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Canadian Diabetes Association Clinical Practice Guidelines

Type 2 Diabetes in Children and Adolescents Chapter 35

Constadina Panagiotopoulos,Michael C. Riddell, Elizabeth A.C. Sellersdiabetes.ca | 1-800-BANTING (226-8464)guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 1Key MessagesAnticipatory guidance regarding healthy eating and active lifestyle is recommended to prevent obesity

Regular targeted screening for type 2 diabetes is recommended in children at risk

Children with type 2 diabetes should receive care from an interdisciplinary pediatric diabetes healthcare team

Early screening, intervention, and optimization of glycemic control are essential, as childhood type 2 diabetes is associated with severe and early onset of microvascular complications2013guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 2OutlineEpidemiologyPreventionScreening & DiagnosisClassification

ManagementImmunizationComplicationsComorbid Conditions

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 3

Epidemiology of T2DM in CanadaAmed S et al. Diabetes Care 2010;33:786-791.guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association Diabetes Care. 2010 Apr;33(4):786-91. doi: 10.2337/dc09-1013. Epub 2010 Jan 12.Type 2 diabetes, medication-induced diabetes, and monogenic diabetes in Canadian children: a prospective national surveillance study.Amed S, Dean HJ, Panagiotopoulos C, Sellers EA, Hadjiyannakis S, Laubscher TA, Dannenbaum D, Shah BR, Booth GL, Hamilton JK.SourceDepartment of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada. samed@cw.bc.caAbstractOBJECTIVE: To determine in Canadian children aged or =7.0 and < or =13.3 mmol/l (> or =126 and < or =240 mg/dl), HbA(1c) > or =7.0%, stimulated C-peptide > or =0.5 nmol/l (> or =1.5 ng/ml), and a BMI > 50th percentile for age.RESULTS: Metformin significantly improved glycemic control. At the last double-blind visit, the adjusted mean change from baseline in FPG was -2.4 mmol/l (-42.9 mg/dl) for metformin compared with +1.2 mmol/l (+21.4 mg/dl) for placebo (P < 0.001). Mean HbA(1c) values, adjusted for baseline levels, were also significantly lower for metformin compared with placebo (7.5 vs. 8.6%, respectively; P < 0.001). Improvement in FPG was seen in both sexes and in all race subgroups. Metformin did not have a negative impact on body weight or lipid profile. Adverse events were similar to those reported in adults treated with metformin.CONCLUSION: Metformin was shown to be safe and effective for treatment of type 2 diabetes in pediatric patients.

Diabetes Care. 2007 Apr;30(4):790-4.Glimepiride versus metformin as monotherapy in pediatric patients with type 2 diabetes: a randomized, single-blind comparative study.Gottschalk M, Danne T, Vlajnic A, Cara JF.SourceUniversity of California, San Diego Medical Center, San Diego, CA 92123, USA. mgottsch@ucsd.eduAbstractOBJECTIVE: To compare the efficacy and safety of glimepiride versus metformin in pediatric subjects with type 2 diabetes inadequately controlled with diet and exercise alone or oral monotherapy.RESEARCH DESIGN AND METHODS: This 26-week, single-blind, active-controlled, multinational study randomized 285 subjects to receive glimepiride (1-8 mg once daily) or metformin (500-1000 mg twice daily) for 24 weeks. The primary end point was mean change in A1C from baseline to week 24. Safety was assessed by incidence of hypoglycemia and other adverse events.RESULTS: Significant reductions from baseline A1C were seen in both the glimepiride (-0.54%, P = 0.001) and metformin (-0.71%, P = 0.0002) groups. A total of 42.4% (56 of 132) and 48.1% (63 of 131) of subjects in the glimepiride and metformin groups, respectively, in the intent-to-treat population achieved A1C 4.2 mmol/L after a 3- to 6-month trial of dietary intervention Comorbid Conditions - Dyslipidemiaguidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 36Screening for high blood pressure should begin at diagnosis and subsequent clinic visits

Surveillance should occur for comorbid conditions associated with insulin resistancePolycystic ovarian syndromeNon-alcoholic fatty liver disease

