type 2 diabetes in adolescents: issues for the sbhc provider kathy love-osborne md, faap
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Type 2 Diabetes in adolescents: Issues for
the SBHC provider
Kathy Love-Osborne MD, FAAPAssociate Professor of
PediatricsCASBHC 5/3/13
No financial disclosures I do plan to discuss the use of
Hemoglobin A1c as a screen for diabetes. This test is not officially recommended by the American Academy of Pediatrics as a screening test in adolescents
Disclosures
American Diabetes Association and AAP recommend screening with fasting glucose every two years starting at age ten or at onset of puberty, whichever is first Insulin resistance increases in puberty
BMI > 85% and 2 risk factors for T2D: Family history of diabetes Minority race at higher risk Signs of insulin resistance
Type 2 Diabetes (T2D) screening
Random glucose Poor sensitivity; not recommendedFasting glucose Poor sensitivity
Sinha et al 2003 – 60 obese children – 4% T2D, 25% IGT – all missed by fasting glucose
Oral glucose tolerance test More sensitive but time consumingHemoglobin A1c (A1c)- Not officially recommended in teens
Diabetes screening options
A1c as a screening tool
A1c had previously not been recommended as a screening test in adults due to lack of assay standardization
In 2010, an expert review committee recommended using A1c as a screen for diabetes in adults ≥ 6.5% presumptive diabetes 6.5% correlated with increased rates of
eye and kidney diseaseThe International Expert Committee 2009
All teens with BMI > 95% (FH often unknown): 1st screen age 10 or pubertal: A1c or fasting
glucose Re-screen every 2 years, sooner if BMI
increases more than 1 kg/m²/year BMI 85-95% with 2 or more risks:
Family history of T2D Acanthosis, hypertension, PCOS Ethnicity at increased risk for T2D
Denver Health adolescent T2D screening recommendations
Confirmation of a single result is required unless symptomatic
Fasting plasma glucose (FPG) > 126 mg/dl
Random or 2-hour after glucose challenge glucose > 200 mg/dl
A1c ≥ 6.5%
T2D diagnosis
Patients should be instructed to check blood sugars:If they are taking insulin or other medications that can cause hypoglycemiaIf they are starting or changing their treatment regimenIf they are not meeting treatment goalsIf they are ill
T2D: blood sugar monitoring
Frequency of testing depends upon the patient; most T2D patients are asked to check 1-3 times/day initially until at target A1c
Post-prandial testing (2-hours after a meal) may be very helpful in patients at diagnosis, as they may notice patterns with foods that tend to raise their blood sugar
New onset diabetics are usually asked to check sugars before meals and at bedtime
Blood sugar monitoring
A1c should be checked every 3 monthsTarget is < 7% for most adolescentsLevels over 8% indicate possible need for change in treatment regimen
Levels over 9% (some endocrinologists use 8%) indicate need for insulin
T2D A1c monitoring
Studies in teens have shown 10% success rates with lifestyle therapy alone
Metformin should be started once the diagnosis is confirmed*
500 mg daily, increase by 500 mg every 1-2 weeks to goal of 2 g daily Lactic acidosis rare but serious side effect
T2D: Metformin
The TODAY trial of treatment of T2D in adolescents showed very high rates of treatment failure (needing insulin in addition to oral medications)
Insulin is typically added when A1c is ≥ 8-9% due to the presence of glucose toxicity (oral medications may not work well at these A1c levels)
Treatment of T2D in teens
Insulin treatment recommended for:Random blood sugar ≥ 250 mg/dlA1c ≥ 9%Ketosis (present in 5-25% of
adolescents eventually diagnosed with T2D)
T2D Treatment: insulin
The most commonly used insulin regimen in adolescents with T2D is long-acting (basal) insulin, usually given once daily at bedtime
Patients on insulin should check fasting blood sugars daily and post-prandial sugar once daily
Short acting insulin may be needed if basal insulin fails to attain A1c in target range
Insulin therapy in T2D
JA 13 y.o. HF BMI 34.2 kg/m² A1c 6.9% at Denver Health Continuous glucose monitoring study at
Children’s Hospital: A1c 5.9% many glucose values > 140 mg/dl and
some > 200 mg Family missed f/u metabolic syndrome
