Type 2 Diabetes in adolescents: Issues for the SBHC provider

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• Type 2 Diabetes in adolescents Issues for the
  SBHC provider
• Kathy Love-Osborne MD, FAAP
• Associate Professor of Pediatrics
• CASBHC 5/3/13

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Disclosures

• 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

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Type 2 Diabetes (T2D) screening

• 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 gt 85 and 2 risk factors for T2D
• Family history of diabetes
• Minority race at higher risk
• Signs of insulin resistance

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Diabetes screening options

• Random glucose
• Poor sensitivity not recommended
• Fasting 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 consuming
• Hemoglobin A1c (A1c)
• - Not officially recommended in teens

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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 disease
• The International Expert Committee 2009

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Denver Health adolescent T2D screening
recommendations

• All teens with BMI gt 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

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T2D diagnosis

• Confirmation of a single result is required
  unless symptomatic
• Fasting plasma glucose (FPG) gt 126 mg/dl
• Random or 2-hour after glucose challenge glucose
  gt 200 mg/dl
• A1c 6.5

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T2D blood sugar monitoring

• Patients should be instructed to check blood
  sugars
• If they are taking insulin or other medications
  that can cause hypoglycemia
• If they are starting or changing their treatment
  regimen
• If they are not meeting treatment goals
• If they are ill

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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

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T2D A1c monitoring

• A1c should be checked every 3 months
• Target is lt 7 for most adolescents
• Levels over 8 indicate possible need for change
  in treatment regimen
• Levels over 9 (some endocrinologists use 8)
  indicate need for insulin

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T2D Metformin

• 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

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Treatment of T2D in teens

• 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)

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T2D Treatment insulin

• Insulin treatment recommended for
• Random blood sugar 250 mg/dl
• A1c 9
• Ketosis (present in 5-25 of adolescents
  eventually diagnosed with T2D)

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Insulin therapy in T2D

• 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

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Case 1 laboratory differences

• JA 13 y.o. HF BMI 34.2 kg/m²
• A1c 6.9 at Denver Health
• Continuous glucose monitoring study at Childrens
  Hospital A1c 5.9
• many glucose values gt 140 mg/dl and some gt 200 mg
• Family missed f/u metabolic syndrome clinic
  appointment I was told she didnt have diabetes
  so I didnt see the point

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Local issues

• 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 use
• Consider ongoing research studies

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Pre-diabetes

• Impaired fasting glucose (IFG)
• Fasting plasma glucose (FPG) gt 100 mg/dl but lt
  126 mg/dl
• Impaired glucose tolerance (IGT)
• 2-hour glucose gt 140 mg/dl but lt 200 mg/dl
• A1c 5.7-6.4
• A1c values gt6.0 have higher risk for progression
  to T2D than values of 5.7-5.9

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Denver Health data

• 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

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Summary of participants
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
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New diabetes cases

• 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 later
• Illustrates importance of regular screening
  intervals

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Case 2 SBHC diagnosis

• KF 13yo HF with BMI 39.4 kg/m²
• seen in SBHC for URI
• asked to return for PE
• PE 2 weeks later A1c 8.7, uninsured
• Seen within 1 week of abnormal result at Barbara
  Davis Center

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Case 3 Failure to f/u after initial abnormal
screen

• TG 10yo HF BMI 39.1 kg/m²
• SBHC physical HbA1c 6.8
• Multiple attempts to schedule f/u by SBHC,
  supervising physician and PCP
• Mother agreed to follow up but NS

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Case 3 Next school year, different SBHC

• 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

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Case 3 follow-up

• 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 gt 1 year since original abnormal A1c

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Case 3 pearls

• 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
• Dont forget to review the medical record before
  you see every patient

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Dysglycemia progression

• 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)

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Results

• 281 adolescents with dysglycemia were identified
• Participants were 15.42.0 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

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Follow-up testing rates

• 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

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Follow-up of A1c 5.7-5.9

• There was a linear trend between BMI change and
  worsening A1c (p0.01 for trend)
• A1c lt 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 gt 6.5 at f/u 1 2.3 kg/m2

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Follow up of A1c 6.0-6.4

• 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

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Follow-up of A1c 6.5-7.9

• 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
• 20continued with A1c values gt 6.5 but were
  managed with lifestyle alone
• 40 improved to A1c lt 6.5
• 35 had T2D treated with medication

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Dysglycemia conclusions

• Dysglycemia in some adolescents may be transient,
  even those with initial A1c results in the
  diabetes range
• Weight 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

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Patient notification

• 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

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Results counseling

• 62 of tests were sent during or shortly after an
  appointment for a physical
• 38 documented generic diet/exercise counseling
• 47 documented specific goals set
• 15 had no counseling documented

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Results A1c 5.7-6.4

• 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

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Results Patient informed of elevated A1c
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 lt 0.001 0.18 0.3
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Discussion Patient notification

• 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

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Lack of documentation

• 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

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Sample letter

• 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 doesnt have to work as hard
  to use carbohydrates that you eat. Try to
  exercise an hour or more every day.

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Management of A1c 6.5-7.0

• 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

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Case 4 how the SBHC can help

• 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

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Follow-up of diabetics in SBHC

• 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

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Conclusions

• Remember to screen at-risk adolescents every 2
  years with either fasting (not random) glucose or
  A1c
• Dont forget to screen early adolescents (10-12
  years old) as diabetes risk 50 higher

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References

• 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)

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Acknowledgements

• Pediatric QI committee for their thoughtful input
  and inquiring minds
• Dr. Phil Zeitler (Childrens hospital
  endocrinology)
• Dr. Steve Daniels
• Denver Health providers for such a fantastic job
  documenting lifestyle recommendations and
  improving diabetes screening rates in adolescents