type 2 diabetes in children and youth
TRANSCRIPT
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Francine Ratner Kaufman, MDProfessor of PediatricsThe Keck School of Medicine of USCHead, Center for Diabetes and EndocrinologyChildrens Hospital Los Angeles
Type 2 Diabetes in Children and Youth
Paula Jameson, ARNP, MSN, CDE
Nemours Children’s ClinicDivision of Endocrinology
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Natural History of Type 2 DiabetesNatural History of Type 2 Diabetes
Geneticsusceptibility Environmentalfactors
AtherosclerosisHyperglycemiaHypertension
RetinopathyNephropathyNeuropathy
BlindnessRenal failureCHDAmputation
Onset ofdiabetes
Complications
Disability
DeathOngoing hyperglycemiaPRE
Obesity Insulin resistance
Risk forDisease
MetabolicSyndrome
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Question
What Do We Know About Type 2 Diabetes in Youth?
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Is it an epidemic?
• The incidence is increasing and probably underestimated– Population based estimates indicate an ~10-fold
increase in incident cases over the past 10-15 years– 8% to 43% of all new cases of diabetes in the United
States depending on ethnicity – The SEARCH Trial– What about prevalence??
Bloomgarden ZT. Diabetes Care. 2004;27:998-1010 Centers for Disease Control. Diabetes Fact Sheet. 2005
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Diabetes Trends Among Adults in the US BRFSS 1990, 1995 and 2001
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Changing Face of Diabetes in Youth Changing Face of Diabetes in Youth in USin US
0
5
10
15
20
25
30
35%
wit
h t
yp
e 2
87 88 89 90 91 92 93 94 95 96
Cincinnati <19 years Little Rock 8-21 yearsSan Antonio <19 years
Source: Fagot-Campagna et al., J Pediatr 136:664-672, 2000
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Question
Is the Pathophysiology the Same as in Adults?
Associated with significant ß-cell failure as well as insulin resistance
Occurs at the time of intense insulin resistance due to puberty
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Natural History of Type 2 DiabetesNatural History of Type 2 Diabetes
Geneticsusceptibility Environmentalfactors
AtherosclerosisHyperglycemiaHypertension
RetinopathyNephropathyNeuropathy
BlindnessRenal failureCHDAmputation
Onset ofdiabetes
Complications
Disability
DeathOngoing hyperglycemiaPRE
Obesity Insulin resistance
Risk forDisease
MetabolicSyndrome
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InsulinInsulinResistanceResistance
AgeAge
PubertyPuberty
Type 2 DiabetesType 2 Diabetes
PrediabetesPrediabetes
Beta Cell DefectBeta Cell Defect
ObesityObesity
BP,BP,
LipidsLipids
Gender – Girls Gender – Girls Polycystic ovary syndromePolycystic ovary syndrome
GeneticsGeneticsEthnicityEthnicity
Sedentary Sedentary LifestyleLifestyle
Beta Cell Defect
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InsulinInsulinResistanceResistance
AutoimmunityAutoimmunity
Type 2 DiabetesType 2 Diabetes
PrediabetesPrediabetes
Beta Cell DefectBeta Cell Defect
Genetic DefectGenetic Defect
Intrauterine Intrauterine
IUGR, DMIUGR, DM GlucoseGlucosetoxicitytoxicity
Beta Cell Defect
Fat cellFat cell toxicitytoxicity
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Question
Is the Presentation the Same as in Adults?
Does not appear to be preceded by long asymptomatic period
Do not find undiagnosed cases on screening
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Natural History of Type 2 DiabetesNatural History of Type 2 Diabetes
Geneticsusceptibility Environmentalfactors
AtherosclerosisHyperglycemiaHypertension
RetinopathyNephropathyNeuropathy
BlindnessRenal failureCHDAmputation
Onset ofdiabetes
Complications
Disability
DeathOngoing hyperglycemiaPRE
Obesity Insulin resistance
Risk forDisease
MetabolicSyndrome
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Pre-diabetes (IGT) and T2DOverweight Sample IGT T2D
Paulsen et al, 196866 multi-ethnic youth (4-
16 years)17% 6%
Weninger et al, 1980 15 subjects 33% 0%
Sinha et al, 200255 multi-ethnic youth
(>95th %ile)25% 0%
Sinha et al, 2002112 multi-ethnic teens
(>95th %ile)21% 4%
Goran et al, 2004150 Hispanic +FH
(8-13 years >85th %ile)28% 0%
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Years from Clinical Diagnosis
B-c
ell F
unct
ion
(%)
UKPDS Data
Type 2 DiabetesProgressive Pancreatic B-cell Failure
Prevention and Early Treatment
? Curve for Youth
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Question
What distinguishes type 1 from type 2 diabetes in youth?
