1. Diabetes Control in Youth: The American Experience Georgeanna J. Klingensmith, MD Keystone Colorado July 2008

2. Diabetes Control: American View ADA recommendations Advances in care since the ADA statement prepared What are HbA1c results in the US? Differing results by insulin regimen Continuing barriers to achieving targets

3. American Diabetes Association Standards for the Care of Children Developed recommendations for glycemic control in 2003-04 - based on DCCT results and - what was considered safe for generalists to accomplish - designed to weigh ideal with practical

4. American Diabetes Association Standards for the Care of Children Target goals should be individualized Aim for the lowest HbA1c each child and family can accomplish Avoid hypoglycemia and excessive hyperglycemia –Both have been shown to result in neurocognitive deficits in the developing brain Perantie DCPerantie DC, Lim A, Wu J, Weaver P, Warren SL, Sadler M, White NH, Hershey T. Pediatr Diabetes. 2008;9:87-95.Lim AWu JWeaver PWarren SLSadler M White NHHershey TPediatr Diabetes.

5. Targets for Type 1 Diabetes Care: ADA Glycemic Guidelines 2008 Targets** Age Fasting overnight A1c % Age Fasting overnight A1c %. < 6yrs 100-180 110-200 7.5-8.5 < 6yrs 100-180 110-200 7.5-8.5 6-12 yrs 90-180 100-180 <8 6-12 yrs 90-180 100-180 <8 13-19 yrs 90-140 90-150 <7.5 13-19 yrs 90-140 90-150 <7.5 adult 90-140 90-150 <7 adult 90-140 90-150 <7 ** Goals should be individualized Silverstein, Klingensmith, et al. Care of Children with type 1 DM. ADA Statement. Diabetes Care, 28:186, 2005 ADA Standards of Care. Diabetes Care, Suppl 1, 2008 2 Hr post meal target= <180

6. Achieving Goal What has changed since 2003-04 to change our perspective on glycemic targets?

7. Recent Advances in Diabetes Care 1996: First rapid acting analog insulin - 2000: First long acting analog insulin - Basal / Bolus injection therapy 2003: First “smart pump” These combinations allowed sophisticated insulin delivery by relatively medically unsophisticated school personnel 2006: Inhaled insulin Continuous glucose sensors 2008: Beginning to close the loop Stuart A. Weinzimer, et al Diabetes Care 31:934-939, 2008

8. Advantage of Long Acting Analogue Insulin Glargine vs NPH: a randomized trial of BID insulin from 3-6 months after diagnosis Hassan, Rodriguez,Johnson, Tadlock and Heptulla. Pediatrics, 21, e466 March 2008

9. Achieving Goal How are we doing?

10. SEARCH for Diabetes Study Six clinical site epidemiological study Aims: To determine –Prevalence and incidence of diabetes –Patterns and outcomes of care

12. SEARCH for Diabetes Study Has evaluated: –average HbA1c and distribution of HbA1c from 2001-2004 and –Types of insulin regimens used and HbA1c outcomes with differing regimens Pititti DB, Klingensmith GJ, et al for the SEARCH study ADA Scientific Sessions 2006 Pihoker et al, ISPAD annual meeting, Berlin 2007

13. * * BDC Pump therapy results, non-randomized: HbA1c values at baseline and follow-up * p < 0.001 Simmons JH, Rewers M, Klingensmith GJ Acedemic Pediatric Society meeting 2007 Pump therapy for >2 years, matched for baseline A1c, age, and insurance status

14. What are longitudinal HbA1c results doing in the US? BDC HbA1c results –2000-2006 and –1995-2008

15. Mean HbA1c by age and year in those diagnosed > 1 year n = 150->171n = 611->850n = 806 -> 1205

16. BDC patients 1 year

17. Continuous Glucose Sensing CGS has contributed to the decrease in HbA1c –More sensor use and ability to apply information gained from sensor use to children and youth not using sensors Give bolus doses prior to meals if possible Monitor at 1-3 am for hypoglycemia, especially following increased exercise

18. . 16 year old boy with T1DM for 6 years, HbA1c = 5.7%

19. CGS in LAA basal bolus therapy Decrease in HbA1c from 8.5% to 7.8% by 5-8 weeks, this persisted through 9-13 weeks Baseline SBGM 4.8 times a day, decreased to 2.9 times a day Navigator sensor worn 4+ days per week Stuart A. Weinzimer and the DirectNet study group. Diabetes Care.31:525-527, 2008

20. Reassurance that hypoglycemia will be averted allows lower glucose targets “The sensor makes me feel safer knowing that I will be warned about low blood glucose before it happens” Mean answer of 3.9 for subjects and 4.5 for parents on a 5 point Likert scale 3 year old on a sensor

21. Barriers to achieving target HbA1c Fear of hypoglycemia –In patient and parents* –In care providers Chaotic family –Teen brain Denial of the seriousness of diabetes and its consequences Patton, et al. Pediatr Diab. 2007: 362-68*

22. Conclusion from the US Perspective Strive for lower HbA1c levels in every patient Problem solve with teens Intensify diabetes regimens –More frequent testing –Possibly more frequent use of CSII –Work toward increased use of CGS Question why management is not more intensified in every patient

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