Developing New Care Models for Pediatric T2D

Developing New Care Models for Pediatric T2D
Clinic explores strategies to diagnose sooner, improve care continuity.

Over half of pediatric patients diagnosed with type 2 diabetes (T2D) are lost to follow-up within 16 months, according to research by Ashley Shoemaker, M.D., pediatric endocrinologist at Vanderbilt University Medical Center, and her colleagues at the Pediatric Diabetes Consortium.

The drop off is particularly concerning due to how T2D progresses in younger patients. “Type 2 diabetes is much more aggressive in children and we don’t understand why,” Shoemaker said. “When kids are lost to follow-up, their prognosis worsens.”

A new Pre-Diabetes Clinic at Vanderbilt, directed by Shoemaker, aims to improve outcomes and care continuity through a unique, comprehensive care model. The clinic’s team also includes Vanderbilt assistant professors Cassie Brady, M.D., Tamasyn Nelson, D.O., and Sharon Karp, Ph.D.

A Dedicated Clinic 

The Pre-Diabetes Clinic provides a “home base” for pediatric patients and families to ease compliance, with access to lab tests, endocrinologists, weight management physicians and dietitians all in one place.

“We try to figure out which kids need medical intervention right now.”

What sets the clinic apart is its focus on borderline cases – patients who have potential signs or symptoms of early T2D but don’t meet diagnostic criteria. Their goal is to meet the needs of a young and growing pre-diabetic population early, before patients lose their ability to make insulin. Studies show even a small delay in T2D onset can reduce mortality in the long run.

“We try to figure out which kids need medical intervention right now and which are at high risk but can really focus on lifestyle and weight management,” Shoemaker said. “We get them the medical evaluation that the families and pediatricians often want but also physician-led, lifestyle management that they really need.”

Medication Support

Medical interventions may include metformin or insulin regimens, but both approaches are associated with weight gain, and drug treatment does not delay T2D for as long in children as it does in adults, Shoemaker said.

“Over half the pediatric patients will fail one drug in the first two years or so. This is especially concerning because in adults we usually have more time to work with. The time to disease progression in adults is much longer, typically five years.”

Ongoing research at the Pre-Diabetes Clinic provides an opportunity to support patients who fail first-line therapy. The clinic is currently enrolling eligible young patients in clinical trials testing alternatives– GLP-1 receptor agonists. One trial is investigating the safety and efficacy of exenatide, the other, linagliptin and empagliflozin in combination. While GLP-1 agonists are now commonly used to treat T2D in adults, they have only recently garnered FDA approval in children. The Vanderbilt clinic is the only site in Tennessee where patients can enroll in clinical trials of potential new treatments for pediatric T2D.

“We get them the medical evaluation that the families and pediatricians often want but also physician-led, lifestyle management that they really need.”

More than Medical Management

Medications are only one part of staving off pediatric T2D. The Pre-Diabetes Clinic couples medical management with guided weight loss in nearly all cases. Said Shoemaker, “We’ve had patients we’ve been able to take off medicine after a year because they’ve been able to exercise more or lose weight with help from our onsite clinic team.”

The Vanderbilt team has also begun to leverage four satellite clinics to ensure care access and encourage follow-up. A manuscript covering their clinic-based approach to diagnosis and management of pre-diabetes in high-risk children and adolescents was recently accepted for publication in the Journal of the Endocrine Society, Shoemaker said.

“Type 2 diabetes requires a new clinic model that is specifically designed for adolescents and their families,” she added. “We have to address the unique socioeconomic, cultural and language barriers of this population if we’re going to be successful.”