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Natural History of Type 2 DiabetesNatural History of Type 2 Diabetes
Geneticsusceptibility Environmentalfactors
AtherosclerosisHyperglycemiaHypertension
RetinopathyNephropathyNeuropathy
BlindnessRenal failureCHDAmputation
Onset ofdiabetes
Complications
Disability
DeathOngoing hyperglycemiaPRE
Obesity Insulin resistance
Risk forDisease
MetabolicSyndrome
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Pediatric Diabetes 2002
Type 1 diabetes
Childhood obesity
Type 2
Monogenic Diabetes
Diabetes +
Syndromes
“Pediatric Diabetes is a DIFFICULT diagnostic speciality”
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T1DM T2DM
Weight 20% may be obese All > 85% overweight
CourseRapid
From DPT-1 can be indolent
Indolent
Virtually none found on screening
DKA 35%-40%Ketonuria (33%)
Mild DKA (5%-25%)
Relative with DM
5% with T1DM
Up to 20% may have with T2DM74%-100% with T2DM
Comorbid thyroid, adrenal, vitiligo, celiacIncrease in polycystic ovary syndrome
Acanthosis nigricans (90%)
C-peptide C-peptide can be preserved at DX Normal or increased
Antibody
Ethnicity
85%
Whites predominate
15%
NA, AA, HA, Asian, Pacific Islander
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Differentiation Between Type 1 and 2
• 48 with type 2 vs 39 with type 1
• Type 2
– Ethnicity, 1st degree relative, BMI>24, +C-peptide, acanthosis
Type 2 Type 1
DKA 33% 53%
C-peptide 2.2+2.2 ug/l 1.8+3.5 ug/l
Abs 8.1% ICA
30% GAD 35%IAA
85% have islet autoimmunity
Hathout et al Pediatrics 107e102,June,2001
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Question
How Does Type 2 Present in Youth?
Is it asymptomatic or symptomatic in youth?
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Natural History of Type 2 DiabetesNatural History of Type 2 Diabetes
Geneticsusceptibility Environmentalfactors
AtherosclerosisHyperglycemiaHypertension
RetinopathyNephropathyNeuropathy
BlindnessRenal failureCHDAmputation
Onset ofdiabetes
Complications
Disability
DeathOngoing hyperglycemiaPRE
Obesity Insulin resistance
Risk forDisease
MetabolicSyndrome
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Diagnosis with Type 2Fagot-Campagna et al J Pediatr 2000
• Mean Age 12-14 years • Girls > Boys 1.7:1• Obese BMI >85th %• Minority Groups 94%• Strong Family History 74-100% • Acanthosis Nigricans 56-92%
•Diagnosis made by Symptoms, not Screening
•HbA1c 10-13%
•Weight loss 19-62%
•Glucose in urine 95%
•Ketosis 16-79%
•DKA 5-10%
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Question
What Are Treatment Targets in Youth with Type 2 Diabetes?
Are they the same as in adults?
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Natural History of Type 2 DiabetesNatural History of Type 2 Diabetes
Geneticsusceptibility Environmentalfactors
AtherosclerosisHyperglycemiaHypertension
RetinopathyNephropathyNeuropathy
BlindnessRenal failureCHDAmputation
Onset ofdiabetes
Complications
Disability
DeathOngoing hyperglycemiaPRE
Obesity Insulin resistance
Risk forDisease
MetabolicSyndrome
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TREATMENT GOALS
• Glucose control, HbA1c <7%– Eliminate symptoms of hyperglycemia
• Maintenance of reasonable body weight
• Improve cardiovascular risk factors
• Reduce microvascular complications
• Improvement in physical and emotional well-being
Goals Goals (Diabetes (Diabetes
Care, 2000)Care, 2000)
FG 80-120FG 80-120
PP 100-160PP 100-160
Bed 100-160Bed 100-160
A1c <7.0A1c <7.0
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ROLE OF FAMILY IN MANAGEMENT
• African-American Family Study• Group 1, direct family supervision• Group 2, no direct supervision• Group 1 ending HbA1c = 7.1+ 0.8%• Group 2 ending HbA1c = 12.3 + 0.6%• P=<0.0005
Bradshaw, J Pediatr Endocrinol Meta 15, 2002
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Question
What are the Treatment Regimens for Youth?
