diabetes control in youth: the american experience georgeanna j. klingensmith, md keystone colorado...
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Diabetes Control in Youth:The American Experience
Georgeanna J. Klingensmith, MD
Keystone Colorado
July 2008
Diabetes Control: American View ADA recommendations Advances in care since the ADA
statement prepared What are HbA1c results in the US? Differing results by insulin regimen Continuing barriers to
achieving targets
American Diabetes Association Standards for the Care of Children
Developed recommendations for glycemic control in 2003-04
- based on DCCT results and
- what was considered safe for generalists to accomplish
- designed to weigh ideal with practical
American Diabetes Association Standards for the Care of Children
Target goals should be individualized Aim for the lowest HbA1c each child and
family can accomplish Avoid hypoglycemia and excessive
hyperglycemia– Both have been shown to result in
neurocognitive deficits in the developing brain
Perantie DC, Lim A, Wu J, Weaver P, Warren SL, Sadler M, White NH, Hershey T. Pediatr Diabetes. 2008;9:87-95.
Targets for Type 1 Diabetes Care:
ADA Glycemic Guidelines 2008Targets** Age Fasting overnight A1c %Age Fasting overnight A1c % .
< 6yrs 100-180 110-200 7.5-8.5< 6yrs 100-180 110-200 7.5-8.5
6-12 yrs 90-180 100-180 <86-12 yrs 90-180 100-180 <8
13-19 yrs 90-140 90-150 <7.513-19 yrs 90-140 90-150 <7.5
adult 90-140 90-150 <7adult 90-140 90-150 <7
** Goals should be individualized
Silverstein, Klingensmith, et al. Care of Children with type 1 DM. ADA Statement. Diabetes Care, 28:186, 2005
ADA Standards of Care. Diabetes Care, Suppl 1, 2008
2 Hr post meal target= <1802 Hr post meal target= <180
Recent Advances in Diabetes Care
1996: First rapid acting analog insulin -2000: First long acting analog insulin -
Basal / Bolus injection therapy2003: First “smart pump” These combinations allowed sophisticated
insulin delivery by relatively medically unsophisticated school personnel
2006: Inhaled insulin Continuous glucose sensors2008: Beginning to close the loop
Stuart A. Weinzimer, et al Diabetes Care 31:934-939, 2008
Advantage of Long Acting Analogue Insulin
Glargine vs NPH: a randomized trial of BID insulin from 3-6 months after diagnosis
Hassan, Rodriguez,Johnson, Tadlock and Heptulla. Pediatrics, 21, e466 March 2008
SEARCH for Diabetes Study
Six clinical site epidemiological study Aims:
To determine
– Prevalence and incidence of diabetes
– Patterns and outcomes of care
SEARCH Study SitesSEARCH Study Sites
Kaiser PermanenteSouthern CaliforniaKaiser PermanenteSouthern California
University of Colorado -WRDY
University of Colorado -WRDY
CincinnatiChildren’sHospital
CincinnatiChildren’sHospital
University ofSouth Carolina
University ofSouth Carolina
Pacific Research InstituteHawaii
Pacific Research InstituteHawaii
Children’s HospitalSeattleChildren’s HospitalSeattle
Wake Forest UniversityCoordinating CenterWake Forest UniversityCoordinating Center
Central Laboratory –University of WashingtonCentral Laboratory –University of Washington
SEARCH Study SitesSEARCH Study Sites
Kaiser PermanenteSouthern CaliforniaKaiser PermanenteSouthern California
University of Colorado -WRDY
University of Colorado -WRDY
CincinnatiChildren’sHospital
CincinnatiChildren’sHospital
University ofSouth Carolina
University ofSouth Carolina
Pacific Research InstituteHawaii
Pacific Research InstituteHawaii
Children’s HospitalSeattleChildren’s HospitalSeattle
Wake Forest UniversityCoordinating CenterWake Forest UniversityCoordinating Center
