2.5.0.0 Prevention and Management of Diabetes Complications
Recommendations
Nephropathy
13.69 Blood pressure should be measured at every visit. A
13.70 Blood pressure should be optimized to reduce risk and/or slow the progression of diabetic kidney disease. A
13.71 If blood pressure is >95th percentile for age, sex, and height, increased emphasis should be placed on lifestyle management to promote weight loss. If blood pressure remains above the 95th percentile after 6 months, antihypertensive therapy should be initiated. C
13.72 Initial therapeutic options include ACE inhibitors or angiotensin receptor blockers. Other blood pressure–lowering agents may be added as needed. C
13.73 Protein intake should be at the recommended daily allowance of 0.8 g/kg/day. E
13.74 Urine albumin-to-creatinine ratio should be obtained at the time of diagnosis and annually thereafter. An elevated urine albumin-to-creatinine ratio (>30 mg/g creatinine) should be confirmed on two of three samples. B
13.75 Estimated glomerular filtration rate should be determined at the time of diagnosis and annually thereafter. E
13.76 In nonpregnant patients with diabetes and hypertension, either an ACE inhibitor or an angiotensin receptor blocker is recommended for those with modestly elevated urinary albumin-to-creatinine ratio (30–299 mg/g creatinine) D and is strongly recommended for those with urinary albumin-to-creatinine ratio >300 mg/g creatinine and/or estimated glomerular filtration rate <60 mL/min/1.73 m2. E
13.77 For those with nephropathy, continued monitoring (yearly urinary albumin-to-creatinine ratio, estimated glomerular filtration rate, and serum potassium) may aid in assessing adherence and detecting progression of disease. E
13.78 Referral to nephrology is recommended in case of uncertainty of etiology, worsening urinary albumin-to-creatinine ratio, or decrease in estimated glomerular filtration rate. E
Neuropathy
13.79 Youth with type 2 diabetes should be screened for the presence of neuropathy by foot examination at diagnosis and annually. The examination should include inspection, assessment of foot pulses, pinprick and 10-g monofilament sensation tests, testing of vibration sensation using 128-Hz tuning fork, and ankle reflexes. C
13.80 Prevention should focus on achieving glycemic targets. C
Retinopathy
13.81 Screening for retinopathy should be performed by dilated fundoscopy or retinal photography at or soon after diagnosis and annually thereafter. C
13.82 Optimizing glycemia is recommended to decrease the risk or slow the progression of retinopathy. B
13.83 Less frequent examination (every 2 years) may be considered if there is adequate glycemic control and a normal eye exam. C
Nonalcoholic Fatty Liver Disease
13.84 Evaluation for nonalcoholic fatty liver disease (by measuring aspartate aminotransferase and alanine aminotransferase) should be done at diagnosis and annually thereafter. B
13.85 Referral to gastroenterology should be considered for persistently elevated or worsening transaminases. B
Obstructive Sleep Apnea
13.86 Screening for symptoms of sleep apnea should be done at each visit, and referral to a pediatric sleep specialist for evaluation and a polysomnogram, if indicated, is recommended. Obstructive sleep apnea should be treated when documented. B
Polycystic Ovary Syndrome
13.87 Evaluate for polycystic ovary syndrome in female adolescents with type 2 diabetes, including laboratory studies when indicated. B
13.88 Oral contraceptive pills for treatment of polycystic ovary syndrome are not contraindicated for girls with type 2 diabetes. C
13.89 Metformin in addition to lifestyle modification is likely to improve the menstrual cyclicity and hyperandrogenism in girls with type 2 diabetes. E
Cardiovascular Disease
13.90 Intensive lifestyle interventions focusing on weight loss, dyslipidemia, hypertension, and dysglycemia are important to prevent overt macrovascular disease in early adulthood. E
Dyslipidemia
13.91 Lipid testing should be performed when initial glycemic control has been achieved and annually thereafter. B
13.92 Optimal goals are LDL cholesterol <100 mg/dL (2.6 mmol/L), HDL cholesterol >35 mg/dL (0.905 mmol/L), and triglycerides <150 mg/dL (1.7 mmol/L). E
13.93 If LDL cholesterol is >130 mg/dL, blood glucose control should be maximized and dietary counseling should be provided using the American Heart Association Step 2 diet. E
13.94 If LDL cholesterol remains above goal after 6 months of dietary intervention, initiate therapy with statin, with goal of LDL <100 mg/dL. B
13.95 If triglycerides are >400 mg/dL (4.7 mmol/L) fasting or >1,000 mg/dL (11.6 mmol/L) nonfasting, optimize glycemia and begin fibrate, with a goal of <400 mg/dL (4.7 mmol/L) fasting (to reduce risk for pancreatitis). C
Cardiac Function Testing
13.96 Routine screening for heart disease with electrocardiogram, echocardiogram, or stress testing is not recommended in asymptomatic youth with type 2 diabetes. B
Comorbidities may already be present at the time of diagnosis of type 2 diabetes in youth (122,163). Therefore, blood pressure measurement, a fasting lipid panel, assessment of random urine albumin-to-creatinine ratio, and a dilated eye examination should be performed at diagnosis. Thereafter, screening guidelines and treatment recommendations for hypertension, dyslipidemia, urine albumin excretion, and retinopathy are similar to those for youth with type 1 diabetes. Additional problems that may need to be addressed include polycystic ovary disease and other comorbidities associated with pediatric obesity, such as sleep apnea, hepatic steatosis, orthopedic complications, and psychosocial concerns. The ADA position statement “Evaluation and Management of Youth-Onset Type 2 Diabetes” (2) provides guidance on the prevention, screening, and treatment of type 2 diabetes and its comorbidities in children and adolescents.
Youth-onset type 2 diabetes is associated with significant microvascular and macrovascular risk burden and a substantial increase in the risk of cardiovascular morbidity and mortality at an earlier age than those diagnosed later in life (164). The higher complication risk in earlier-onset type 2 diabetes is likely related to prolonged lifetime exposure to hyperglycemia and other atherogenic risk factors, including insulin resistance, dyslipidemia, hypertension, and chronic inflammation. There is low risk of hypoglycemia in youth with type 2 diabetes, even if they are being treated with insulin (165), and there are high rates of complications (139-142). These diabetes comorbidities also appear to be higher than in youth with type 1 diabetes despite shorter diabetes duration and lower A1C (163). In addition, the progression of vascular abnormalities appears to be more pronounced in youth-onset type 2 diabetes compared with type 1 diabetes of similar duration, including ischemic heart disease and stroke (166).