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Robert Rapaport Part 1, Transitioning from Pediatric to Adult Treatment

In part 1 of this Exclusive Interview, Dr. Robert Rapaport talks with Diabetes in Control Publisher Steve Freed during the AACE 2017 convention in Austin, Texas about the necessity of a proper, eventual transition of pediatric patients to adult care.

Robert Rapaport, MD is Professor of Pediatrics, Chief of the Division of Pediatric Endocrinology and Diabetes and the Emma Elizabeth Sullivan Professor of Pediatric Endocrinology and Diabetes at Icahn School of Medicine at Mount Sinai, New York.

Transcript of this video segment:

Steve:  This is Steve Freed with Diabetes in Control.  We are here at the AACE 2017 meeting in Austin, TX.  We have with us a really special guest, an expert in pediatric diabetes, who is a professor.  We can start by you telling us a little about your practice, and what you do, and where you do it?

Dr. Rapaport:  I am the chief of pediatric endocrinology and diabetes section at the Icahn School of Medicine at Mount Sinai. This is a division of the pediatric endocrinology and diabetes, so we have a triple mission of doing clinical care, doing research, and doing education.  We have a fellowship program for training in endocrinology and diabetes.  We see patients with diabetes and endocrine disorders, and we try to do a little bit of research as well.

Steve:  You are here [at the AACE meeting], and you are sharing a couple of presentations.  The title of one is, The Transition Process: A Key to Best Adjuvant Care.  Maybe you can start off by describing to us the transition from what to what?

Dr. Rapaport:  There are multiple areas of transition. Being at AACE, most of the attendees are adult endocrinologists and diabetes specialists. When children age out of our age group of comfort, we do want to have a place for these individuals to continue their care. That is what the transition program is all about.  When they become emerging adults, the idea would be to have them go from a pediatric practice to the adult practice.  The ways of doing that are the core to having continuity of care and assuring excellence in care.  There are ADA guidelines on the transition that have been published for youth with diabetes, focusing mostly on type 1 diabetes.  Over the last several years, maybe 10 to 15 years, we’ve seen an increased number of youth with type 2 diabetes, and that’s why I thought it would be appropriate to have an individual such as Dr. Brink from Boston talk about transition in type 2 diabetes.  While criteria for transition are mostly focusing on type 1 patients, there is a positive data about type 2 individuals.  While there is a huge increase in an epidemic of obesity, and there is an increase in type 2 diabetes in youth, I don’t think it’s quite of such of epidemic proportions.  Still, we see a lot more individuals with type 2 diabetes than we have previously seen.  It also depends on the ethnic background of the individual you see.  For example, in African Americans, Native Americans, Asians, and Pacific Islanders see a lot more of type 2 diabetes.  Overall, if you look at all youth with diabetes, still the majority have the type 1 diabetes.  Type 2 diabetes is interesting because there is only one approved medication for it, namely metformin.  There are numerous companies trying to do studies now to look for other agents to participate in clinical trials for other agents that may help with care for type 2 individuals, including injectable medications. Unfortunately, it’s very difficult to recruit for some of these studies, but I think it’s very valuable, worthwhile endeavor to do.

Steve: At what age do you feel comfortable transferring them over to an adult specialist?

Dr. Rapaport:  When I turn 50, I’ll try to transfer them then. [laughter] The age of transition varies tremendously, somewhere between 18 and 21, but most of our patients with diabetes we do take them through college and arrange for transition after that.  There is an impetus at  some pediatric practices to treat some young adults, and Dr. Brink actually mentioned that in his practice as long as they are doing it in conjunction with other healthcare providers, they do see young adults with diabetes to assure a continuity of care.  Certainly by the time of their mid-twenties, I think it is reasonable to transition them to an adult care practice.

Steve:  When you see a pediatric patient, you are not really dealing with that patient on a face-to-face basis, you’re really dealing with the parents.

Dr. Rapaport:  We are dealing with a whole host of things and the child is at the center of this care package.  But, certainly, the parents, other healthcare providers, the school system are all involved in the care of a child with diabetes. You asked about transition from what to what, but, in fact, there are multiple areas of transition.  When people say transitions, they usually mean transition from the pediatric to adult care.  In fact there’s a transition if a child develops diabetes, we have a child in the hospital right now who is less than a year of age, so there will be a transition for them when a child becomes 3 or 4 and starts going through school.  There will be a transition when he is going to start 1st grade.  There will be transition when this child enters puberty.  Ultimately, there will be a transition to an adult practice.  There are multiple areas of transition that most people lose in translation when they talk about transition.  It is really an ongoing course of transition.

Steve: I would imagine your youngest patient is a day old or not even a day old…

Dr. Rapaport: Not even a year old. Having diabetes at one day old is a different kind of diabetes. That’s very unusual. 

Steve:  OK. So at a year old, and you also have patients that are older.  What’s the oldest patient that you work with?

Dr. Rapaport:  Well, [laughter] it’s not fair but, it’s a patient who is well beyond what is regarded as the pediatric age.

Steve:  So they just can’t bear to leave you?

Dr. Rapaport:  There are few patients who do get attached, not only to us, but to our way of doing things.  Occasionally, we transition patients to the adult healthcare team and sometimes they come back.  That is why a successful transition needs a lot of work, a lot of preparation, and a lot of collaboration between all the members of the healthcare team, both on the pediatric and adult side.  And special transition units should be constructed.

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