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Children and teens with type 2 diabetes should be treated initially with a combination of metformin and lifestyle changes, much like adults, a new practice guideline from the American Academy of Pediatrics indicated.
Most pediatric patients newly diagnosed with type 2 diabetes should receive metformin along with a program of lifestyle modification covering diet and physical activity, according to the guideline, authored by an AAP committee headed by Kenneth Copeland, MD, and Janet Silverstein, MD.
The committee made two exceptions: children and teens presenting with ketosis or diabetic ketoacidosis and "in whom the distinction between types 1 and 2 ... is unclear," and those with blood sugar levels of at least 250 mg/dL or glycated hemoglobin (HbA1c) higher than 9%.
Such patients should be started immediately on insulin therapy, the panel recommended.
The American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians, and the Academy of Nutrition and Dietetics contributed to the guidelines, billed as the first ever for this population and published in the February issue of Pediatrics.
Reviewing literature published between 1990 and 2008, the AAP committee concluded that "the practicing physician is likely to be faced with the need to provide care for children with type 2 diabetes mellitus."
Yet, the members found, nonspecialist clinicians have too little data to consult when treating these cases, especially as the numbers accelerated.
The recommendation of metformin and lifestyle changes for most cases was based on an evidence review contained in a separate, 18-page "technical report." The bottom line was improved outcomes and preponderance of benefits over harms in published studies.
The guideline cautioned against prescribing more than 500 mg daily at the onset because of metformin's gastrointestinal adverse affects. But such effects "are often transient and often disappear completely if medication is continued," the authors wrote. Use of extended-release metformin with evening dosing is also an option.
More than 2,000 mg dose a day has not provided additional benefits, the committee warned.
Metformin was preferred over insulin for several other reasons, the guidelines stated. These include weight loss, less risk of hypoglycemia, fewer finger sticks, improved insulin sensitivity, and ease and patient preference of oral medication over injections.
But, the committee cautions, physicians should be aware of recent trials in the TODAY (Treatment Options for type 2 Diabetes in Adolescents and Youth) program showing that metformin does not sustain glycemic control in most youths with diabetes. Adding rosiglitazone (Avandia) to metformin alone improved the outcomes, but rosiglitazone is not FDA-approved for children and is now restricted even for adults.
Other anti-diabetic drugs for adults such as pioglitazone (Actos) and incretin-type agents are also not approved in children, although evidence suggests that they are sometimes prescribed off-label in teens, the committee indicated.
While metformin should be the first-line treatment for most cases, the guideline indicated that insulin achieves metabolic control more quickly. Also, insulin use may have another, more indirect benefit, the committee speculated -- the necessity of frequent injections may send the message to patients and their families that diabetes has to be taken seriously.
While taking into consideration cultural attitudes toward diabetes, food and weight loss, clinicians should motivate children and adolescents with type 2 diabetes to exercise moderately to vigorously at least one hour daily. The guideline recommended limiting screen time to no more than 2 hours a day.
The committee noted that failure to alter lifestyle often stems from lack of follow-up, depression in teenagers, and peer pressure.
Younger patients typically adapt better to behavioral changes, with commensurately better outcomes, the guideline noted.
The recommendations emphasized that physicians should have realistic expectations for behavioral changes in children. Asking pediatric patients and their families to maintain diets and eating behaviors requires sensitivity to the family's understanding of the disease. Cultural sensitivity is important, the guidelines cautioned, because type 2 diabetes disproportionately affects minority populations.
The committee also recommended that primary care physicians monitor HbA1c concentrations every 3 months and increase treatments if goals are not met, and monitor blood glucose with finger-stick tests for those taking insulin to avoid hypoglycemia.
Primary care physicians should partner with a specialist to ensure the best outcomes for pediatric patients, the guideline urged as well.
Because of the limitations of existing evidence, the guideline authors emphasized that the recommendations apply only to nonpregnant children and teens 10 to 17 years old.
The guidelines do not apply to children and teens with blood glucose values that fall short of criteria for type 2 diabetes, such as those with impaired fasting plasma glucose (in the range of 100 to 125 mg/dL) or impaired glucose tolerance (140 to 200 mg/dL in a 2-hour oral glucose tolerance test).
From the American Heart Association:
Copeland and Silverstein reported relationships with Pfizer, Novo Nordisk, Lilly, Genentech, sanofi aventis, and Abbott. Among other guideline authors, one reported serving on a Merck-associated foundation board. Others declared they had no relevant financial interests.
- Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner