DIABETES IN ADOLESCENTS AND YOUNG ADULTS. Rasa VERKAUSKIENĖ LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

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1 DIABETES IN ADOLESCENTS AND YOUNG ADULTS Rasa VERKAUSKIENĖ LITHUANIAN UNIVERSITY OF HEALTH SCIENCES EASD Postgraduate Course 2017

2 TYPE 1 in ADOLESCENCE and YOUNG ADULTS Major advances past 30 yrs No reduction in acute complications Potential benefits of improved glycemic control reaching a minority of patients

3 TARGETS Parameter HbA1c Blood glucose Target Level 7.5% Pre-prandial : mmol/l Bedtime : mmol/l BP* LDL-C HDL-C TG BMIª <95 th percentile <2.6 mmol/l >1.1 mmol/l <1.7 mmol/l <95 th percentile *Adjusted for age, sex, and height; ªAdjusted for age and sex ISPAD Guidlines 2014, ADA, Diabetes Care 2017

4 TYPE 1 DIABETES EXCHANGE Struggles with Glycemic Control n = 16,791 Miller at el: Diabetes Care

5 TYPE 1 DIABETES EXCHANGE Glycemic Control (2015) n = 16,791 HbA1c Goal = <7.5% < 18 yr HbA1c Goal = <7.0% Miller at el: Diabetes Care

6 Centres of Reference ( ): 48 centres from 33 countries over 5 continents, > patients

7 Procentai % n ,9 66, , , ,2 37,4 62,7 33,3 0 < 7,5 7, ,1 11,4 > <6 6-<12 12-<18 18-<25 Age groups

8 RATES OF DKA AND SEVERE HYPOGLYCEMIA IN TYPE 1 DIABETES EXCHANGE

9 WHY IS IT SO HARD? BARRIERS TO SUCCESS Burn out Inadequate motivation and support Family Healthcare team Fear of and actual hypoglycemia Weight gain Need for frequent BG monitoring Insulin pharmacokinetics

10 In addition, in adolescence Endocrine changes leading to increased insulin resistance Erratic meal and exercise pattern Poor adherence to treatment regiments omission of insulin Eating disorders Hazardous and risk taking behavior

11 Adolescence period For all young people, adolescence is a period of biological, social and emotional change, in which they work through four developmental tasks: To consolidate their identity To achieve independence from their parents To establish adult relationships outside their families To find a vocation

12 Differences of the brain Adolescence Limbic >>>Frontal lobe Frontal lobe develops in Girls years old Boys years old Emerging adulthood y y.

13 Attitudes of adolescents and emerging adults Autonomy To be as different from caring adults as possible Affiliation To be admired by peers

14 Omission of insulin to control weight Omission of insulin Glucose continues to circulate in the blood Glucosuria Body forced to obtain energy from fat and muscle stores Rapid weight loss

15 Prevalence rates of insulin omission Prevalence of insulin omission (%) Age range (yr) Number and sex Reference Female Male Female Male Colton et al. 26,2 4, Wisting et al Jones et al Rodin et al Neumark-Sztainer et al Rydall et al Stancin et al Philippi et al.

16 HbA1c fluctuations Insulin omission is characterized by both high HbA1c levels and wide fluctuations from visit to visit. (3) Warning sign - high HbA1c levels. (2)

17 Intentional insulin omission Intentional insulin omission has recently been called as diabulimia. (2) It can be: inappropriate compensatory feature of bulimia nervosa component of other specified eating disorder (when insulin omission occurs without binge eating).(1) Pinhas-Hamiel, World Journal of Diabetes Colton et al, Diabetes Spectrum 2009

18 Eating disorders and T1DM Meta-analysis Anorexia nervosa in T1DM patients was not significantly different from that of controls (0.27 vs 0.06%).(1) Bulimia nervosa in T1DM females has significantly higher prevalence than in not diabetics (1.73 vs 0.69%, p < 0.05).(1) T1DM adolescents are at 2.4 times risk of developing bulimia nervosa compared to healthy ones.(3) Overall prevalence of eating disorders: 7.0% in T1DM, compared with 2.8% in individuals without T1DM.(1) Pinhas-Hamiel, World Journal of Diabetes Eating disorders in adolescents with Type 1 Diabetes

19 Eating disorders: Complications Result in poor metabolic control and cause short and long-term complications and leads to higher hospitalication rates.(3) Short term complications: Insulin omission is associated with recurrent events of DKA, disturbed eating behavior is associated with recurrent episodes of severe hypoglycemia.

20 Eating disorders: Complications 4 year follow-up study Retinopathy: 86% of girls with T1DM + severe ED 24% of girls with T1DM, but without ED (p=0.004)(3) 11 year follow-up study of females with T1DM (mean age - 45 yr; mean diabetes duration - 28 years): Nephropathy: 25% of those with insulin omission 10% of those without insulin omission (p < 0.01) foot problems 25% of those with insulin omission 12% of those without insulin omission (p < 0.05)(9) Eating disorders in adolescents with Type 1 Diabetes

21 Eating disorders: Mortality Mortality rates per 1000 person years 2.2 in girls with T1DM, 7.3 in girls with ED 34.6 in girls with both T1DM and ED. During an 11-year period, self-reported insulin restriction at baseline increased the relative risk of death by 3.2 times in women; Women with ED died younger than those without ED (aged 44 vs 58 years, P < 0.01). (9) Pinhas-Hamiel, World Journal of Diabetes Goebel-Fabbri et al, Diabetes Care 2008

22 Adolescents: care issues Education Glycemic targets Insulin therapy Glucose monitoring Nutrition Hypoglycemia DKA Alkohol, Smoking, Drugs Sexual Health Driving Psychology Comorbidities Complications Transition to Adult care

23 Education: identifying the components of care that are unique to adolescents Psychoeducational interventions: modest effect on psychological outcomes, but no effect on HbA1c Developing trusting relationship Clarify priorities and set achievable targets Having an index of suspicion of mental health problems (the HEADS technique) Encouraging the adolescent to participate in making decisions about diabetes management Offering a variety of educational opportunities (CD/videos, apps, games, text messages, peer involvement, group learning ) Helping parents in their changing role from full responsibility toward a gradual transition to cooperative care

24 Parental involvement

25 Education: identifying the components of care that are unique to adolescents Healthcare providers should regularly initiate discussions with adolescents and their families about School Diabetes camp Psychological issues Substance use Contraception Career choices Driving

26 HbA1c and motor vehicles crash Motor vehicles accident - one of the leading causes of deaths among teenagers in USA - 1 of 3 deaths. HbA1c <= 6.9 associated with 3X higher risk of accident compared to HbA1c >= 9.0

27 HOW TO MINIMIZE RISK OF HYPOGLYCEMIA WHILE IMPROVING GLYCEMIC CONTROL? Address hypoglycemia at each visit Education Frequent BG monitoring, CGMS Physiologic flexible insulin regimens, CSII Exercise strategy Bedtime strategy, check overnight BG awareness training (BGAT) Counsel about effects of alcohol New Insulin analogs Individualize glycemic targets Ongoing professional support

28 An ultra-long glucose-lowering effect of beyond 40 hours Type 1 diabetes (n=66) Nocturnal hypoglycaemia 25% Figure shows mean and individual blood glucose profiles following once-daily s.c. dosing of IDeg (0.6 U/kg) for 8 days Kurtzhals P et al., Diabetes 2011

29 GIR (mg/kg/min) IAsp serum conc. (pmol/l) FA LAP kick-off PL&CZ Faster aspart via s.c. injection (PK/PD) Compared with insulin aspart, faster aspart has: Faster aspart Insulin aspart Twice as fast onset of appearance in the bloodstream Two-fold higher insulin exposure within the first 30 min Time (min) 6 >50% greater insulin action within the first 30 min 4 2 GIR, glucose infusion rate; IAsp, insulin aspart; SC, subcutaneous Heise T et al. Diabetes 2016;65(S1):A Time (min)

30 PPG increment (mmol/l) PPG increment (mg/dl) onset 1: PPG increment at Week 26 Meal test. Faster aspart (mealtime) vs insulin aspart (mealtime) 7 1h ETD: mmol/l [95%CI: -1.65; -0.71] Week 26 2h ETD: mmol/l [95%CI: -1.29; -0.04] 126 Faster aspart (mealtime) Insulin aspart (mealtime) * * Bolus dose 0.1 U/kg Time (min) 0 *Statistically significant Error bars: ± standard error (mean). The conversion factor between mmol/l and mg/dl is PPG, postprandial plasma glucose; ETD, estimated treatment difference [Faster aspart (mealtime) insulin aspart (mealtime)] for PPG changes from baseline. Russell-Jones D et al. Diabetes 2016;65(S1):A77

31 HbA1c: pumps vs. MDI Doyle (Boland) E. A randomized, prospective trial comparing the efficacy of continuous subcutaneous insulin infusion with multiple daily injections using insulin glargine. Diabetes Care. 2004;27:

32 Hypoglycemia: pumps vs. MDI Rudolph JW, Hirsch IB. Assessment of Therapy with Continuous Subcutaneous Insulin Infusion in an Academic Diabetes Clinic. Endocr Pract. 2002;8:401-5.

