2-drug combinations. Ann Intern Med. 2011 May 3. 154(9):602-13. [Medline].
Jaiswal M, Lauer A, Martin CL, Bell RA, Divers J, Dabelea D, et al. Peripheral Neuropathy in Adolescents and Young Adults With Type 1 and Type 2 Diabetes From the SEARCH for Diabetes in Youth Follow-up Cohort: A pilot study. Diabetes Care. 2013 Dec. 36(12):3903-8. [Medline]. [Full Text].
Tucker M. Peripheral Neuropathy Common in Youth With Type 2 Diabetes. Medscape Medical News. Available at http://www.medscape.com/viewarticle/815107. Accessed: December 3, 2013.