2.4.2 Overview

Treat­ment of youth-‍onset type 2 di­a­betes should in­clude lifestyle man­age­ment, di­a­betes self-‍man­age­ment ed­u­ca­tion, and phar­ma­co­log­ic treat­ment. Ini­tial treat­ment of youth with obe­si­ty and di­a­betes must take into ac­count that di­a­betes type is often uncer­tain in the first few weeks of treat­ment, due to over­lap in pre­sentation, and that a sub­stan­tial per­cent­age of youth with type 2 di­a­betes will pre­sent with clin­i­cally significant ke­toaci­do­sis (138). There­fore, ini­tial ther­a­py should ad­dress the hy­per­glycemia and as­so­ci­at­ed metabol­ic de­range­ments irre­spective of ul­ti­mate di­a­betes type, with ad­just­ment of ther­a­py once metabol­ic com­pen­sa­tion has been es­tab­lished and sub­se­quent infor­mation, such as islet autoan­ti­body re­sults, be­comes avail­able. Fig­ure 13.1 pro­vides an ap­proach to ini­tial treat­ment of new-‍onset di­a­betes in over­weight youth.

Glycemic tar­gets should be in­di­vid­u­al­ized, tak­ing into con­sid­eration long-‍term health benefits of more strin­gent tar­gets as well as risk for ad­verse ef­fects, such as hy­po­glycemia. A lower tar­get A1C in youth with type 2 di­a­betes when com­pared with those rec­om­mend­ed in type 1 di­a­betes is justified by lower risk of hy­po­glycemia and high­er risk of com­pli­ca­tions (139-142).

Pa­tients and their fam­i­lies must pri­or­i­tize lifestyle modifications such as eat­ing a bal­anced diet, achiev­ing and main­taining a healthy weight, and ex­er­cising reg­u­lar­ly. A fam­i­ly-cen­tered ap­proach to nu­tri­tion and lifestyle modi- fication is es­sen­tial in chil­dren with type 2 di­a­betes, and nu­ti­tion rec­om­men­da­tions should be cul­tur­al­ly ap­pro­pri­ate and sen­si­tive to fam­i­ly re­sources (see Sec­tion “Lifestyle Man­age­ment”). Given the com­plex so­cial and en­vi­ron­men­tal con­text sur­round­ing youth with type 2 di­a­betes, in­di­vid­u­al-‍level lifestyle in­ter­ven­tions may not be sufficient to tar­get the com­plex in­ter­play of fam­i­ly dy­nam­ics, men­tal health, com­mu­ni­ty readi­ness, and the broad­er en­vi­ron­men­tal sys­tem (2).

A mul­ti­dis­ci­plinary di­a­betes team, in­clud­ing a physi­cian, di­a­betes nurse ed­u­ca­tor, reg­is­tered di­eti­tian, and psy­chol­o­gist or so­cial work­er, is es­sen­tial. In ad­di­tion to blood glu­cose con­trol and self-‍man­age­ment ed­u­ca­tion (143-145), ini­tial treat­ment must in­clude man­age­ment of co­mor­bidities such as obe­si­ty, dys­lipi­demia, hy­per­ten­sion, and mi­crovas­cu­lar com­pli­ca­tions.

Cur­rent phar­ma­co­log­ic treat­ment op­tions for youth-‍onset type 2 di­a­betes are lim­it­ed to two ap­proved drugsdin­sulin and met­formin (2). Pre­sen­ta­tion with ke­toaci­do­sis or marked ke­to­sis re­quires a pe­ri­od of in­sulin ther­a­py until fast­ing and postpran­di­al glycemia have been re­stored to nor­mal or near-‍nor­mal lev­els. Met­formin ther­a­py may be used as an ad­junct after res­o­lu­tion of ke­to­sis/ ke­toaci­do­sis. Ini­tial treat­ment should also be with in­sulin when the dis­tinc­tion be­tween type 1 di­a­betes and type 2 di­a­betes is un­clear and in pa­tients who have ran­dom blood glu­cose con­cen­tra­tions ≥250 mg/dL (13.9 mmol/‍L) and/‍or A1C ≥8.5% (69 mmol/‍mol) (146). In­sulin is need­ed when the glycemic tar­get is not met on met­formin alone, or if there is met­formin intol­er­ance or renal or hep­at­ic insufficien­cy (147).

When in­sulin treat­ment is not re­quired, ini­ti­a­tion of met­formin is rec­om­mend­ed. The Treat­ment Op­tions for Type 2 Di­a­betes in Ado­les­cents and Youth (TODAY) study found that met­formin alone pro­vided durable glycemic con­trol (A1C ≤8% [64 mmol/‍mol] for 6 months) in ap­prox­i­mate­ly half of the sub­jects (148). To date, the TODAY study is the only trial com­bin­ing lifestyle and met­formin ther­a­py in youth with type 2 di­a­betes; the com­bi­na­tion did not per­form bet­ter than met­formin alone in achiev­ing durable glycemic con­trol (148).