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

Achieving Goal

What has changed since 2003-04 to change our perspective on glycemic targets?

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

Achieving Goal

How are we doing?

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

What are longitudinal HbA1c results doing in the US? BDC HbA1c results

– 2000-2006 and

– 1995-2008

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

.

16 year old boy with T1DM for 6 years, HbA1c = 5.7%

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

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