clinic appointment: “I was told she didn’t have diabetes so I didn’t see the point”
Case 1: laboratory differences
Due to differences such as in Case 1, it is reasonable to follow patients with A1c 6.5-6.9 for 3 months with lifestyle changes before starting medication or referring to specialty care
Consider glucometer useConsider ongoing research studies
Local issues
Impaired fasting glucose (IFG) Fasting plasma glucose (FPG) > 100
mg/dl but < 126 mg/dl Impaired glucose tolerance (IGT)
2-hour glucose > 140 mg/dl but < 200 mg/dl
A1c 5.7-6.4% A1c values >6.0% have higher risk
for progression to T2D than values of 5.7-5.9%
Pre-diabetes
• Obese adolescents ages 12-18 years seen during two 18-month periods in community or school settings• Wave 1: 4/08-10/09 (n = 2949)• Wave 2: 5/10-11/11 (n = 3944)• Ethnicity: 13% black, 76% Hispanic, 8% white and 3% other
Denver Health data
Wave 1 Wave 2
Adolescents served 15,500 17,200 % with BMI available 76% 95%
Obese teens 2,949 3,954
Number of diabetes tests 1,151 1,845
% with diabetes testing 39.0% 46.7%
New T2D cases identified 8 13 Diabetes rate 0.7% 0.7%
Summary of participants
21 confirmed incident T2D cases 38% identified on the first screen 43% identified on follow-up of
normal testing, mean 2.9 years later 19% identified on follow-up of pre-
diabetes, mean 1.6 years laterIllustrates importance of regular
screening intervals
New diabetes cases
KF 13yo HF with BMI 39.4 kg/m²seen in SBHC for URIasked to return for PE
PE 2 weeks later: A1c 8.7%, uninsured
Seen within 1 week of abnormal result at Barbara Davis Center
Case #2: SBHC diagnosis
TG 10yo HF BMI 39.1 kg/m²SBHC physical: HbA1c 6.8%
Multiple attempts to schedule f/u by SBHC, supervising physician and PCP
Mother agreed to follow up but NS
Case #3: Failure to f/u after initial abnormal screen
1st 2 visits for asthma do not note previous elevated A1c. BMI up to 44.8 kg/m²
3rd visit: unable to draw blood in SBHC Labs at community clinic: A1c 7.9%Family now without health insurance. Referred to enrollment specialist. Multiple notes in chart about recommended f/u in endocrinology and unsuccessful attempts to reach mother
Case 3: Next school year, different SBHC
4 months and 5 visits later: multiple notes documenting attempts to contact mother:
• Repeat A1c 8.8%• 1 week later mother came in to SBHC• 3 weeks after that visit seen at Barbara Davis Center, now > 1 year since original abnormal A1c
Case 3 follow-up
• Call your subspecialist. They can schedule the appointment and help with insurance • This is diabetes. Notes said “elevated
A1c” and “metabolic syndrome”• Consider a medical neglect report• Don’t forget to review the medical record
before you see every patient
Case 3: pearls
Obese adolescents 12-18 years old with first-time A1c 5.7-7.9% were identified through electronic medical record review
Dysglycemia was defined as: A1c 5.7-5.9% (mild pre-diabetes) A1c 6.0-6.4% (moderate pre-diabetes) A1c 6.5-7.9% (diabetes range)
Dysglycemia progression
281 adolescents with dysglycemia were identified
Participants were 15.4±2.0 years old 67% Hispanic, 21% Black, 3% white,
and 9% other 213 had mild A1c elevation 60 had moderate A1c elevation 8 had diabetes range A1c elevation
Results
F/U testing one year after identification to most recent f/u was available in:57% of patients with mild A1c elevation
82% of patients with moderate A1c elevation
88% of patients with diabetes-range A1c
Follow-up testing rates
There was a linear trend between BMI change and worsening A1c (p=0.01 for trend)
A1c < 5.7% at f/u: 35% +0.2 kg/m2
A1c 5.7-5.9 at f/u: 40% +0.8 kg/m2
A1c 6.0-6.4% at f/u: 24% +1.5 kg/m2
A1c > 6.5 at f/u: 1% +2.3 kg/m2
Follow-up of A1c 5.7-5.9%
There was not a similar trend with regards to BMI change in patients with A1c over 6.0%
There was a much higher rate of progression to diabetes (16% in one year)Patients with A1c ≥ 6% need close follow-up
Follow up of A1c 6.0-6.4%
20 patients had A1c values in this range during the study period; 19 had f/u 65% were not on medication at last f/u
20%continued with A1c values > 6.5% but were managed with lifestyle alone
40% improved to A1c < 6.5% 35% had T2D treated with medication
Follow-up of A1c 6.5-7.9%
