Clinical Practice Guidelines

Diabetes

Management of Newly Diagnosed Type 2 Diabetes Mellitus in Children and Adolescents

(Endorsed With Qualifications, 2013)

The following guideline on the Management of Newly Diagnosed Type 2 Diabetes Mellitus in Children and Adolescents was developed by the American Academy of Pediatrics, and endorsed with qualifications by the AAFP. This guideline was developed to provide evidence-based recommendations on managing 10- to 18-year old patients in whom T2DM has been diagnosed.

Summary of Recommendations

  • Key Action: Statement 1
     (Grade: strong recommendation: evidence quality X, validating studies cannot be performed, and C, observational studies and expert opinion; preponderance of benefit over harm.)
     
    Clinicians must ensure that insulin therapy is initiated for children and adolescents with T2DM who are ketotic or in diabetic ketoacidosis and in whom the distinction between T1DM and T2DM is unclear; and, in usual cases, should initiate insulin therapy for patients:
     1.Who have random venous or plasma BG concentrations ≥250 mg/dL; or
     2.Whose HbA1c is >9%.
  • Key Action: Statement 2
     (Grade: strong recommendation: evidence quality B; 1 RCT showing improved outcomes with metformin versus lifestyle; preponderance of benefits over harms.)
     
    In all other instances, clinicians should initiate a lifestyle modification program, including nutrition and physical activity, and start metformin as first-line therapy for children and adolescents at the time of diagnosis of T2DM.

  • Key Action: Statement 3
     (Option: evidence quality D; expert opinion and studies in children with T1DM and in adults with T2DM; preponderance of benefits over harms.)
     
    The American Academy of Pediatrics’ committee suggests that clinicians monitor HbA1c concentrations every 3 months and intensify treatment if treatment goals for BG and HbA1c concentrations are not being met.
  • Key Action: Statement 4
     (Option: evidence quality D; expert consensus. Preponderance of benefits over harms.)
     
    The American Academy of Pediatrics’ committee suggests that clinicians advise patients to monitor finger-stick BG concentrations in those who:
     
    1.Are taking insulin or other medications with a risk of hypoglycemia; or
     2.Are initiating or changing their diabetes treatment regimen; or
     3.Have not met treatment goals; or
     4.Have intercurrent illnesses.

  • Key Action: Statement 5
     (Option: evidence quality D; expert opinion; preponderance of benefits over harms. Role of patient preference is dominant.)
     
    The American Academy of Pediatrics’ committee suggests that clinicians incorporate the Academy of Nutrition and Dietetics’ Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines in the nutrition counseling of patients with T2DM both at the time of diagnosis and as part of ongoing management.

  • Key Action: Statement 6
     (Option: evidence quality D, expert opinion and evidence from studies of metabolic syndrome and obesity; preponderance of benefits over harms. Role of patient preference is dominant.)

The American Academy of Pediatrics’ Committee suggests that clinicians encourage children and adolescents with T2DM to engage in moderate-to-vigorous exercise for at least 60 minutes daily and to limit nonacademic screen time to less than 2 hours per day.

Qualifications

The reasons for the AAFP's endorsement with qualifications are as follows:

  • Five of the six key action statements in the guideline are based on expert opinion (only statement No. 2 is based on evidence quality B or higher); and
  • The AAFP does not believe that co-management or referral is necessary for all children, as indicated in the guideline introduction.

Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline from the American College of Physicians

(Endorsed, 2013)

The following guideline on the Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus was developed by the American College of Physicians and endorsed by the AAFP.

Summary of Recommendations

  • (Grade: strong recommendation; high-quality evidence)
    The American College of Physicians recommends that clinicians add oral pharmacologic therapy in patients diagnosed with type 2 diabetes when lifestyle modifications, including diet, exercise, and weight loss, have failed to adequately improve hyperglycemia.
  • (Grade: strong recommendation; high-quality evidence)
    The American College of Physicians recommends that clinicians prescribe monotherapy with metformin for initial pharmacologic therapy to treat most patients with type 2 diabetes.
  • (Grade: strong recommendation; high-quality evidence)
    The American College of Physicians recommends that clinicians add a second agent to metformin to treat patients with persistent hyperglycemia when lifestyle modifications and monotherapy with metformin fail to control hyperglycemia.

These guidelines are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute the individual judgment brought to each clinical situation by the patient’s family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These guidelines are only one element in the complex process of improving the health of America. To be effective, the guidelines must be implemented.