Chapter 23: Type 2 diabetes mellitus in children and adolescents S109
1. Family history of type 2 diabetes in first-degree or second-degree relative.
2. High risk race or ethnic group (e.g. South Asians). 3. Signs of insulin resistance or conditions associated with
insulin resistance (e.g. acanthosis nigricans, hypertension dyslipidaemia, PCOS).
General recommendations for screening include:
1. Screening should begin at age 10 years, or at onset of puberty if this occurs at a younger age.
2. If the initial screening is normal, repeat testing every 2 years. 3. A fasting plasma glucose test is the preferred screening test. 4. If the fasting glucose does not meet diagnostic criteria but
clinical suspicion is high, then an OGTT is a more sensitive tool.
23.3 Management of type 2 diabetes in children and
adolescents
The aim of management in children and adolescents with type 2 diabetes mellitus is to minimise the risk of acute and chronic complications of diabetes by:
• Achieving and maintaining weight loss in obese individuals. • Increasing exercise capacity.
• Normalising blood glucose levels and HbA1C to <7%.
• Controlling associated co-morbidities e.g. hyperlipidaemia and hypertension.
23.3.1 Emergency management
If the child or adolescent presents in diabetic ketoacidosis (DKA) or hyperglycaemic hyperosmolar non-ketotic coma (HHNK), immediately refer the patient to a paediatric diabetes specialist. If this is not possible, contact a paediatric diabetes specialist telephonically for guidance and assistance.
The risk of cerebral oedema and death is high in childhood and adolescence, and a paediatric protocol for management must be used.
23.3.2 Management strategy
1-5Best practice: ANY diabetes in a child or adolescent <18yrs should be referred to or discussed with a paediatric diabetes specialist. There are three components to managing type 2 DM in children and adolescents:
1. Diet/Lifestyle modification
• The patient and parents must be referred to a dietitian. 2. Medication
• NB: NO Aspirin is to be used in children and adolescents <21 years.
• If ketosis, acidosis, or dehydration is present the management is insulin first, adding metformin later once hydrated and ketone-free.
• If the diagnosis is in doubt whether type 1 or type 2 DM, the management is insulin and metformin, weaning the insulin once the HbA1C is controlled.
• Ketones (preferably ß-hydroxybutyrate) must be monitored and if they recur, insulin must be reinitiated. • Metformin is used in the otherwise well, less symptomatic
child with type 2 phenotype.
• Initiate insulin if the HbA1C is not controlled after 6 months.
Metformin initiation: Low dose (500 mg) daily, then twice daily (over 3-4 weeks), then increase dose as tolerated to a maximum of 1 g twice daily, titrated to HbA1C and self-
monitoring blood glucose testing (SMBG). 3. Education including SMBG
• It must be emphasised that there is a possibility that the diagnosis is Type 1 diabetes, and that insulin may be required. SMBG is essential to prevent DKA/HHNK.
Figure I describes the management algorithm with titration thresholds.
23.4 Screening for complications and associated risk
factors
1-5• Albuminuria should be evaluated at diagnosis and annually thereafter. Either micro- or macro-albuminuria may be present at diagnosis. An ACE inhibitor is the first line therapy. Remember to counsel fertile girls/women about the teratogenicity of ACE inhibitors.
• Hypertension (>95th percentile for age, height and gender)
may be present at or prior to diagnosis of DM and each individual should be assessed at each visit for HPT is estimated to account for 35-75% of diabetes complications i.e. both micro and macrovascular. An ACE inhibitor is first line therapy (especially if microalbuminuria).
• Dyslipidaemia is more common in Type 2 DM and in family members and should be screened for when metabolic stability is achieved. Hypertriglyceridaemia and decreased HDLC are hallmarks of Type 2 dyslipidaemia. This is primarily treated with weight loss, lower cholesterol diet and improved glucose control. Statins are only to be used under specialist care – and with extreme caution in childbearing age adolescent girls/ young women.
• Evaluate for non-alcoholic fatty liver disease (NAFLD) at diagnosis and annually thereafter, with a screening ALT level. Hepatic steatosis is present in 25-45% of adolescents with Type 2 DM. NAFLD now represents the most common cause of cirrhosis in children and is the most common reason for liver transplantation in the adults in the United States. Metformin must not be used if the liver enzymes are >2.5 times the upper limit of normal.
• Screening for diabetic retinopathy is to be performed at diagnosis and annually. The preferred method is retinal imaging by fundus photography, or dilated fundoscopy performed by an ophthalmologist or trained clinician.
• A history of pubertal development, menstrual irregularities and obstructive sleep apnoea, should be elicited at diagnosis and regularly thereafter with appropriate management as required.
Journal of Endocrinology, Metabolism and Diabetes of South Africa 2017 ; 22(1) S110
Fertility may improve on metformin and contraception should be emphasised in the sexually active individual.
Discuss with or refer to paediatric specialist if any risk factors or complications are present.
