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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 62% of tests were sent during ... – PowerPoint PPT presentation

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Title: Type 2 Diabetes in adolescents: Issues for the SBHC provider


1
  • Type 2 Diabetes in adolescents Issues for the
    SBHC provider
  • Kathy Love-Osborne MD, FAAP
  • Associate Professor of Pediatrics
  • CASBHC 5/3/13

2
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

3
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

4
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

5
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

6
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

7
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

8
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

9
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

10
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

11
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

12
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)

13
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)

14
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

15
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

16
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

17
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

18
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

19
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
20
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

21
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

22
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

23
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

24
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

25
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

26
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)

27
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

28
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

29
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

30
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

31
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

32
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

33
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

34
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

35
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

36
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
37
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

38
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

39
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.

40
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

41
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

42
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

43
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

44
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)

45
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
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