Comorbid Conditions Hypertension and Othersguidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 37ComplicationIndications & intervals for screeningScreening method NephropathyYearly screening commencing at diagnosisFirst morning (preferred) or random ACR Abnormal ACR requires confirmation at least 1 month later with a first morning ACR, and if abnormal, followed by timed, overnight or 24-hour split urine collections for albumin excretion rate Repeated sampling should be done ever y 34 months over a 12-month period to demonstrate persistence RetinopathyYearly screening commencing at diagnosis of diabetes 7-standard field, stereoscopic-colour fundus photography with interpretation by a trained reader (gold standard); or Direct ophthalmoscopy or indirect slit-lamp fundoscopy through dilated pupil; or Digital fundus photography NeuropathyYearly screening commencing at diagnosis of diabetesQuestion and examine for symptoms of numbness, pain, cramps and paresthesia, as well as sensation, vibration sense, light touch & ankle reflexes ACR = albumin-creatinine ratioguidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 38ComplicationIndications & intervals for screeningScreening method DyslipidemiaScreening should commence at diagnosis of diabetes and every 1 -3 years thereafter as clinically indicatedFasting total cholesterol, high-density lipoprotein cholesterol, triglycerides, calculated low-density lipoprotein cholesterol HypertensionAt diagnosis of diabetes and every diabetes-related clinical encounter thereafter (at least twice annually) Use appropriate cuff size Polycystic ovarian syndromeYearly clinical screening commencing at diagnosis of diabetes in pubertal femalesClinical assessment on history and physical exam of oligo-/amenorrhea, acne, and/or hirsutism Non-alcoholic fatty liver diseaseYearly screening commencing at diagnosis of diabetes ALTguidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 39Children with type 2 diabetes should be screened annually for microvascular complications (nephropathy, neuropathy, retinopathy) beginning at diagnosis of diabetes [Grade D, Level 4]. Recommendation 9: Complicationsguidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 40Children with type 2 diabetes should be screened for microalbuminuria with a first morning urine ACR (preferred) [Grade B, Level 2] or a random ACR [Grade D, Consensus]. Abnormal results should be confirmed [Grade B, Level 2] at least 1 month later with a first morning ACR and, if abnormal, followed by timed, overnight urine collection for albumin excretion rate [Grade D, Consensus].

Recommendation 10: Complicationsguidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 41Microalbuminuria (ACR >2.5 mg/mmol) should not be diagnosed in adolescents unless it is persistent as demonstrated by 2 consecutive first morning ACR or timed collections obtained at 3- to 4-month intervals over a 6- to 12-month period [Grade D, Consensus]. Those with persistent albuminuria should be referred to a pediatric nephrologist for assessment of etiology and treatment [Grade D, Level 4].

Recommendation 10: Complications (continued)guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 42Children with type 2 diabetes should have a fasting lipid profile measured at diagnosis of diabetes and every 1 to 3 years thereafter, as clinically indicated [Grade D, Consensus].

Children with type 2 diabetes should be screened for hypertension beginning at diagnosis of diabetes and at every diabetes-related clinical encounter thereafter (at least biannually) [Grade D, Consensus].

Recommendations 11 and 12: Comorbid Conditionsguidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 43Children with type 2 diabetes should be screened at diagnosis for comorbid conditions associated with insulin resistance, including non-alcoholic fatty liver disease [Grade D, Level 4] and polycystic ovarian syndrome in pubertal females [Grade D, Level 4] and yearly thereafter, as clinically indicated [Grade D, Consensus]. 2013Recommendation 13: Comorbid Conditionsguidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 44Summary MessagesClinicians must be vigilant for risk factors of type 2 diabetes in childrenSelected screening and timely diagnosis is important in reducing complicationsAn experienced multidisciplinary team should manage diabetes using a range of interventions from lifestyle to oral agents to insulinScreen for comorbidities and complicationsguidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 45CDA Clinical Practice Guidelineshttp://guidelines.diabetes.ca for professionals

1-800-BANTING (226-8464)

http://diabetes.ca for patients

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.caCopyright 2013 Canadian Diabetes Association 46