Type 2 Diabetes Flashcards
Type 2 diabetes diagnosed in childhood is associated with _____ and _____ onset of complications
Severe and early
Which ethnic groups are at highest risk for DM2?
- African
- Arab
- Asian
- Hispanic
- Indigenous
- South Asian
What is the incidence of DM2 in children in Canada?
1.54 per 100,000
Highest in Manitoba (12.45)
_____ % of children with DM2 also have a first or second degree relative who also has DM2
90%
List 5 behaviours associated with prevention of DM2
- Breastfeeding
- Prevention/management of obesity (not very effective)
- Improve sleep quality/quantity
- Decrease sedentary behaviuors
- Increase light and vigorous physical activity
- Reduce sugar-sweetened beverages
- Reduce screen time
List 8 risk factors for the development of DM2 in children
- DM2 in a first or second degree relative
- High-risk ethnic population (African, Arab, Asian, Hispanic, Indigenous, South Asian)
- Obesity (BMI >95th percentile)
- Impaired glucose tolerance
- PCOS
- Exposure to daibetes in utero
- Acanthosis nigricans
- Hypertension
- Dyslipidemia
- NAFLD
- (Possibly) atypical antipsychotic medications
What is the mean age of diagnosis of DM2 in Canadian youth?
13.7 years
What is the preferred screening test for DM2?
HbA1c and fasting or random BG
2-hour OGTT should be considered in children with 3 or more risk factors or if there is a discrepancy between A1c and fasting/random BG
Who should be screened for DM2? and how often?
Every 2 years in children with any of the following:
- 3+ risk factors in prepubertal children beginning at age 8 OR 2+ risk factors in pubertal children
- PCOS
- IFG and/or IGT
- Use of atypical antipsychotic medications
Who are the members of an interprofessional team managing children with DM2?
- Pediatric endocrinologist or pediatrician with diabetes expertise
- Dietician
- Diabetes nurse educator
- Mental health professional
What is the target HbA1c for children with DM2?
= 7.0%
HOWEVER, there is evidence that achieving an A1c of = 6.0% within the first 6 months of diagnosis may reduce the risk of treatment failure
Name 3 lifestyle factors to address in diabetes management
Healthy eating
Physical activity (60 minutes/day of moderate to vigorous)
Screen time (<2 hours)
Smoking prevention/cessation
Contraception in females (high risk of congenital anomalies)
When is treatment with insulin indicated in DM2?
Severe metabolic decompensation at diagnosis (ex. DKA, HbA1c >/= 9.0%, symptoms of severe hyperglycemia)
May be successfully weaned once glycemic targets are achieved
How should insulin be started in DM2?
Once daily, long-acting basal insulin
How should metformin be started in DM2?
At diagnosis, even if also starting insulin (except if acidosis is present)
500 mg PO daily x7 days, increase by 500 mg daily until reach maximum dose of 1,000 mg PO BID
Reduce increments to 250 if GI side effects
If not reaching glycemic targest within 3-6 months, add insulin
What oral antihyperglycemic agents have been studied in children?
Metformin (reduced A1c and FPG)
Glimepiride (sulfonylurea, reduced A1c but significant weight gain)
Rosiglitazone (TODAY study, no evidence re: long-term safety)
Bariatric surgery (case reports)
What extra vaccines should be recommended in children with DM2?
Pneumococcal
Influenza (annual)
____ % of Canadian youth with DM2 present with DKA at the time of diagnosis.
10%
List 3 management principles of HHS
- More aggressive fluid resuscitation
- Delayed insulin administration at a lower dose
- Careful replacement of potassium, phosphate and magnesium
What are the screening recommendations for complications and comorbidities of DM2?
- Neuropathy (at diagnosis + yearly): ask about symptoms of neuropathy, examine vibration sense, light touch and ankle reflexes
- Retinopathy (at diagnosis + yearly): 7-standard field stereoscopic-colour fundus photography with interpretation by a trained reader OR direct ophthalmoscopy OR indirect slit-lamp fundoscopy through dilated pupil OR digital fundus photograph
- Nephropathy (at diagnosis + yearly): first morning ACR
- Dyslipidemia (at diagnosis + yearly): fasting TC, HDL, TG, calculated LDL
- Hypertension (at diagnosis + at least twice yearly): BP measurement using appropriately sized cuff
- NAFLD (yearly, at diagnosis): ALT and/or fatty liver on ultrasound
- PCOS (yearly, at diagnosis in pubertal females): clinical assessment for oligo/amenorrhea, acne, or hirsutism
- OSA (at diagnosis + yearly): symptoms of snoring, apnea, AM headaches, fatigue, daytime sleepiness, nocturia, enuresis
- Depression (at diagnosis + yearly): clinical symptoms of fatigue, depressed mood, anhedonia, feelings of worthlessess/guilt
- Binge eating (at diagnosis + yearly): clinical symptoms of loss of control/eating large amounts
What should you do in the case of one abnormal ACR in a child with DM2?
- Repeat 1 month later with repeat ACR or timed overnight urine collection
- Repeat sampling should be done every 3-4 months over a 6-12 month period to demonstrate persistence
- If persistent: referral to pediatric nephrologist
When should you start a statin in children with DM2?
If LDL >4.1 after a 3-6 month trial of dietary interventions
List 3 risk factors for development of hypertension in children with DM2
- Male gender
- Higher BMI
- Older age)
*Note: NOT A1c or ethnicity
Biguanides (ex. metformin): Mechanism of action, impact on A1c lowering/hypoglycemia/weight/CVD, side effects
- Enhances insulin sensitivty in liver and peripheral tissues by activation of AMP-activated protein kinase
- HbA1c 1.0%
- Negligible hypoglycemia as monotherapy
- Weight-neutral
- Reduction in MI in overweight individuals
- Side effects: GI, vitamin B12 deficiency
- Contraindicated if eGFR <30, caution in 30-60
