Treating younger patients
As in adults, the first line of treatment in younger patients is a proper diet and regular exercise. But less than 10% of children and adolescents with the disease will achieve effective glycemic control with these measures alone. Pharmacologic agents are often needed.3 Knowledge of efficacy and long-term effects of pharmacologic agents in patients who are younger than 20 years is minimal. Insulin and metformin are the only two drugs currently approved by the FDA for use in children.8 About half of children and adolescents with diabetes are treated with insulin; the other half are treated with oral agents, mostly metformin.4 The ADA recommends metformin monotherapy as a first-choice oral regimen.2 If monotherapy is inadequate, an oral sulfonylurea or insulin may be added.2 Other classes of oral agents can be combined with metformin but are used less frequently in children2 (see Table 2). When ketoacidosis is present or the type of diabetes is in question, the ADA recommends treatment with insulin instead of oral agents.
The ADA recommendations for disease management and evaluation of treatment effectiveness among these annual ophthalmologic examination, annual urinalysis for microalbuminuria, regular BP measurements, and lipid profiles every 2 years once glycemic control is achieved.2,3 Other recommendations are glucose monitoring once or twice daily, especially after any adjustments in treatment regimen, and hemoglobin A1C measurements every 3 months with periodic foot examinations.8 
Conclusion
The multifaceted approach to management of type 2 diabetes in children and adolescents is similar to that used in adults with the disease. First, patients and their families must acknowledge that lifestyle modifications such as eating a balanced diet, maintaining a healthy weight, and exercising regularly are essential. Health care providers should encourage all patients to adhere to these principles, but this is especially important for those patients at higher risk for developing this disease. Screening those children who are at increased risk for developing type 2 diabetes can lead to earlier recognition of its onset and intervention, which can slow down or even halt progression to a clinical diagnosis. Type 2 diabetes in the pediatric population is a growing problem. The subtle differences in risk factors, screening and diagnosis protocols, and management of younger patients with this disease present a challenge for clinicians. As further studies provide a better understanding of the effects of type 2 diabetes and its longterm treatment in pediatric patients, it is important for PAs to keep up to date with the evolving protocols for diagnosis and treatment. JAAPA
Karla Von is a PA in a family practice in Columbia, South Carolina. Mary Hewett is Assistant Professor at the Medical University of South Carolina in Charleston.
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