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'.)
- Pinhas-Hamiel O, Zeitler P. Acute and chronic complications of type 2 diabetes mellitus in children and adolescents. Lancet 2007; 369:1823.
- TODAY Study Group, Zeitler P, Hirst K, et al. A clinical trial to maintain glycemic control in youth with type 2 diabetes. N Engl J Med 2012; 366:2247.
- Dart AB, Sellers EA, Martens PJ, et al. High burden of kidney disease in youth-onset type 2 diabetes. Diabetes Care 2012; 35:1265.
- Zeitler P, Hirst K, Copeland KC, et al. HbA1c After a Short Period of Monotherapy With Metformin Identifies Durable Glycemic Control Among Adolescents With Type 2 Diabetes. Diabetes Care 2015; 38:2285.
- Nadeau KJ, Anderson BJ, Berg EG, et al. Youth-Onset Type 2 Diabetes Consensus Report: Current Status, Challenges, and Priorities. Diabetes Care 2016; 39:1635.
- Anderson BJ. Diabetes self-care: lessons from research on the family and broader contexts. Curr Diab Rep 2003; 3:134.
- Anderson BJ, Cullen K, McKay S. Quality of life, family behavior, and health outcomes in children with type 2 diabetes. Pediatr Ann 2005; 34:722.
- Copeland KC, Silverstein J, Moore KR, et al. Management of newly diagnosed type 2 Diabetes Mellitus (T2DM) in children and adolescents. Pediatrics 2013; 131:364.
- Springer SC, Silverstein J, Copeland K, et al. Management of type 2 diabetes mellitus in children and adolescents. Pediatrics 2013; 131:e648.
- Klingensmith GJ, Pyle L, Nadeau KJ, et al. Pregnancy Outcomes in Youth With Type 2 Diabetes: The TODAY Study Experience. Diabetes Care 2016; 39:122.
- American Diabetes Association Task Force for Writing Nutrition Principles and Recommendations for the Management of Diabetes and Related Complications. American Diabetes Association position statement: evidence-based nutrition principles and recommendations for the treatment and prevention of diabetes and related complications. J Am Diet Assoc 2002; 102:109.
- Academy of Nutrition and Dietetics, Pediatric weight management evidence-based nutrition practice guideline. Available at: http://andevidencelibrary.com/topic.cfm?cat=2721 (Accessed on February 25, 2013).
- Evert AB, Boucher JL, Cypress M, et al. Nutrition therapy recommendations for the management of adults with diabetes. Diabetes Care 2013; 36:3821.
- Reinehr T, Kiess W, Kapellen T, Andler W. Insulin sensitivity among obese children and adolescents, according to degree of weight loss. Pediatrics 2004; 114:1569.
- Willi SM, Martin K, Datko FM, Brant BP. Treatment of type 2 diabetes in childhood using a very-low-calorie diet. Diabetes Care 2004; 27:348.
- Barlow SE, Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007; 120 Suppl 4:S164.
- Academy of Nutrition and Dietetics. Diabetes mellitus type 1 and 2 evidence-based nutrition practice guideline. Available at: http://andevidencelibrary.com/topic.cfm?cat=3252 (Accessed on February 26, 2013).
- Fedewa MV, Gist NH, Evans EM, Dishman RK. Exercise and insulin resistance in youth: a meta-analysis. Pediatrics 2014; 133:e163.
- Gottschalk M, Danne T, Vlajnic A, Cara JF. Glimepiride versus metformin as monotherapy in pediatric patients with type 2 diabetes: a randomized, single-blind comparative study. Diabetes Care 2007; 30:790.
- Kelly AS, Rudser KD, Nathan BM, et al. The effect of glucagon-like peptide-1 receptor agonist therapy on body mass index in adolescents with severe obesity: a randomized, placebo-controlled, clinical trial. JAMA Pediatr 2013; 167:355.
- Zinman B, Wanner C, Lachin JM, et al. Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes. N Engl J Med 2015; 373:2117.
- Hasan FM, Alsahli M, Gerich JE. SGLT2 inhibitors in the treatment of type 2 diabetes. Diabetes Res Clin Pract 2014; 104:297.
- Tahrani AA, Barnett AH, Bailey CJ. SGLT inhibitors in management of diabetes. Lancet Diabetes Endocrinol 2013; 1:140.
- TODAY Study Group, Zeitler P, Epstein L, et al. Treatment options for type 2 diabetes in adolescents and youth: a study of the comparative efficacy of metformin alone or in combination with rosiglitazone or lifestyle intervention in adolescents with type 2 diabetes. Pediatr Diabetes 2007; 8:74.
- 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; 96:159.
- Laffel L, Chang N, Grey M, et al. Metformin monotherapy in youth with recent onset type 2 diabetes: experience from the prerandomization run-in phase of the TODAY study. Pediatr Diabetes 2012; 13:369.
- TODAY Study Group. Design of a family-based lifestyle intervention for youth with type 2 diabetes: the TODAY study. Int J Obes (Lond) 2010; 34:217.
- Plotnick L. Diabetes Mellitus. In: Principles and Practice of Pediatric Endocrinology, Kappy SM, Allen DB, Geffner ME (Eds), Charles C. Thomas, Springfield 2005. p.635.
- Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg 2003; 238:467.
- Dixon JB, O'Brien PE, Playfair J, et al. Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial. JAMA 2008; 299:316.
- Pories WJ, MacDonald KG Jr, Morgan EJ, et al. Surgical treatment of obesity and its effect on diabetes: 10-y follow-up. Am J Clin Nutr 1992; 55:582S.
- Inge TH, Miyano G, Bean J, et al. Reversal of type 2 diabetes mellitus and improvements in cardiovascular risk factors after surgical weight loss in adolescents. Pediatrics 2009; 123:214.
- Dixon JB, Dixon AF, O'Brien PE. Improvements in insulin sensitivity and beta-cell function (HOMA) with weight loss in the severely obese. Homeostatic model assessment. Diabet Med 2003; 20:127.
- Inge TH, Courcoulas AP, Jenkins TM, et al. Weight Loss and Health Status 3 Years after Bariatric Surgery in Adolescents. N Engl J Med 2016; 374:113.
- Shah AS, D'Alessio D, Ford-Adams ME, et al. Bariatric Surgery: A Potential Treatment for Type 2 Diabetes in Youth. Diabetes Care 2016; 39:934.
- Inge TH, Jenkins TM, Xanthakos SA, et al. Long-term outcomes of bariatric surgery in adolescents with severe obesity (FABS-5+): a prospective follow-up analysis. Lancet Diabetes Endocrinol 2017; 5:165.
- Inge TH, Laffel L, Jenkins T, et al. Surgical therapy is more effective than medical therapy in the treatment of type 2 diabetes (T2D) in severely obese adolescents. (Meeting Abstract, #159-LB). Available at: http://diabetes.diabetesjournals.org/content/diabetes/suppl/2016/06/20/65.Supplement_1.DC1/2016_ADA_LB_Abstracts_HiRes_FINAL_5_11_16.pdf (Accessed on February 11, 2017).
- 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
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS