BOSTON — The use of insulin early in the management of adolescent type 2 diabetes mellitus may provide substantially improved glycemic control compared with the use of oral hypoglycemic agents alone, Dr. Aneesh K. Tosh said at the annual meeting of the Society for Adolescent Medicine.
Additionally, inpatient admission for newly diagnosed adolescents may provide a more effective means for facilitating intensive disease education compared with outpatient education programs.
A review of 51 patient charts from an adolescent type 2 diabetes mellitus subspecialty clinic showed, via multivariable regression, that the 11 patients who received insulin only at the time of diagnosis experienced a 30% improvement from baseline in their hemoglobin A1c (HbA1c) levels compared with a 5% improvement among the 23 patients who received oral agents only, after controlling for age, race, and body mass index. The 6 patients who did not receive insulin or oral agents experienced a 6% improvement from baseline, whereas the 11 who received both insulin and oral agents experienced a 26% improvement, reported Dr. Tosh of the department of pediatrics at Indiana University in Indianapolis.
Furthermore, the regression analysis showed that hospitalization for diabetes eduction was independently associated with improvements in glucose control. Among patients receiving only oral agents, inpatient education was associated with an 11% HbA1c improvement, compared with a 3% improvement among those receiving outpatient education, said Dr. Tosh. Among patients receiving insulin therapy alone or in combination with an oral agent, inpatient education was associated with a 29% improvement compared with 18% for those who received outpatient education. The inpatient education protocol consisted of 3 days of intensive education about diabetes management and glucose control, whereas the outpatient program consisted of a half-day of education.
“One reason the inpatient program may have led to greater improvements is the fact that it requires, by design, significant parental involvement, which in turn impacts patient understanding and compliance,” said Dr. Tosh. However, there is also the potential for selection bias. “Presumably, patients who were admitted for inpatient management were sicker at diagnosis, so you would expect more substantial improvement.”
Similarly, with respect to the choice of oral agents vs. insulin at diagnosis, patients with lower hemoglobin A1c initially might be more likely to receive oral agents, Dr. Tosh noted.
Although the study results are limited by the potential selection bias and small sample size, the findings suggest “that we need to take a closer look at the evolving role of insulin therapy for adolescents with type 2 diabetes,” said Dr. Tosh.
Current practice typically favors lifestyle management and oral hypoglycemic agents as first-line therapy for adolescents newly diagnosed with type 2 diabetes, with insulin being reserved for those diagnosed with severe disease or as second-line therapy. “There are a number of examples in the literature of the benefits of early insulin therapy, but most of the studies look at adults. Our findings are a call for studies of insulin management in the growing number of children and adolescents with type 2 diabetes,” Dr. Tosh said.