New Guideline Recommends Insulin Therapy in Some Younger Patients With Type 2 Diabetes

February 06, 2013 05:10 pm Matt Brown

A new clinical practice guideline from the American Academy of Pediatrics (AAP) encourages physicians who are managing newly diagnosed type 2 diabetes in children and adolescents ages 10-18 years to use insulin as first-line treatment for patients who present with ketosis or frank ketoacidosis, as well as for those in whom "the distinction between type 1 and type 2 diabetes is not clear."

[Girl getting finger pricked for insulin reading]

Initiation of insulin therapy also may benefit children and teens who are markedly hyperglycemic but who show no evidence of ketosis or ketoacidosis. When glycemic control is restored, many of these patients can be weaned from insulin therapy.

The guideline(pediatrics.aappublications.org), which was published in the February issue of Pediatrics, recommends metformin and a lifestyle modification program for all other patients in this age range who are newly diagnosed with type 2 diabetes.

Written in consultation with the AAFP, the American Diabetes Association, the Pediatric Endocrine Society, and the Academy of Nutrition and Dietetics (formerly the American Dietetic Association), the guideline's evidence-based recommendations are the first of their kind for this age group, according to an AAP news release(www.aap.org).

Other Management Advice

In addition to the above recommendations, the guideline suggests that clinicians

story highlights

  • A new American Academy of Pediatrics (AAP) guideline encourages physicians to use insulin as first-line treatment in specific subsets of children and adolescents with newly diagnosed type 2 diabetes.
  • The guidelines also recommend that metformin and lifestyle modification be initiated in all other patients in this 10- to 18-year-old age range who are newly diagnosed as having type 2 diabetes.
  • The AAFP Commission on Health of the Public and Science's Subcommittee on Clinical Practice Guidelines currently is reviewing the AAP guidelines for endorsement consideration.
  • monitor patients' HbA1c concentrations every three months and intensify treatment if treatment goals for finger-stick blood glucose and HbA1c concentrations are not being met;
  • advise the following patients to monitor finger-stick blood glucose concentrations:
    • those who are taking insulin or other medications that confer a risk of hypoglycemia,
    • those who are initiating or changing their diabetes treatment regimen,
    • those who have not met treatment goals, and
    • those who have intercurrent illnesses;
  • incorporate the Academy of Nutrition and Dietetics' Pediatric Weight Management Evidence-based Nutrition Practice Guidelines into their dietary or nutritional counseling of patients; and
  • encourage their young patients to engage in moderate-to-vigorous exercise for at least 60 minutes daily and to limit nonacademic "screen time" to fewer than two hours a day.

Family Physician Perspective

Stephen Spann, M.D., the AAFP's liaison to the committee that produced the guideline, said the growing incidence and prevalence of type 2 diabetes in children and adults, as well as the lack of knowledge and experience many physicians have in dealing with this disease, provided the primary impetus for writing the new guideline.

"This is an evidence-based guideline that provides broad and in-depth advice to primary care physicians providing care to these patients, advocating for a team-based approach to care," Spann told AAFP News Now.

Spann, who currently is chief medical officer at Tawam Hospital in Al Ain, Abu Dhabi, United Arab Emirates, said that he plans to change his practice behavior as a result of the new recommendations.

"I will be more aggressive in testing for diabetes and prediabetes in at-risk children and adolescents," Spann said. "I will also be more aggressive in treating children with prediabetes with lifestyle modification and will try to involve a larger number of other health care professionals in the team providing care to patients.

"Lastly, I will try to provide more or better education about type 2 diabetes mellitus to patients and their families."

The AAFP Commission on Health of the Public and Science's Subcommittee on Clinical Practice Guidelines currently is reviewing the guideline, as well as the accompanying technical report, for endorsement consideration and plans to make a determination sometime in the spring.


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