Management of type 2 diabetes in children and adolescents

T2DM: type 2 diabetes mellitus; DKA: diabetic ketoacidosis; HHS: hyperosmolar hyperglycemic state; BG: blood glucose; A1C: hemoglobin A1c; GLP-1 agonist: glucagon-like peptide 1 agonist (eg, exenatide or liraglutide); BMI: body mass index; IAA: insulin autoantibodies; ICA: islet cell antibodies; GAD: glutamic acid decarboxylase antibodies; IA2: insulinoma-associated protein 2 antibodies; ZnT8: zinc transporter 8 antibodies.
* T2DM is typically characterized by overweight or obesity (BMI ≥85^th percentile), a strong family history of T2DM, normal or elevated insulin and C-peptide concentrations, gradual onset of disease, evidence of insulin resistance (eg, acanthosis nigricans), and no evidence of diabetic autoimmunity (negative tests for islet autoantibodies such as IAA, ICA, GAD, IA2, and ZnT8). If all or most of these characteristics are present, the patient probably has T2DM. Some patients have mixed features and will be difficult to classify. Refer to UpToDate topic review on presentation and diagnosis of T2DM in children.
¶ In patients beginning insulin therapy, metformin should only be started after ketosis is cleared and BG is improved. In those patients with A1C >13% prior to insulin therapy, we suggest beginning metformin only after A1C has improved and BG has returned to a normal or near-normal concentration with insulin therapy. Insulin therapy generally consists of basal insulin, with the addition of rapid acting insulin when ketosis is present or hyperglycemia persists.
Δ Lifestyle changes include dietary counseling as outlined by the Academy of Nutrition and Dietetics, physical activity (moderate to vigorous for at least 1 hour daily), and restricting nonacademic "screen time" to less than 2 hours daily.
◊ Intensification of treatment consists of optimizing nonpharmacologic therapy and intensification of pharmacotherapy if needed.