Specific treatment recommendations outlined for this growing patient population.
There has been an increasing amount of youth-onset type 2 diabetes diagnoses in recent years. Unlike their adult counterparts, youth who have diabetes have comparatively greater insulin resistance as well as an increased rate of beta cell burnout and increased rates of morbidity and mortality. Unfortunately, the research regarding youth-onset diabetes has not kept pace with the recent increases in occurrence. Consequently, the American Diabetes Association (ADA) has issued a position statement that helps to summarize the currently available data into a usable clinical guideline.
The diagnostic criteria for type 2 diabetes is the same for both adult and youth-onset; however, the recommendations for initial and follow-up screening are different. The ADA recommends that youth who have excess weight or obesity with an additional risk factor (i.e. family history, susceptible race, or signs of insulin resistance) be screened for type 2 diabetes at puberty or the age of 10 (whichever comes first) and then every three years, thereafter, if no diagnosis can be made.
To all youth who are at risk for developing diabetes or have type 2 and their families, education on appropriate and culturally sensitive diet with lifestyle modifications should be provided and integrated into any treatment plan. Once a diagnosis is made, metformin is the first-line pharmacotherapy of choice. However, if the patient’s presenting A1C is ≥ 8.5%, then basal insulin should be initiated while metformin is being titrated to an effective dose. It should be noted that, aside from insulin and metformin, none of the remaining anti-diabetes medications have been approved for the treatment of youth. Therefore, use of other types of anti-diabetes medications in youth should be done with caution and on a case-by-case basis. Pharmacotherapy should be titrated to an ideal goal A1C of < 7%; however, glycemic goals should be adjusted on a case-by-case basis in order to minimize risk of hypoglycemia.
Assessment for nephropathy, neuropathy, retinopathy, and liver dysfunction should be conducted at the time of diagnosis and yearly thereafter. Preventive measures consist mostly of achieving and maintaining glycemic goals. However, monitoring and adequately treating elevated blood pressure (> 95th percentile for sex, age, and height) is particularly important for the prevention of nephropathy. Once glycemic control is achieved, the patient’s lipid panel should then be assessed, followed by yearly assessments thereafter. The ADA recommends cholesterol goals of < 100, > 35, and < 150 mg/dL for LDL, HDL, and triglycerides respectively. The ADA also suggests use of statin therapy if LDL remains above goal 6 months after implementing lifestyle modifications. Adequate glycemic control coupled with the prevention and management of the previously mentioned complications of type 2 diabetes is emphasized as an important means of reducing risk of developing cardiovascular disease.
Another issue that has recently come to light is the need for better transitional care when switching from pediatric to adult care. It has been noted in numerous observational studies that there is no uniform transitional process and what typically takes place results in gaps in care and confusion on the part of the patient and often the physician. Despite the apparent interest this subject has fostered in the research community, no viable system has been proposed or studied. Consequently, the ADA recommends that transitioning to adult care should be discussed thoroughly with the patient so that the options and expectations are known and agreed upon prior to any change taking place.
Overall, the ADA’s position statement emphasizes that youth with type 2 diabetes or who are at risk for type 2 diabetes should be approached differently than adults. Moreover, the recommendations made in the ADA’s statement stresses the caution that is needed in this patient population due to the shortage of studies providing data on this subject.
- Relatively little research has been done concerning youth with type 2 diabetes; therefore, caution must be taken when treating this patient population.
- Only metformin and insulin are FDA-approved for the treatment of diabetes in youth. Other antidiabetes regimens have little evidence supporting their use in this population.
- Transitioning from pediatric to adult diabetes care must be done cautiously in order to prevent gaps in care or patient confusion.
Arslanian, Silva, et al. “Evaluation and Management of Youth-Onset Type 2 Diabetes: A Position Statement by the American Diabetes Association.” Diabetes Care, 2018, p. dci180052., doi:10.2337/dci18-0052.
Michael Zaccaro, Pharm. D. Candidate 2019, LECOM School of Pharmacy