A Pediatrician s Perspective of the Current State of Diabetes Management

Transcription

1 A Pediatrician s Perspective of the Current State of Diabetes Management Desmond Schatz, MD Professor of Pediatrics Medical Director, Diabetes Center University of Florida

2 Financial Disclosure There are no relevant financial relationships with any commercial interests to disclose.

3 SEARCH for Diabetes in Youth Study Group Pediatrics 2006; 118; DOI: /peds New Cases of Diabetes in Youth (USA) 3-5% increase in T1D consistently T2D <2% to 25% of new onset diabetes; incidence tripled

4 Treatment Goals for Children and Adolescents Maintain BG, lipids, BMI, BP as near to normal as possible where not possible, improvement on follow up Setting realistic goals for each child and family Close surveillance for co-morbidities and prevention of micro- and macrovascular complications Avoid acute complications of diabetes.severe hypoglycemia, DKA Normal physical growth and development Normal psychosocial development

5 CURRENT STAUS QUO 2013 UNACCEPTABLE WE CANNOT AFFORD TO DO NOTHING: TYPE 1 Potential benefits of improved glycemic control reaching a minority of youth Epidemic worldwide Increasing burden to individual and society No reduction in acute complications Even current `successful immune interventions of questionable translation

6 WE CANNOT AFFORD TO DO NOTHING: TYPE 2 Early and rapid deterioration in ß cell function Metformin monotherapy inadequate for half of youth Role of intensive lifestyle interventions in youth uncertain High (and increasing) rates of hypertension, microalbuminuria, and dyslipidemia, depression as well as evidence for end organ cardiac damage Important race/ethnicity differences among youth with type 2 diabetes in the US: families challenged by poverty, poor education and widespread poor health Diabetes Care, June 2013

7 PREDICTED TRENDS IN INCIDENCE OF TYPE 1 IN FINNISH CHILDREN < 15 YRS INCIDENCE (per 100,000/yr)

8 How Well are Kids with T1D Doing? T1D Exchange Clinic Registry 67 clinical sites through the US Longitudinal data collected through clinic medical records and participant questionnaires Specific objectives: Address pertinent clinical issues Conduct exploratory/hypothesis-generating analyses Identify participants interested in future research studies ~ 25,833 participants, ages 1 93 years Beck et al. J Clin Endocrinol Metab. 2012;97:4383 9

9 Targets (by age).not just glucose!!! 1 5 y 6 12 y y 20 y HbA1c* <8.5% <8.0% <7.5% <7.0% BP <90 th percentile <130/80 mm/hg HDL LDL-Fasting TG-Fasting >40 mg/dl (1.0 mmol/l) for males >50 mg/dl (1.3 mmol/l) for females <100 mg/dl (2.6 mmol/l) <150 mg/dl (1.7 mmol/l) BMI 5 th <85 th percentile 18.5 <25 kg/m 2 *ISPAD < 7.5% ADA. Diabetes Care 2013;36(suppl 1):11 66

10 Higher HbA1c in Children

11 Higher Proportion of Children Meeting (Higher) ADA HbA1c Targets A1c Goal<8.5% A1c Goal = <7.0% A1c Goal < 8% A1c Goal <7.5%

12 But not by ISPAD (HbA1c 7.5%).. Guidelines Mean A1C = 8.1% Mean A1C = 8.2% Mean A1C = 8.7% Wood JR et al. Presented at the 37 th ISPAD, Miami, October 19 th 22 nd, 2011

13 Percent of Pediatric Patients Meeting Other Goals DiMeglio LA et al. Diabetes 2012;61(Suppl 1): A345 A403

14 Percent of Patients Meeting ALL ADA Goals DiMeglio LA et al. Diabetes 2012;61(Suppl 1): A345 A403

15 Characteristics of Children with Excellent and Poor Control Excellent (<7%) n=699 Poor (>9%) n=2,915 Age 8 17 yrs Duration 2 yrs Ped Diabetes (in Press, 2013)

16 Factors Associated with Better Control* Sociodemographic Higher income Private insurance Younger More non-hispanic whites *P< for all Management (=modifiable) More pump use More frequent SMBG Bolusing before meals Counting carbs Missing less boluses Less daily insulin use? CGMS Ped Diabetes (in press, 2013)

17 Percent of Pediatric Patients Meeting Goals by Insulin Administration Method DiMeglio LA et al. Diabetes 2012;61(Suppl 1): A345 A403

18 Insulin Pump Use 80% 70% 60% 50% 40% 30% 20% 10% 0% Children 69% Pump Use 44% Excellent Control Poor Contol

19 Self-Monitoring of Blood Glucose 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Children 79% 54% 5 Times/day Excellent Control Poor

20 Association between Frequency of SMBG per Day and HbA1c by Age

21 Never Miss Insulin Doses 80% 70% 60% 50% 40% 30% 20% 10% 0% Children 61% Never 31% Excellent Control Poor Control

22 Insulin:Carb Ratios 60% 50% 40% 30% 20% 10% 0% Children 52% 28% Yes, 3 meals not all the same Excellent Control Poor Control

23 Bolusing Before a Meal 80% 70% 60% 50% 40% 30% 20% 10% 0% 64% Children 52% Excellent Control Poor Control Before Meal

24 Total Daily Insulin Doses 80% 70% 60% 50% 40% 30% 20% 10% 0% Children 76% <0.6 units/kg day 64% Excellent Control Poor Control

25 Mean HbA1c by CGM Use P<0.001 P<0.001 P<0.001

26 Children with Better Control.. Associated with: More use of insulin pumps self-monitoring of blood glucose (SMBG) missing fewer insulin doses Consistently bolusing before meals using meal specific insulin:carbohydrate ratios using a lower mean total daily insulin dose

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28 Mean HbA1c According to Race/Ethnicity and Insulin Method

29 Mean HbA1c According to Race/Ethnicity and Insulin Method

30 Type1 Type 2

31 How are Youth with T2D Doing? The TODAY Trial N Engl J Med 2012; 366:

32 N Engl J Med 2012; 366:2247

33 Summary Youth with type 2 diabetes are more likely to be minorities, lower SES, have high rates of depression Metformin monotherapy is inadequate for half of youth with T2D aggressive course in youth Rapid decline in ß cell function Role of intensive lifestyle interventions in youth uncertain. Youth with T2D have high and increasing rates within 5 yrs of : hypertension (12 33%), microalbuminuria (6 17%), (14%) dyslipidemia (11%), early cardiac damage (TODAY; Diabetes Care, June 2013) retinopathy

34 Conclusions In Both Type 1 and Type Diabetes in Youth Few reach age-specific HbA1c goals Overweight/obesity, dyslipidemia, hypertension common. Current therapeutic approaches inadequate Both modifiable and non-modifiable factors contribute Strategies to target persons and providers not meeting or observing guidelines, determine who is at highest risk for treatment failure, and novel ways to improve compliance must be explored.