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A Step in the Right Direction: New Clinical Guidelines for Type 2 Diabetes in Children and Adolescents

Jennifer N. Clements, Pharm.D., BCPS, CDE

Associate Professor of Pharmacy Practice

Presbyterian College School of Pharmacy

Clinton, South Carolina

In the United States, childhood obesity has dramatically increased over the past thirty years.¹  This epidemic has lead to a rise in other health problems, such as type 2 diabetes mellitus among the younger population.¹  Pediatricians may be more familiar with the management of type 1 diabetes mellitus – commonly diagnosed among children and adolescents.  However, primary care physicians are more familiar with the management of type 2 diabetes mellitus among adults. 

To provide treatment options, the American Academy of Pediatrics recently published clinical practice guidelines for newly diagnosed patients (10 to 18 years of age) with type 2 diabetes mellitus.  This publication is the first-ever type 2 diabetes guidelines for this specific patient population.²  Alongside the American Academy of Pediatrics, these guidelines were developed with the support among the following organizations: American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians, and the Academy of Nutrition and Dietetics.² 

These guidelines have the following key point statements²:

1. Insulin therapy should be started for patients with ketosis or ketoacidosis.  Insulin therapy should also be initiated among patients whom type 1 and type 2 diabetes cannot be distinguished.  Any patient with elevated glucose levels (above 250 mg/dL) or A1c (above 9%) is a candidate for insulin therapy.

1. All patients diagnosed with type 2 diabetes mellitus and have glucose level below 250 mg/dL or A1c below 9% should be initiated on a lifestyle modification program and metformin (500 mg orally daily, increased by 500 mg every 1 to 2 weeks to the maximum daily dose of 2000 mg).  Compared to the management of an adult patient, metformin is recommended as a first-line agent for similar reasons, such as weight loss or neutral and low risk of hypoglycemia. 

1. A1c levels should be monitored every 3 months.  Treatment should be intensified if desired goals are not met with current therapy. 

1. Self-monitoring of glucose levels is important and should be advised for the patients who are taking oral hypoglycemic agents, injecting insulin, starting or changing treatment agents, not achieving desired treatment goals or having intercurrent illnesses (e.g. febrile illnesses).  Similar to the recommendations for adult management of type 2 diabetes, self-monitoring should be intensified for patients prescribed multiple insulin injections or receiving pump therapy. 

1. All individuals between the ages of 10 to 18 years should be counseled about diet and nutrition at the time of diagnosis.  This counseling should also be incorporated into the ongoing treatment plan.  Patients should be referred to a clinical dietitian.  Based on the age of the patient, specific treatment options for weight management are provided through the Academy of Nutrition and Dietetics guidelines.

1. All individuals between the ages of 10 to 18 years should be encouraged to exercise for at least 1 hour a day.  This recommendation should be encouraged at the time of diagnosis and evaluated at follow-up visits.    Exercise should be completed at a moderate-to-vigorous intensity.  Children and adolescents should also limit non-academic screen time to 2 hours per day (e.g. watching television, playing video games).

Overall, these guidelines offer the first-step in evidence-based management for pediatricians to family medicine physicians for the treatment of type 2 diabetes mellitus among children and adolescents. 

References:

1. Centers for Disease Control and Prevention.  Data and Statistics.  Obesity rates among children in the United States.  Available at:  http://www.cdc.gov/obesity/data/childhood.html.  Accessed 25 February 2013. 
2. Copeland KC, Silverstein J, Moore KR, et al.  Clinical Practice Guidelines: Management of newly diagnosed type 2 diabetes mellitus (T2DM) in children and adolescents.  Pediatrics 2013;131:364-382.

Additional Readings:

-          Inzucchi SE, Burgenstal RM, Buse JB, et al.  Management of hyperglycemia in type 2 diabetes: A patient-centered approach.  Position statement of the American Diabetes Association and the European Association for the Study of Diabetes.  Published online April 19, 2012, doi: 10.2337/dc12-0413.

-          TODAY Study Group.  A clinical trial to maintain glycemic control in youth with type 2 diabetes.  N Engl J Med 2012;366:2247-2256.