San Diego — Children in type 2 diabetes They face a surprisingly high complication rate as they age into young adulthood, with a newly diagnosed 80% incidence of at least one vascular complication during up to 15 years of follow-up. Results from the TODAY prospective longitudinal study of 699 children in the United States are presented. Type 2 diabetes.
Atherosclerosis and deterioration of cardiac function are common in these children within 2 to 5 years of diagnosis and may be partly due to the development of symptoms such as: high blood pressure and get worse A1c Rachel G. Gundika, M.D., Ph.D., said at the 83rd Annual Scientific Sessions of the American Diabetes Association (ADA):
In fact, an A1c > 6.2% at the beginning of the study is generally predictive of treatment failure in these children and is a red flag, Gandhika said. “I always tell my peers that if a child’s A1c is over 6.2%, they will fail, so they have to be careful,” she said.
Outcomes of treatment options for type 2 diabetes in adolescents and adolescents (today) Studies have shown, for example, an overall cardiovascular event rate of 3.7/1000 patient-years in a population that has just reached the mean age of 26 years and has been diagnosed with type 2 diabetes for an average of 13 years or more. I was.
During follow-up, there were 6 cases of: congestive heart failure4 cases of myocardial infarction, 4 cases of stroke, coronary artery disease within a cohort. The prevalence of hypertension rose from 19% at the beginning of the study to 68% at the end of follow-up.
Professor Gandhika called these and other findings “solemn details” documenting the enormous toll type 2 diabetes has on children. They were an average of 14 years old at the time they entered the study, and had been diagnosed with diabetes for an average of about eight months. They had an average follow-up of 12.6 years.
Investigators also found:
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49% of cohort developed after 12+ years of type 2 diabetes diabetic retinopathy3.5% have macular edema.
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Kidney injury (diabetic nephropathy) affected 8% of the cohort at initiation, but the prevalence increased to 55% after up to 14 years of follow-up.
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Of the 452 girls who participated in the study, 141 (31%) later became pregnant, for a total of 260 pregnancies. A quarter of pregnancies were delivered prematurely (43% were term) and 25% were premature. abortion The remaining 8% had elective abortions or unknown outcomes.
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Neonatal complications were common. hypoglycemia (29%), respiratory disease (19%), heart problems (10%).
Dismal prognosis provides reason to aggressively treat these patients
From this and other studies of adolescents with type 2 diabetes, differences in outcomes between adolescents and adults are evident, suggesting that childhood and adolescent type 2 diabetes have different underlying pathologies and natural histories. It may indicate that there is a high probability that there is Aggressive disease course.
Therefore, this dismal prognosis is likely due to drug classes of antidiabetic agents with proven cardiovascular prophylaxis, particularly sodium-glucose cotransporter 2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1). Gandhika said it gives reason to aggressively treat these patients with agonists. , a pediatric endocrinologist at Columbia University Medical Center in New York City.
“It is safe to say that we are using it more aggressively now. [these agents] In children,” she said in an interview, referring to the approval of an SGLT2 inhibitor by the US Food and Drug Administration just last week. Empagliflozin (Jardiance, Boehringer Ingelheim/Lilly) For children around 10 years old report To Medscape Medical News.
“We look forward to prescribing empagliflozin to children with type 2 diabetes to lower blood pressure and have additional benefits for cardiovascular disease,” said Gandhika.
Other new type 2 diabetes treatments approved for US children in the last few years include once-weekly injectable GLP-1 agonists. Extended release exenatide (Bydureon/Bydureon BCise, AstraZeneca) For children 10 years and older with type 2 diabetes, in 2021a daily injectable GLP-1 agonist liraglutide (Victoza, Novo Nordisk) and 2019.
A1c Spike Herald Cure Failure: “watch out for that”
Beginning in 2004, TODAY enrolled 699 children with type 2 diabetes at 16 centers in the United States for an average of 8 months from diagnosis. The protocol began with a run-in phase of up to 6 months during which participating children discontinued their existing antidiabetic medications. She was then started on a metformin-only regimen to bring her A1c below 8.0%. If achieved, patients were eligible to continue randomization.
Participants were randomly assigned to one of three treatment groups: metformin Alone, metformin plus lifestyle intervention, or metformin plus metformin Rosiglitazone (Avandia, GSK). The primary endpoint was the incidence of treatment failure, defined as re-elevated A1c above 8.0% for at least 6 months, or persistent metabolic failure during initial follow-up for an average of just under 4 years.
Results showed that only metformin and rosiglitazone significantly outperformed metformin alone in preventing treatment failure. reported in 2012 in the New England Journal of Medicine.
Recent reports on long-term follow-up results have been published in several journals including cardiovascular disease results. Reported in 2021 again, New England Journal of Medicine.
Another important finding today is the importance of A1c as a risk marker for impending treatment failure. research result A1c of 6.2% or more best predicted poorer glycemic control during follow-up when children entered the study. Also, an increase in A1c of at least 0.5 percentage points was significantly associated with subsequent loss of glycemic control within 3-6 months.
This is an important message for clinicians, Gandhika concluded.
TODAY and TODAY2 are not commercially funded. Gandhika has not reported any related financial relationships.
ADA Scientific Sessions. Session CT-1.5-SY25. Announced June 24, 2023.
Mitchel L. Zoler is a Medscape and MDedge reporter based in the Philadelphia area. @mitchelzoler
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