New pediatric guidelines for type 2 diabetes emphasize starting drugs, lifestyle changes simultaneously

Guidelines for treating type 2 diabetes in children and teenagers suggest integrating diet and exercise with medication, as well as offering advice on frequency of hemoglobin A1c (HbA1c) and fingerstick blood glucose monitoring.

The guidelines appeared in the February Pediatrics.

Clinicians should prescribe a lifestyle modification program, including nutrition and physical activity, and can also start metformin as first-line therapy. They can incorporate the Academy of Nutrition and Dietetics' Pediatric Weight Management Evidence-Based Nutrition Practice Guidelines in their dietary or nutrition counseling. Children should exercise for at least 60 minutes daily and should limit television and video games to less than two hours a day.

Because gastrointestinal adverse effects are common (but transient) with metformin therapy, the committee recommended starting with a low dose of 500 mg daily, increasing by 500 mg every one to two weeks, up to an ideal and maximum dose of 2,000 mg daily in divided doses.

Clinicians should start insulin therapy for children who are ketotic or in diabetic ketoacidosis and in whom the distinction between types 1 and 2 diabetes is unclear, the guidelines state. Otherwise, clinicians should start insulin for patients who have random venous or plasma blood glucose concentrations of 250 mg/dL or greater or those whose HbA1c level is above 9%. Those who lack evidence of ketosis or ketoacidosis may also benefit from short-term insulin, which provides quicker restoration of glycemic control and may allow islet β cells to “rest and recover.” Insulin may also increase long-term adherence to treatment by enhancing the patient's perception of the seriousness of the disease, the guidelines said. Patients may later gradually be weaned from insulin and managed with metformin and lifestyle modification.

Clinicians should monitor HbA1c concentrations every three months and should intensify treatment if treatment goals for fingerstick blood glucose and HbA1c concentrations are not being met. Ideally, the HbA1c goal should be less than 7%, but goals must be achievable. “In addition, in the absence of hypoglycemia, even lower HbA1c target concentrations can be considered on the basis of an absence of hypoglycemic events and other individual considerations,” the guidelines state.

Clinicians should tell patients who are taking insulin or other medications with a risk of hypoglycemia to monitor fingerstick blood glucose concentrations if they are starting or changing their diabetes treatment regimen, have not met treatment goals or have other illnesses.

Although normoglycemia may be difficult to achieve in teenagers, a fasting blood glucose concentration of 70 to 130 mg/dL is a reasonable target for most, the guidelines state. Because postprandial hyperglycemia has been associated with increased risk of cardiovascular events in adults, postprandial blood glucose testing may be valuable in select patients. Blood glucose concentrations taken before eating paired with readings taken two hours after meals may be useful in improving glycemic control, particularly for patients whose fasting plasma glucose is normal but whose HbA1c is not at target.

Primary care clinicians who are not confident that they can treat diabetes in children because of the child's age or coexisting conditions should refer the patient to a pediatric medical subspecialist, the guidelines advise.