Pediatric Type 2 Diabetes Mellitus Treatment & Management

Ideally, management of diabetes should involve a pediatric endocrinologist, a diabetes nurse educator, a nutritionist, and a behavioral specialist.

The goal of therapy is to achieve and maintain euglycemia, as well as near-normal hemoglobin A_1c (HbA_1c) 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.^[30]

Evidence from a study by Bennett et al supported the use of metformin as a first-line agent to treat type 2 diabetes in adults. The study assessed the efficacy and safety of medications such as metformin, second-generation sulfonylureas, thiazolidinediones, meglitinides, dipeptidyl peptidase-4 (DPP-4) inhibitors, and glucagonlike peptide-1 receptor agonists used in monotherapy and in combination for adults with type 2 diabetes mellitus. The results found that although most 2-drug combinations reduced HbA1c levels, some drugs increased adverse events (eg, increased the risk for hypoglycemia).^[35]

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.

HbA1c levels should be measured every 3 months (at every clinic visit) with the goal of keeping these levels below 7%. Blood pressure should be measured at every clinic visit.

Glycemic and nonglycemic goals should be clearly stated and may include the following^[36] :

• 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.

Diet

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.^[30]

Activity

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.^[37]

Prevention

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.^[38]

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.^[30]

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.^{[39, 34]} ACE inhibitors are the agents of choice to treat hypertension and microalbuminuria.^[40]

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%.^[36] 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.^[41]

Hypertension

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.

Diabetes

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.

Dyslipidemia

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.

Diet

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.

Physical activity

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.^[36] 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.

Hemoglobin monitoring

HbA_1c 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 HbA_1c assay for the diagnosis of diabetes mellitus in nonpregnant adults.^[42] The committee’s recommendation to diagnose diabetes is an HbA_1c 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 HbA_1c assay is unavailable. The committee listed the following advantages of HbA_1c 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 concerns

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.