Type 2 Diabetes in adolescents: Issues for the SBHC provider Kathy Love-Osborne MD, FAAP

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 > 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 > 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) > 126 mg/dl Random or 2-hour after glucose challenge glucose > 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 < 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 Children’s Hospital: A1c 5.9% • many glucose values > 140 mg/dl and some > 200 mg • Family missed f/u metabolic syndrome clinic appointment: “I was told she didn’t have diabetes so I didn’t 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) > 100 mg/dl but < 126 mg/dl • Impaired glucose tolerance (IGT) • 2-hour glucose > 140 mg/dl but < 200 mg/dl • A1c 5.7-6.4% • A1c values >6.0% 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

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 > 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 • Don’t 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 15.4±2.0 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 (p=0.01 for trend) A1c < 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 > 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 • 20%continued with A1c values > 6.5% but were managed with lifestyle alone • 40% improved to A1c < 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

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 doesn’t 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 Don’t 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 (Children’s hospital endocrinology) Dr. Steve Daniels Denver Health providers for such a fantastic job documenting lifestyle recommendations and improving diabetes screening rates in adolescents