2008 Clinical Practice Guidelines - Canadian Diabetes Association

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<strong>2008</strong> CLINICAL PRACTICE GUIDELINES S154 COMORBID CONDITIONS Autoimmune thyroid disease <strong>Clinical</strong> autoimmune thyroid disease (AITD) occurs in 15 to 30% of individuals with type 1 diabetes (72). The risk for AITD during the first decade of diabetes is directly related to the presence or absence of thyroid antibodies at diabetes diagnosis (73). Early detection and treatment of hypothyroidism will prevent growth failure and symptoms of hypothyroidism (Table 3). Addison disease Addison disease is rare, even in those with type 1 diabetes (74). Targeted screening is required in those with unexplained recurrent hypoglycemia and decreasing insulin requirements (Table 3). Celiac disease Celiac disease can be identified in 4 to 9% of children with type 1 diabetes (72), but in 60 to 70% of these children the disease is asymptomatic (silent celiac disease). Children with type 1 diabetes are at increased risk for classic or atypical celiac disease during the first 10 years of diabetes (75). There is good evidence that treatment of classic or atypical Table 3. Recommendations for screening for comorbid conditions in children with type 1 diabetes Condition Indications for screening Autoimmune thyroid disease Addison disease Celiac disease All children with type 1 diabetes Positive thyroid antibodies, thyroid symptoms or goiter Unexplained recurrent hypoglycemia and decreasing insulin requirements Recurrent gastrointestinal symptoms, poor linear growth, poor weight gain, fatigue, anemia, unexplained frequent hypoglycemia or poor metabolic control TSH = thyroid-stimulating hormone Screening test Serum TSH level + thyroperoxidase antibodies Serum TSH level + thyroperoxidase antibodies 8 AM serum cortisol + serum sodium and potassium Tissue transglutaminase + immunoglobulin A levels Frequency At diagnosis and every 2 years thereafter Every 6–12 months As clinically indicated As clinically indicated celiac disease with a gluten-free diet improves intestinal and extra-intestinal symptoms (76) and prevents the long-term sequelae of untreated classic celiac disease (77). However, there is no evidence that untreated asymptomatic celiac disease is associated with short- or long-term health risks (78) or that a gluten-free diet improves health in these individuals (79). Thus, universal screening for and treatment of asymptomatic celiac disease remain controversial (Table 3). DIABETES COMPLICATIONS There are important age-related considerations regarding surveillance for diabetes complications and interpretation of investigations (Table 4). Nephropathy A first morning urine albumin to creatinine ratio (ACR) has high sensitivity and specificity for the detection of microalbuminuria (80,81). Although screening with a random ACR is associated with greater compliance than with a first morning sample, its specificity may be compromised in adolescents due to their higher frequency of exercise-induced proteinuria and benign postural proteinuria. Abnormal random ACRs require confirmation with a first morning ACR or timed urine collection. Microalbuminuria is rare in prepubertal children, regardless of the duration of diabetes or metabolic control (82). Furthermore, the likelihood of transient or intermittent microalbuminuria is higher during the early peripubertal years (83). Individuals with transient or intermittent microalbuminuria may be at increased risk of progression to overt nephropathy (84). Abnormal screening results require confirmation and follow-up to demonstrate persistent abnormalities. Treatment is indicated only for those adolescents with persistent microalbuminuria. One short-term RCT in adolescents demonstrated that angiotensin-converting enzyme (ACE) inhibitors were effective in reducing microalbuminuria compared to placebo (85). However, there are no long-term intervention studies assessing the effectiveness of ACE inhibitors or angiotensin II receptor antagonists in delaying progression to overt nephropathy in adolescents with microalbuminuria. Therefore, treatment of adolescents with persistent microalbuminuria is based on the effectiveness of treatments in adults with type 1 diabetes (86). Retinopathy Retinopathy is rare in prepubertal children with type 1 diabetes and in postpubertal adolescents with good metabolic control (87,88). Neuropathy When present, neuropathy is mostly subclinical in children (89). While prospective nerve conduction studies and autonomic neuropathy assessment studies have demonstrated increased prevalence of abnormalities over time (90), persistence of abnormalities is an inconsistent finding (91).
Vibration and monofilament testing have suboptimal sensitivity and specificity in adolescents (92).With the exception of intensifying diabetes management to achieve and maintain glycemic targets, no other treatment modality has been studied in children and adolescents. Dyslipidemia Most children with type 1 diabetes should be considered at low risk for vascular disease associated with dyslipidemia. The exceptions are those with longer duration of disease, microvascular complications or other cardiovascular disease (CVD) risk factors including smoking, hypertension, obesity and/or family history of premature CVD (93). Dyslipidemia screening should be targeted at those >12 years of age and younger children with specific risk factors for dyslipidemia. Statin therapy has not been studied specifically in children with diabetes, and there is no evidence linking specific lowdensity lipoprotein cholesterol (LDL-C) cutoffs in children with diabetes with long-term outcomes. In pubertal children without diabetes but with familial hypercholesterolemia, statin therapy is safe and effective at lowering LDL-C levels, and attenuating progression of carotid intima-media thickness, a surrogate marker for future vascular disease (94). Hypertension Up to 16% of adolescents with type 1 diabetes have hypertension (95). Twenty-four-hour ambulatory blood pressure (BP) monitoring has been used to exclude white coat hypertension and to identify loss of diurnal systolic rhythm (nondippers) with nocturnal hypertension in some normotensive adolescents with type 1 diabetes (96). These abnormalities may be predictive of future microalbuminuria (96). However, the role of ambulatory BP monitoring in routine care remains uncertain. Children with type 1 diabetes and confirmed hypertension should be treated according to the guidelines for children without diabetes (97). TRANSITION TO ADULT CARE The change of physician or DHC team can have a major impact on disease management and metabolic control in the person with diabetes. Between 25 and 65% of young adults have no medical follow-up during the transition from pediatric to adult diabetes care services (98,99). Those with no follow-up are more likely to experience hospitalization for DKA during this period. Organized transition services may decrease the rate of loss of follow-up (100). Table 4. Screening for diabetes complications, dyslipidemia and hyperglycemia in children with type 1 diabetes Complication Indications and intervals for screening Screening method Nephropathy • Yearly screening commencing at 12 years of age in those with duration of type 1 diabetes >5 years Retinopathy • Yearly screening commencing at 15 years of age with duration of type 1 diabetes >5 years • Screening interval can increase to 2 years if good glycemic control, duration of diabetes
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2008 Clinical Practice Guidelines - Canadian Diabetes Association

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