Author: Michelle Carrihill, in conjunction with PAEDS-SA Editors: Ankia Coetzee and Aslam Amod
References
1. ISPAD Clinical Practice Consensus Guidelines 2014 Compendium, Type 2 diabetes in the child and adolescent. Pediatric diabetes 2014:15(suppl. 20):26 2. Copeland KC, Silverstein J, Moore KR, et al. Management of newly diagnosed
type 2 diabetes mellitus in children and adolescents. Pediatrics 2013: 2: 131,364 3. Stringer SC, Silverstein J, et al. Management of newly diagnosed type 2 diabetes
mellitus in children and adolescents. Pediatrics 2013: 2: 131, e650
4. Executive summary. Type 2 diabetes in children and adolescents. Can J Diabetes 2013; 37: s341
5. NICE. Diabetes (type 1 and type 2) in children and young people: diagnosis and management (NG18) 2015
Initiate insulin therapy; metformin once ketones cleared; lifestyle and diet management
Initiate metformin and lifestyle and diet management Does patient have any of the following:
• Ketosis or ketoacidosis
• Uncertainty whether type 1 or type 2 • HbA1C > 9%
Type 2 diabetes mellitus diagnosed in a child or adolescent
Intensify treatment Continue current treatment;
attempt to wean off insulin
Continue current treatment Intensify treatment
Yes
Yes Yes
SMBG, titrate insulin
HbA1C every 3 months HbA1C every 3 months
HbA1C <7% HbA1C <7%
No
No No
JEMDSA
ISSN 1608-9677 EISSN 2220-1009 © 2017 The Author(s)
SEMDSA GUIDELINES
24.1 Introduction
There is no general agreement on the age at which a person becomes old. The common use of chronological age to mark the threshold of old age assumes equivalence with biological age, yet these two are not necessarily synonymous. There is no universally accepted age that defines the older person; the United Nations, World Health Organisation and Statistics South Africa accept age 60+ as being older, while many developed countries use age 65+ (the pensionable age). This chapter will use age 60+ as a basis to define the age at which a progressive decline in health and functional status is more likely to occur, and co-morbidities are likely to be common enough to justify some generalisations about diabetes management. Ageism (discrimination based only on age) is unacceptable. The aim of this chapter is to improve the care of the older person, not to deny care based only on the age of the person.
Ageing is regarded as a major contributor to the diabetes epidemic. The percentage of the South African population aged 60 years and above rose from 7.1% (2.8 million) in 1996 to 8.0% (4.1million) in 2011.1 Estimates show that the older
population will continue to increase, and it is estimated that by 2030 there will be ~7 million older persons in South Africa.1 The
national prevalence of diabetes, hypertension, dyslipidaemia and obesity in 2012 is shown in Appendix 2 (SANHANES-1). For the population older than 65 yrs, 40% have abnormal glucose
regulation and 50% have dyslipidaemia.2 Diabetes in older adults
is linked to higher mortality, yet they are often excluded from randomised controlled trials of diabetes.3,4 The care of older
persons with diabetes impacts on the whole family, and this must be taken into account.
Diabetes in older persons is unique and may be complicated by a non- specific clinical presentation with vague symptoms. Age- related insulin resistance (IR) coupled with age-related declines of pancreatic beta-cell function both contribute.5,6 A small
increase in fasting plasma glucose (FPG) and significant increase in post-prandial or 2 hours post oral glucose tolerance test (OGTT) are usually seen. It has also been shown that the renal threshold for glucose increases with age and therefore may not demonstrate glycosuria despite elevated blood glucose.7 The
recommended diagnostic criteria for diabetes remains the same. Caution needs to prevail with the interpretation of the HbA1c as it may be altered by co-existing conditions. These biological differences have important therapeutic relevance to this patient population.
24.2 Hypoglycaemia
Impaired liver and renal function due to ageing, with or without coexisting disease leads to decreased gluconeogenesis. This can be compounded by the reduced clearance of medications such as insulin and sulphonylureas and may put patients at higher risk of hypoglycaemia. The normal (autonomic) defences against
SEMDSA 2017 Recommendations
A holistic individualised care plan for older individuals, with the aim of maintaining independence should be sought. C Prevention of hypoglycaemia should take priority over attainment of glycaemic targets. C The healthy older adult who has a life expectancy that exceeds the duration of randomised controlled trials showing
benefit, should generally receive diabetes care with goals and targets similar to those for younger adults.
C Patients older than 65 years should be screened annually for cognitive impairment, dementia and depression because these impact on diabetes management decisions.
B Metformin is the initial drug of choice for older adults unless contra-indicated or not tolerated. B Sulphonylureas should be used with caution as the risk of hypoglycaemia increases exponentially with age. They should be avoided in older adults at particularly high risk for hypoglycaemia or its consequences.
B Thiazolidinediones should be used with caution due to the risk of fractures and heart failure. C DPP-4 inhibitors have excellent tolerability profiles, very low risk of hypoglycaemia and is the preferred second drug
for the older person with comorbidities.
B If insulin mixture is used, premixed solutions and prefilled pens should be used to reduce dosing error. B The clock drawing test may be used when assessing capability of a patient to administer insulin. C Journal of Endocrinology, Metabolism and Diabetes of South Africa 2017 ; 22(1)
http://dx.doi.org/10.1080/16089677.2015.1056468 Open Access article distributed under the terms of the Creative Commons License [CC BY-NC-ND 4.0] http://creativecommons.org/licenses/by-nc-nd/4.0