Dysglycemia in some adolescents may be transient, even those with initial A1c results in the diabetes rangeWeight stabilization lead to resolution
of pre-diabetes in patients with A1c values in the 5.7-5.9 range
Patients with higher baseline A1c values (6.0% and higher) had significant rates of progression to T2D over the next year
Dysglycemia conclusions
Chart audits were done on 234 patients with A1c ≥ 5.7%
•Documentation of patient notification of elevated A1c was recorded
•Patients seen after lecture to peds/SBHC providers advised use of A1c and defined pre-diabetes
Patient notification
62% of tests were sent during or shortly after an appointment for a physical38% documented generic
diet/exercise counseling 47% documented specific goals set15% had no counseling documented
Results: counseling
37% had no documentation that abnormal results were recognized
10% results were inaccurately documented as normal
24% notified in clinic 17% notified by phone 8% notified by letter 3% unable to contact
Results: A1c 5.7-6.4
Informed n Laboratory Follow-up
A1c change
BMI change
(median)
No 119 57 (48%) +0.12% + 0.7 kg/m2
Yes 115 114 (75%) -0.04% + 0.4 kg/m2
p-value < 0.001 0.18 0.3
Results: Patient informed of elevated A1c
Patient notification of abnormal laboratory results was associated with increased rates of follow-up testing
Patient notification was associated with trends towards improved BMI outcomes and improved follow-up A1c values
Discussion: Patient notification
Provider awareness? Failure to document conversations? Documentation of unsuccessful
attempt to contact, but no further attempt to notify patient in other way
Chart documentation of message left, but unclear if patient received needed information
Lack of documentation
When you were at the clinic, you had a diabetes test called a Hemoglobin A1c done. Your blood test is in the range that is considered “pre-diabetes” (5.7% to 6.4%). This means that you have a higher than normal chance of getting diabetes over the next 2 years. If your Hemoglobin A1c gets higher than 6.5%, that means you have diabetes.
Your hemoglobin A1c was: ________ For preventing diabetes, the most important change you can make is cutting
down on sugary drinks and other foods with a lot of carbohydrates (sugars), such as cookies, candy, sweet cereals, white bread, and flour tortillas. This will cut down the amount of work your body has to do to use sugars and may lower your chance of getting diabetes.
Exercise is also important because when you exercise, your body doesn’t have
to work as hard to use carbohydrates that you eat. Try to exercise an hour or more every day.
Sample letter
Repeat A1c, glucose, UA for ketones within 1 week
Consider glucometer to check 2-hour glucose daily for 2 weeks (with outside PCP) Blood sugar log sheet Immediate feedback is often helpful
to promote lifestyle changes F/U 2 weeks to review results F/U 3 months for repeat A1c
Management of A1c 6.5-7.0
KDTC 16 y.o. HF BMI 32 kg/m² diagnosed in Community Health center
with T2d 3/12, A1c 9.2%; seen at BDC No f/u notes in Community Health Multiple SBHC visits for family planning Found on chart review 1/13 to have been
lost to follow-up by BDC after 2nd visit 5/12 Patient recalled to SBHC and re-started on
medication, facilitated follow-up with BDC
Case 4: how the SBHC can help
Any patient with serious medical problems (including diabetics) should be co-managed with an outside PCP to minimize loss to follow –up over school breaks or in the case of school change
Keep diabetics on your “tickler” to see every three months and make sure they are not lost to specialty follow-up
Follow-up of diabetics in SBHC
Remember to screen at-risk adolescents every 2 years with either fasting (not random) glucose or A1c
Don’t forget to screen early adolescents (10-12 years old) as diabetes risk ≈ 50% higher
Conclusions
Management of newly diagnosed Type 2 Diabetes Mellitus (T2DM) in children and adolescents Clinical practice guideline by American Academy of
Pediatrics 2013
Website with great handouts for teens dealing with diabetes: www.yourdiabetesinfo.org(go to healthcare provider and enter children/teens as age group)
References
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