Sarah K. Lyons

Transfer from pediatric to adult health care: effects on diabetes outcomes

The transfer from pediatric to adult diabetes health care for emerging adults with type 1 diabetes (T1D) has received increasing attention in the literature. This review analyzes the effect of this health care transfer on the outcomes of diabetes care visit attendance, glycemic control, and acute diabetes‐related complications, and assesses the methodological strength of the studies reporting observational and interventional data. Observational studies, often limited by incomplete data, report a decline in diabetes care visits but an improvement or no change in hemoglobin A1c (HbA1c) after transfer to adult care. Results from studies reporting a transition intervention are restricted by lack of appropriate control groups and the collection of data both before and after transfer of care. Very few methodologically strong studies are available to guide clinicians with the transition from pediatric to adult care, and these shortcomings should be addressed in future studies designed to facilitate and improve the care of emerging adults with T1D.

Use of Adjuvant Pharmacotherapy in Type 1 Diabetes: International Comparison of 49,996 Individuals in the Prospective Diabetes Follow-up and T1D Exchange Registries

The majority of those with type 1 diabetes (T1D) have suboptimal glycemic control (1–4); therefore, use of adjunctive pharmacotherapy to improve control has been of clinical interest. While noninsulin medications approved for type 2 diabetes have been reported in T1D research and clinical practice (5), little is known about their frequency of use. The T1D Exchange (T1DX) registry in the U.S. and the Prospective Diabetes Follow-up (DPV) registry in Germany and Austria are two large consortia of diabetes centers; thus, they provide a rich data set to address this question. For the analysis, 49,996 pediatric and adult patients with diabetes duration ≥1 year and a registry update from 1 April 2015 to 1 July 2016 were included (19,298 individuals from 73 T1DX sites and 30,698 individuals from 354 DPV sites). Adjuvant medication use (metformin, glucagon-like peptide 1 [GLP-1] receptor agonists, dipeptidyl peptidase 4 [DPP-4] inhibitors, sodium–glucose cotransporter 2 [SGLT2] inhibitors, and other noninsulin diabetes medications including pramlintide) was extracted from …

Health Care Transition Preparation and Experiences in a U.S. National Sample of Young Adults With Type 1 Diabetes

OBJECTIVE Young adults with type 1 diabetes transitioning from pediatric to adult care are at risk for adverse outcomes. We developed a survey to evaluate transition experiences in two groups of young adults with type 1 diabetes, before (PEDS) and after (ADULT) transition to adult care. RESEARCH DESIGN AND METHODS We fielded an electronic survey to young adults (18 to <30 years) at 60 T1D Exchange Clinic Registry centers. RESULTS Surveys were completed by 602 young adults, 303 in the PEDS group (60% female, age 20 ± 2 years) and 299 in the ADULT group (62% female, age 24 ± 3 years). In the PEDS group, mean anticipated transition age was 22 ± 2 years; 64% remained in pediatric care because of emotional attachment to the provider. The ADULT group transitioned at age 19 ± 2 years, mainly after pediatric provider recommendation. More than 80% of respondents reported receiving counseling on type 1 diabetes self-management and screening tests from pediatric providers, but less than half (43% PEDS and 33% ADULT) reported discussing reproductive health. In the PEDS group, half had discussed transfer with pediatric providers. Of the ADULT participants, 63% received an adult provider referral, and 66% felt mostly/completely prepared to transition. ADULT participants with fewer pretransition pediatric visits or who felt unprepared for transition had increased odds of gaps >6 months between pediatric and adult care. Receipt of transition preparation counseling was not associated with self-reported hemoglobin A1c <7.0% in either group. CONCLUSIONS These results support the need for intensive efforts to integrate transition preparation counseling and care coordination into pediatric type 1 diabetes care.