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Natural History of Type 2 DiabetesNatural History of Type 2 Diabetes
Geneticsusceptibility Environmentalfactors
AtherosclerosisHyperglycemiaHypertension
RetinopathyNephropathyNeuropathy
BlindnessRenal failureCHDAmputation
Onset ofdiabetes
Complications
Disability
DeathOngoing hyperglycemiaPRE
Obesity Insulin resistance
Risk forDisease
MetabolicSyndrome
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TZD = thiazolidinedioneSilverstein JH, Rosenbloom AL.J Pediatr Endcrinol Metab. 2000;13 Suppl 6:1406-1409.
DiagnosisDiagnosisAsymptomatic
Start with insulin and diet, exercise
Diet and exercise
Monthly review, A1C q3mo
>>7%7%
Add metformin
Add metforminAttempt to
wean insulin
Add insulin, TZD, sulfonylurea
BG 250 mg/dL or 12 mmol/LBG 250 mg/dL or 12 mmol/L
Add 3rd agent
<<7%7%
>>7%7%
>>7%7%
<<7%7%
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Metformin improves glycaemia in type 2 diabetic adolescents
9.0
10.7
7.0
11.5
6
7
8
9
10
11
12
Metformin Placebo
FP
G (
mm
ol/L
) 8.2
8.9
7.2
8.9
5
6
7
8
9
Metformin Placebo
Hb
A1C
(%
)
–3.6 mmol/L
(p<0.001)
–1.2% (p<0.001)
Jones KL et al. Diabetes Care 2002; 25: 89–94
Baseline Last double-blind measurement
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Metformin is well tolerated in pediatric subjects
• Obese nondiabetic adolescents
– Transient abdominal discomfort or diarrhea in21% on metformin vs. 6% on placebo
– Nausea in 6% on metformin vs. 0% on placebo
• Type 2 diabetic adolescents
– Abdominal pain in 25% on metformin vs. 12% on placebo
– Diarrhea 17% on metformin vs. 10% on placebo
• No treatment withdrawals for drug-related gastrointestinal side-effects in either trial
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Use of Rosiglitazone in T2DM Children
Drug Naive Prior Therapy
• More homogeneous response throughout study
• Both groups well matched at screen and baseline
• Both groups behaved similarly
• Increase in HbA1c at all visits
• No improvement in HbA1c from screening
Visit (weeks)
-6 0 4 8 16 24
MeanHbA1c
(%)
6.8
7.0
7.2
7.4
7.6
7.8
8.0
8.2
8.4
8.6
8.8
Metformin (N=50)
Rosiglitazone (N=55)
Error Bar = SE
Screen Baseline
Visit (weeks)
-6 0 4 8 16 24
7.6
7.8
8.0
8.2
8.4
8.6
8.8
9.0
9.2
Screen Baseline
MeanHbA1c
(%)
Metformin (N=48)
Rosiglitazone (N=42)
Error Bar = SE
K. Jones et al, poster 1904-P, 65th ADA Scientific Sesssions
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Adverse Events Of Interest
Metformin Rosiglitazone
Any GI adverse event 24 14
Diarrhea 13 1
Nausea 11 4
Vomiting 9 3
Anemia 1 0
Edema 0 1
Weight gain 0 2
Elevated liver function test 2 1
K. Jones et al, poster 1904-P, 65th ADA Scientific Sesssions
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Glimepiride vs. Metformin as Monotherapy in Pediatric Subjects with T2DM: A Single
Blind Comparison Study.
