Management of type 2 diabetes mellitus in children and adolescents
- Lori Laffel, MD, MPH
Lori Laffel, MD, MPH
- Professor of Pediatrics
- Harvard Medical School
- Britta Svoren, MD
Britta Svoren, MD
- Assistant Professor of Pediatrics
- University of Rochester Medical Center
Data on the long-term outcome of adolescent-onset type 2 diabetes mellitus (T2DM) are only now becoming available from limited populations [1-4]. However, studies in adults show that T2DM and its comorbidities are important risk factors for adult vascular disease. As a result, it is likely that identifying and treating children and adolescents with T2DM will improve long-term outcome; however, pediatric-onset T2DM differs from adult onset disease, especially regarding durability of glycemic control .
There are few studies examining the management of T2DM in the pediatric age group. The largest clinical trial, Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY study), suggests that oral agent monotherapy does not maintain durable glycemic control in about 50 percent of those with adolescent-onset T2DM (see 'Approach to treatment' below), and an A1c >6.3 percent in females and >5.6 percent in males following initial metformin monotherapy predicts glycemic deterioration [2,4]. Thus, it is important to optimize treatment using a combination of pharmacologic and nonpharmacologic interventions, with close monitoring and follow-up.
Ideally, the care of an adolescent with T2DM should be managed by a multidisciplinary team, including an endocrinologist, nurse educator, dietitian, mental health professional, and sometimes an exercise physiologist. However, in locations where these resources are not available, many patients can be effectively managed by primary care clinicians, following the guidelines outlined in this topic review [6-9]. Patients in need of insulin therapy should be managed by or in consultation with an endocrinologist, if at all possible. Family involvement is essential to initiate and support the lifestyle changes required in the management of a pediatric patient with this disorder.
The management of T2DM in children and adolescents is presented here. The epidemiology, presentation, diagnosis, comorbidities, and complications of pediatric T2DM are discussed separately. (See "Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and adolescents" and "Comorbidities and complications of type 2 diabetes mellitus in children and adolescents".)
Diabetes – Diabetes mellitus can be diagnosed based on abnormal plasma glucose (fasting or random), and oral glucose tolerance test (OGTT), or hemoglobin A1c (A1C). Thresholds for diagnosing diabetes with each of these tests are shown in the table (table 1). (See "Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and adolescents", section on 'Diagnosis'.)
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- NONPHARMACOLOGIC THERAPY
- Nutrition therapy
- - Weight goals
- - Dietary prescription
- Physical activity
- PHARMACOLOGIC AGENTS
- APPROACH TO TREATMENT
- TODAY study
- Goals for glycemic control
- Initial treatment
- - Metformin
- - Insulin
- Ongoing care
- - Monitoring therapy
- - Intensification of therapy
- Failure of metformin
- Failure of insulin
- TESTING FOR COMORBIDITIES
- PREGNANCY PREVENTION AND RISK
- SURGICAL THERAPY
- SUMMARY AND RECOMMENDATIONS