Diabetes Device Use and Glycemic Control among Youth with Type 1 Diabetes: A Single-Center, Cross-Sectional Study

Aim The purpose of this cross-sectional study was to determine the rates of diabetes device use (insulin pump and continuous glucose monitor (CGM)) and association with glycemic control in youth with type 1 diabetes in a large, diverse pediatric center. Methods Demographic and clinical data were obtained from 1992 patients who met the eligibility criteria (age < 26 years, diabetes duration ≥ 1 year, and ≥1 clinic visit in the preceding 12 months). Statistical analyses assessed the likelihood of device use based on demographic characteristics and the association between device use and glycemic control based on most recent hemoglobin A1c (HbA1c). Results Mean age was 13.8 ± 4.2 years, 50.7% were female, diabetes duration was 6.2 ± 4 years, and mean HbA1c was 8.7 ± 1.8%. Overall, 38.2% of patients were on pump therapy and 18.5% were on CGM. Patients who were non-Hispanic (NH) white, privately insured, and with primary English-speaking parent(s) had higher rates of insulin pump use, as well as CGM use (P < 0.001 for both). Female patients had higher rates of pump use only (P < 0.01). Private health insurance, NH white race/ethnicity, and CGM use were each associated with lower HbA1c (P = 0.03, <0.001, and <0.008, resp.). Conclusion At a large, diverse, pediatric diabetes center, disparities in diabetes device use were present across sex, race/ethnicity, health insurance coverage, and primary language of parent(s). CGM use was associated with lower HbA1c. Quality improvement efforts are underway to ensure improved access, education, and clinical programs for advanced diabetes devices for T1D patients.

Dyslipidaemia and statin use in individuals aged 10 to <40 years in the T1D Exchange clinic registry

For individuals aged 10 to <40 years with type 1 diabetes and dyslipidaemia, US national guidelines recommend consideration of statin therapy based on age, low‐density lipoprotein cholesterol (LDL‐C) level and other cardiovascular risk factors. We evaluated dyslipidaemia prevalence, statin therapy use, and associations between not meeting target LDL‐C [<100 mg/dL (<5.55 mmol/L)] and other cardiovascular disease (CVD) risk factors in individuals aged 10 to <40 years in the T1D Exchange clinic registry. In 7223 participants, statin use was 2% in 10 to <18 year olds, 4% in 18 to <25 year olds, and 21% in 25 to <40 year olds. Individuals not on statin therapy with LDL‐C above target were more likely to have ≥1 additional CVD risk factor(s) than those with LDL‐C in the target range for all age groups (all P < 0.01). While most individuals not on statin therapy had LDL‐C in the target range, those who did not were more likely to have ≥1 additional CVD risk factor(s), and therefore longitudinal study of lipid levels and statin use is needed to see if treatment of dyslipidaemia to target LDL‐C levels may lower the risk of future CVD in individuals aged 10 to <40 years with type 1 diabetes.

Adjuvant Pharmacotherapies to Insulin for the Treatment of Type 1 Diabetes

Purpose of ReviewInsulin therapy alone fails to achieve target glycemic control in the majority of individuals with type 1 diabetes (T1D), motivating the investigation of additive medications. This review focuses on the recent findings on the use of adjunctive pharmacotherapy in T1D.Recent FindingsMetformin and glucagon-like peptide-1 receptor agonists have been associated with weight reduction and decrease in daily insulin requirements without sustainable improvement in glycemic control. Sodium-glucose cotransporter (SGLT)-2 inhibitors, dual SGLT-1/2 inhibitors, and pramlintide have been shown to reduce hemoglobin A1c, induce weight loss, and lower insulin dose. The benefits of dipeptidyl peptidase-4 inhibitors, thiazolidinediones, and alpha glucosidase inhibitors appear to be more limited. Gastrointestinal symptoms and increased hypoglycemia are adverse effects of certain classes.SummaryAlthough not devoid of side effects, additive pharmacotherapies in T1D can improve glycemic control and lower body weight and insulin requirement. Longer studies are needed before consideration for widespread clinical care.