– 26 week randomized, single-blind, parallel-group, forced-titration study to evaluate the efficacy and safety of GLIM and MET in subjects age 9-17 yrs inadequately controlled with diet/exercise and/or failed oral monotherapy
– Reduction in A1C and SMBG levels similar between groups
– GLIM and MET have comparable safety profiles
•Gottschalk M, Danne T, et al •Abstract 264-OR (ADA Oral Presentation,
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LWPES Survey130 Clinical Practices
• 48% treated with insulin alone– 2 injections
• 44% with oral agents– 71% metformin– 46% sulfonylurea– 9% TZD– 4% meglitinide
• 8% lifestyle
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An Answer
The Today Trial?
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Studies to Treat Or Prevent Pediatric Type 2 Diabetes
STOPP-T2DFunded by
National Institute of Diabetes and Digestive and Kidney Diseases
National Institutes of Health
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STOPP-T2 TREATMENTPRIMARY AIM
To compare the efficacy of 3 treatment regimens– Metformin– Metformin + lifestyle– Metformin + TZD
On Time to Treatment Failure and on Glycemic Control
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Outcome Measures• Glycemia
– HbA1c, fasting and postprandial glucose by home monitoring
• Insulin sensitivity and secretion – OGTT, HOMA, QUICKI, proinsulin, C-peptide
• Body composition – BMI, DEXA, waist circumference, abdominal height
• Fitness and physical activity – PDPAR, PWC 170, accelerometer
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Outcome Measures (continued)
• Nutrition – food frequency questionnaire
• Cardiovascular disease risk– BP, lipids, inflammatory markers, coagulation factors
• Microvascular complications – microalbuminuria, neuropathy
• Quality of life• Cost
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Inclusion Criteria• Age 10 to 17 years
• Duration of diabetes < 2 years
• BMI 85th percentile
• Adult involved in the daily activities of the child agrees to participate in the intervention
• Absence of pancreatic autoimmunity
• Fasting C-peptide > 0.6 mmol/L
• Fluency in English or Spanish
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Question
What are the Complications & Co-Morbidities of Type 2 in Youth?
Are they the same as in adults?
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Natural History of Type 2 DiabetesNatural History of Type 2 Diabetes
Geneticsusceptibility Environmentalfactors
AtherosclerosisHyperglycemiaHypertension
RetinopathyNephropathyNeuropathy
BlindnessRenal failureCHDAmputation
Onset ofdiabetes
Complications
Disability
DeathOngoing hyperglycemiaPRE
Obesity Insulin resistance
Risk forDisease
MetabolicSyndrome
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Long term outcome
Arslanian S. Hormone Res 2002; 57 Suppl 1: 19-28 Yokoyama H. Kidney Int 2000; 58: 302-311 Dean., Diabetes 2002;51(Suppl 2):A24.
• Pima Indians - diagnosed < 20 years of age –22% had microalbuminuria at diagnosis–Increased to 60% at 20-29 years of age
•Japan -School Children•Retinopathy
•36% had incipient retinopathy at diagnosis•Increased to 39% at 2 years’ follow-up
•Young Diagnosed Patients•44% diagnosed at <30 years of age had nephropathy 25 years later
• Indigenous Canadians- mean age 23 yrs, 9 yrs duration of diabetes•HbA1c 10.9%
•67% poor glycemic control •45% hypertension requiring treatment•35% microalbuminuria (6% required dialysis) •38% pregnancy loss •9% mortality
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Are there specific lipid and BP abnormalities documented in children
with T2DM?• Lipids
– Same as in adults– increased TG, slight elevation LDL, decreased
HDL– Added risk factor of obesity and metabolic
syndrome
• BP (CHLA)– 3.4% systolic > 97th%ile– 20.1% diastolic > 97th%ile
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Management of Dyslipidemia in Children and Adolescents with
Diabetes• A consensus panel – In the absence of data,
get experts to give an opinion
• Consensus panel members – met July 2002
• Representing Pediatric Endocrinology, Cardiology and Nephrology– Kaufman FR, Arslanian S, Berenson G, Clark
NG, Gidding S, Jones KL, Lauer R, Schieken R, Sinaiko AR
Diabetes Care 26:2194;2003
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Conclusion• Increased incidence• Difficult to distinguish from type 1• Occurs at the time of intense insulin resistance due
to puberty• Does not appear to be preceded by long
asymptomatic period• More insulin deficiency and requirement for
exogenous insulin early• Safety and efficacy of therapeutic agents• Rapid progression of co-morbidities and
complications