From the Journals

ADA underscores distinctions in youth, adult T1DM



Management of type 1 diabetes mellitus in children should include careful consideration of the unique features and challenges that differentiate it from T1DM in adults, according to a new position statement released by the American Diabetes Association.

The statement, published Aug. 10 in Diabetes Care, includes guidance on diagnosis, staging, screening, monitoring, treatment, nutrition, physical activity, and transition from pediatric to adult care.

With regard to diagnosis and staging, the recommendations emphasize the importance of distinguishing between T1DM, type 2 diabetes mellitus, and monogenic diabetes. It also asserts that a pediatric endocrinologist should be consulted before making a diagnosis when “isolated glycosuria or hyperglycemia is discovered in the setting of acute illness and in the absence of classic symptoms,” wrote Jane L. Chiang, MD, of McKinsey & Company and chief medical officer at Diasome Pharmaceuticals in Palo Alto, Calif., and coauthors.

The guidance also describes the three stages of type 1 diabetes development. Stage 1 is presymptomatic and features the presence of beta-cell autoimmunity. Stage 2, also presymptomatic, includes the presence of beta-cell autoimmunity with dysglycemia. Symptomatic disease from insulin deficiency begins in stage 3, and may include hyperglycemia, polyuria, polydipsia, weight loss, polyphagia, fatigue, and blurred vision. Perineal candidiasis is common in girls, and about one-third of cases present with diabetic ketoacidosis (DKA).

In patients with hyperglycemia symptoms, blood glucose, not hemoglobin A1c, should be used to diagnose acute onset of disease. Delays in diagnosis and insulin replacement therapy should be avoided and a definitive diagnosis made quickly, the authors added.

Because the current method of using HbA1c to diagnose diabetes was based on studies limited to adults, there is still debate over whether to use HbA1c to diagnose T1DM in children and adolescents, Dr. Chiang and colleagues noted. Additionally, physicians must take care to distinguish between diabetes types because of increased numbers of overweight children with T1DM, as well as frequent misdiagnosis of monogenic diabetes as T1DM.

The position statement emphasizes the importance of insulin therapy as treatment for children with T1DM and recommends that most patients should be treated with either multiple injections of prandial and basal insulin, or with continuous subcutaneous insulin infusion. HbA1c should be measured at 3-month intervals to assess glycemic control, with a target HbA1c of less than 7.5%, the authors said. Also covered are recommendations for blood glucose monitoring, blood and urine ketone monitoring, and continuous glucose monitoring.

The importance of integrating an exercise and nutrition plan is also highlighted in the guidance. In addition to monitoring carbohydrate and caloric intake with the help of a dietitian, 60 minutes of moderate to vigorous activity daily are recommended as an exercise goal. Steps should also be taken to prevent hypoglycemia during and after exercise, the authors added.

Measures must also be taken to anticipate and address the unique behavioral and social challenges that accompany diabetes management in developing adolescents, the authors said. Social and family issues, peer relationships, and disordered eating should all be considered, and, starting at age 12 years, patients should be allowed time to speak in confidentiality with their health care provider, Dr. Chiang and colleagues said.

Additionally, as adolescents assert increased independence and autonomy, independent disease management should be facilitated, and issues such as depression and risky behaviors discussed.

The guidelines also discuss the importance of following the Centers for Disease Control and Prevention immunization schedule, and monitoring growth and weight gain. Patients with T1DM and their caregivers should also be sufficiently educated on comorbidities such as diabetic ketoacidosis, hypoglycemia, retinopathy, dyslipidemia, autoimmune diseases, and other complications.

Supportive environments such as diabetes camps, as well as technological advances, may be effective tools in encouraging diabetes self-management. Though there is no “optimal transition age” for the shift from pediatric to adult care, ADA recommends that providers begin transition preparation in the early adolescent years, and provide counseling on diabetes self-management.

“An ineffective transition from pediatric to adult diabetes care may contribute to fragmentation of health care and increased risk for adverse outcomes,” the authors said. “An individualized approach to transition timing is recommended, prioritizing the developmental needs and preferences of the patient.”

The authors reported relationships with Diasome Pharmaceuticals and numerous other companies.

SOURCE: Chiang J et al. Diabetes Care. 2018 Jul. doi: 10.2337/dci18-0023.

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