What is the initial management for an adolescent with hyperglycemia and a healthy Body Mass Index (BMI)?

Initial Management for an Adolescent with Hyperglycemia and Healthy BMI

For adolescents with hyperglycemia and a healthy BMI, initial management should include metformin therapy if metabolically stable (A1C <8.5% and asymptomatic), or insulin therapy if marked hyperglycemia (≥250 mg/dL, A1C ≥8.5%) with symptoms or ketosis/ketoacidosis is present, along with comprehensive lifestyle interventions. 1

Diagnostic Considerations

• Initial treatment must consider that diabetes type is often uncertain in the first few weeks, as there is overlap in presentation between type 1 and type 2 diabetes, even in patients with healthy BMI 1
• Adolescents with hyperglycemia and healthy BMI may have type 1 diabetes, atypical diabetes, or other forms such as maturity-onset diabetes of the young 1

Initial Pharmacologic Management

For Metabolically Stable Patients:

• If A1C <8.5% and patient is asymptomatic, metformin is the initial pharmacologic treatment of choice (if renal function is normal) 1
• Start pharmacologic therapy at diagnosis, in addition to lifestyle interventions 1

For Symptomatic Patients with Marked Hyperglycemia:

• If blood glucose ≥250 mg/dL or A1C ≥8.5% with symptoms (polyuria, polydipsia, nocturia, weight loss), initiate treatment with long-acting insulin while simultaneously starting metformin 1
• Titrate metformin while continuing insulin therapy 1

For Patients with Ketosis/Ketoacidosis:

• Immediately start subcutaneous or intravenous insulin to rapidly correct hyperglycemia and metabolic derangement 1
• Once acidosis resolves, initiate metformin while continuing subcutaneous insulin therapy 1
• For severe hyperglycemia (≥600 mg/dL), assess for hyperglycemic hyperosmolar state 1

Lifestyle Management

• All youth with diabetes should receive comprehensive diabetes self-management education and support that is culturally appropriate 1
• Encourage at least 60 minutes of moderate to vigorous physical activity daily with muscle and bone strength training at least 3 days/week 1
• Focus nutrition on healthy eating patterns emphasizing nutrient-dense, high-quality foods and decreased consumption of calorie-dense, nutrient-poor foods, particularly sugar-sweetened beverages 1
• A family-centered approach to nutrition and lifestyle modification is essential 1

Glycemic Targets and Monitoring

• Assess glycemic status every 3 months 1
• A reasonable A1C target for most adolescents with diabetes treated with oral agents alone is <7% 1
• More stringent A1C targets (<6.5%) may be appropriate for selected patients with short duration of diabetes, lesser degrees of β-cell dysfunction, or those treated with lifestyle or metformin only who achieve significant weight improvement 1
• Less stringent A1C goals (7.5%) may be appropriate if there is increased risk of hypoglycemia 1
• Individualize home blood glucose monitoring regimens based on pharmacologic treatment 1

Follow-up Management

• If glycemic targets are not met with metformin alone, consider adding GLP-1 receptor agonist therapy in children 10 years or older (if no family history of medullary thyroid carcinoma or multiple endocrine neoplasia type 2) 1
• For patients initially treated with insulin and metformin who meet glucose targets, insulin can be tapered over 2-6 weeks by decreasing the dose by 10-30% every few days 1
• If patients on basal insulin do not meet glycemic targets, transition to multiple daily injections with basal and premeal bolus insulins 1

Multidisciplinary Approach

• Involve an interprofessional diabetes team including a physician, diabetes care and education specialist, registered dietitian nutritionist, and behavioral health specialist or social worker 1
• Address comorbidities and psychosocial factors that may affect diabetes management 1

Pitfalls and Caveats

• Avoid assuming type 2 diabetes based solely on weight status, as adolescents with healthy BMI often have type 1 diabetes or other forms of diabetes 1
• Do not delay insulin therapy in symptomatic patients with marked hyperglycemia or ketosis while awaiting definitive diabetes classification 1
• Use of medications not approved by the FDA for youth with diabetes is not recommended outside of research trials 1
• Be aware that the evidence for obesity prevention and management interventions is primarily from high-income countries, with limited data from low and middle-income regions 2