33 Small kids Teenagers with down fenomenon Recurrent severe hypoglycemia Brittle diabetes Large glycemic variability Micro-, macrovascular complications Pregnancy Diabetes Care 2007; 30(6)

34 Sensor augmented insulin pump therapy

35 Mean HbA1c by CGM use P<0.001 P<0.001 P<0.001

36 Artificial Pancreas or Closed Loop system Continuous glucose monitoring Insulin pump Control algorithm

37 Alcohol Adopting realistic advisory approach Information on the effects of alcohol Inhibiting gluconeogenesis risk of late hypoglycemia Hypoglycemia may be confused with intoxication inform friends Eat carbs Maintain good hydration Check blood glucose before bed ISPAD Clinical Practice Consensus Guidelines 2014 Compendium

38 Smoking Inform on increased risk of cardiovascular complications Help to quit (nicotin-patches, cognitive-behavioral therapies, drugs, ) Recognize that cannabis may alter eating habits (increased apetite during and decreased after smoking) May reduce motivation to maintain good metabolic control.

39 Illicit drugs May alter brain function Increase the rsik of mistakes and mishaps with diabetes management

40 Australian study: interview of 504 adolescents with type 1 diabetes 77% tried drugs at least once 2/3 used several types Consumers were of similar age as non-consumers Drug users had higher HbA1c vs. non-users P.Lee Managing young people with type 1 diabetes in a rave new world.2012

41 Sexual Health Non-jugemental approach to sexual activity Advice methods of avoiding pregnancy and sexually transmitted infections (STIs) Prevention of hypoglycemia during or after intercourse Advice on genital hygiene, vulvovaginal candidiasis and STIs Pre-pregnancy counceling

42 Contraception Barrier methods (condoms, diaphragms not recommended, coitus interruptus high pregnancy rate) Oral contraceptives (OCs) <35 mcg of EE not associated with cardiovascular risk, metabolic disturbances, weight gain or dyslipidemia If diabetes duration <20 yrs and no micro-/macrocomplications - any hormonal contraception may be used If diabetes duration > 20 yrs or having micro-/macrocomplications avoid Ocs, may use progestins only (magers due to pills omission) Morning after hormone pill Depot hormone injections no studies in T1D. Medroxiprogesterone decreased bone mass gain Long acting reversible contraception (IUD and implantable rod) acceptable, but no protection against STIs

43 Transition Transition is a process not an event

44 Transition to adulthood 5 milestones Completing school Leaving home Becoming financially independent Getting married Having a child And on the top manage your disease

45 Transition to adult care Danger that young people become lost in transition process and cease regular attendance to specialized services Transition should be an organized process of preparation and adaptation Pediatric team is responsible for full diabetes control screening visit before transition Provide a joint clinic with members of both pediatric and adult team Good communication, written patient care pathway and protocol, common database

46 Current methods of transfer of young people with Type 1 diabetes to adult services 229 subjects with T1D Mean age at transfer was 17.9 years (range years) High rate of clinic attendance (at least 6 monthly) 2 years pretransfer (94%), but this declined to 57% 2 years post-transfer (P < ). higher rates in clinic attendance 2 years post-transfer were seen in districts where young people had the opportunity to meet the adult diabetes consultant prior to transfer (71 vs. 29%).. Kipps et al, Diabet Med. 2002

47 Recommendations Train staff to work with young people and transition issues. Good relationship with general practitioners Children and adult services need to communicate and work together effectively. Multi-disciplinary teams to provide coordinated care A qualified psichological care is essencial in all stages of transition period Rosen et al. 2003; Department of Health 2004, 2007a; Shaw et al. 2004; Department of Health & Department for education and skills 2006; Department of Health & Department for children schools and families 2007, 2008b; Royal Australasian College of Physicians 2007; Collis et al. 2008; All Party Parliamentary Group on Autism & Allard 2009

48 Where to start from Not teach and tell Doctor tells the patient what he/she needs to know and do Doctors usually Diagnose the disease Determine the treatment Measure the outcomes But collaborate and empower Doctor and patient have a role making a decision Doctors should Description (understand the disease) Prediction Choic

49 Communicate to Negotiate Ask Listen Summarize Invite When a patient feels that you listen to him adequately, he will be more open to your suggestions

50 Motivational communication Nonjudgmental curiosity Expressing empathy (ask, listen, summarize, invite) Avoid arguing

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52 Thank you!