Central Laboratory –University of WashingtonCentral Laboratory –University of Washington
SEARCH Study SitesSEARCH Study Sites
Kaiser PermanenteSouthern CaliforniaKaiser PermanenteSouthern California
University of Colorado -WRDY
University of Colorado -WRDY
CincinnatiChildren’sHospital
CincinnatiChildren’sHospital
University ofSouth Carolina
University ofSouth Carolina
Pacific Research InstituteHawaii
Pacific Research InstituteHawaii
Pacific Research InstituteHawaii
Pacific Research InstituteHawaii
Children’s HospitalSeattleChildren’s HospitalSeattle
Wake Forest UniversityCoordinating CenterWake Forest UniversityCoordinating CenterWake Forest UniversityCoordinating CenterWake Forest UniversityCoordinating Center
Central Laboratory –University of WashingtonCentral Laboratory –University of WashingtonCentral Laboratory –University of WashingtonCentral Laboratory –University of Washington
SEARCH for Diabetes Study
Has evaluated: – average HbA1c and distribution of
HbA1c from 2001-2004 and– Types of insulin regimens used and
HbA1c outcomes with differing regimens
Pititti DB, Klingensmith GJ, et al for the SEARCH study ADA Scientific Sessions 2006
Pihoker et al, ISPAD annual meeting, Berlin 2007
7.00%
7.20%
7.40%
7.60%
7.80%
8.00%
8.20%
8.40%
8.60%
8.80%
CSII Injection
Baseline A1c 6-12Follow-up A1c 6-12Baseline A1c 13-19Follow-uo A1c 13-19
**
BDC Pump therapy results, non-randomized:HbA1c values at baseline and follow-up
* p < 0.001
Simmons JH, Rewers M, Klingensmith GJ
Acedemic Pediatric Society meeting 2007
Pump therapy for >2 years,
matched for baseline A1c, age,
and insurance status
7.2
7.4
7.6
7.8
8
8.2
8.4
8.6
8.8
9
9.2
HbA1c
<6 yr 6-12 yr 13-19 yr
HbA1c values
BDC HbA1c by Age
2000200220042006
Mean HbA1c by age and yearin those diagnosed > 1 year
n = 150->171 n = 611->850 n = 806 -> 1205
0
5
10
15
20
25
30
35
% of HbA1c values
<=7.5 7.6-8.0 8.1-8.5 8.6-9.0 >9.0
HbA1c values
BDC HbA1c at Age < 6
4/1/95-3/31/044/1/04-3/31/064/01/06-3/31/08
BDC patients < 6 years and diagnosed > 1 year
Continuous Glucose Sensing
CGS has contributed to the decrease in HbA1c– More sensor use and ability to apply
information gained from sensor use to children and youth not using sensors• Give bolus doses prior to meals if
possible• Monitor at 1-3 am for hypoglycemia,
especially following increased exercise
CGS in LAA basal bolus therapy
Decrease in HbA1c from 8.5% to 7.8% by 5-8 weeks, this persisted through 9-13 weeks
Baseline SBGM 4.8 times a day, decreased to 2.9 times a day
Navigator sensor worn 4+ days per week
Stuart A. Weinzimer and the DirectNet study group. Diabetes
Care.31:525-527, 2008
Reassurance that hypoglycemia will be averted allows lower glucose targets
“The sensor makes me feel safer knowing that I will be warned about low blood glucose before it happens”
Mean answer of 3.9
for subjects and 4.5 for parents on a 5 point Likert scale
QuickTime™ and a decompressor
are needed to see this picture.
3 year old on a sensor
Barriers to achieving target HbA1c
• Fear of hypoglycemia– In patient and parents*
– In care providers
• Chaotic family– Teen brain
• Denial of the seriousness of diabetes and its consequences
Patton, et al. Pediatr Diab. 2007: 362-68*
Conclusion from the US Perspective Strive for lower HbA1c levels in every patient Problem solve with teens Intensify diabetes regimens
– More frequent testing– Possibly more frequent use of CSII– Work toward increased use of CGS
Question why management is not more intensified in every patient