Progressnotes - October/November 2012
- About MUSC Health
The Division of Pediatric Endocrinology and Diabetes at MUSC Children’s Hospital is dedicated to improving care for today’s pediatric patients with diabetes through innovative programs such as its new diabetes transition program, while participating actively in a number of national clinical trials that will inform the future care of these patients.
The Division recently opened a diabetes transition program, which is meant to help patients with diabetes make the too often difficult transition from pediatric to adult care. When they reach the age of 18, patients who have long been treated by a pediatrician for their diabetes suddenly must find an adult provider. Some patients, covered by insurance as children, lose coverage as adults. Many patients find it difficult to navigate the health care system during this tenuous time and can be lost to care, meaning that their diabetes is left unregulated and their risk of complications is higher.
The decision to create such a transition program was based on the findings of a study tracking patients with established diabetes who were admitted to MUSC in 2011 for diabetic ketoacidosis (DKA), a potentially life-threatening condition. In 2011, 33 patients with established diabetes presented 53 times with DKA. The study found that adolescent girls with long-standing type 1 diabetes, poor glycemic control, and infrequent diabetes outpatient visits and a history of mental issues (ie, depression, attention deficit disorder, bipolar disorder) were the most likely to present with DKA. It is just this type of patient that the diabetes transition program is intended to help.
The diabetes transition program includes the services of Katherine A. Lewis, M.D., MSCR, a physician trained in both pediatric and adult endocrinology. She can ease the transition from pediatric to adult care, ensuring that these young adults are not lost from the system.
The Division of Pediatric Endocrinology and Diabetes serves as a site for a number of national clinical trials seeking to better understand the recent increase in the incidence of pediatric diabetes and to find ways to better screen and monitor at-risk pediatric populations as a first step toward prevention.
The Division of Pediatric Endocrinology and Diabetes serves as a site for the Natural History Study of the Development of Type 1 Diabetes (TrialNet), which is screening close family members of patients with type 1 diabetes to assess their risk. Close blood relatives of patients with type 1 diabetes are thought to be 10 to 15 times more likely to develop diabetes than the general population. Patients who eventually develop type 1 diabetes have autoantibodies in their blood that can be detected years in advance of the actual onset of disease. If one of these antibodies is detected in study participants during screening, they will be asked to join the monitoring portion of the study. Those with one autoantibody and test results showing a low risk of developing disease within five years will be monitored annually, and those with more than one antibody or other test results suggesting an earlier onset will be monitored semi-annually. Such close monitoring means that diabetes can be diagnosed early, staving off some of the serious acute complications at the time of diagnosis. In the opinion of Deborah Bowlby, M.D., the Chief of the Division of Pediatric Endocrinology and Diabetes, “one of the ultimate goals of diabetes research is trying to figure out a way to prevent diabetes, and this study is a wonderful first step to a prevention trial.”
The Division of Pediatric Endocrinology and Diabetes is also fortunate to be a site for the SEARCH for Diabetes in Youth study, a national multicenter study that was initiated in response to the rising incidence of diabetes among children and adolescents in the United States. Likely as a result of the obesity epidemic and the low level of activity among the nation’s youth, diabetes, particularly type 2 diabetes, is on the rise among children and adolescents. Clinicians who are accustomed to treating type 2 diabetes in adults aged 40 and older can find it challenging to tailor their treatment approach to children and adolescents. SEARCH for Diabetes in Youth seeks to increase our understanding of the scope of the problem by studying diabetes (eg, type 1, type 2, cystic fibrosis–related) in children and young adults in five states—South Carolina, Ohio, Colorado, California, and Washington. Some especially hard-hit states such as South Carolina have a number of SEARCH sites. MUSC Children’s Hospital is the SEARCH site for the Lowcountry.
One finding of the SEARCH study to date is that complications of type 2 diabetes with childhood onset are far more aggressive than type 2 diabetes that develops later. Clinicians are beginning to see adolescents with severe kidney disease and hypertension, something that would have been unheard of a couple of decades ago. SEARCH is already showing that clinicians need to be vigilant in watching for possible diabetic complications in pediatric patients, some of whom may have undiagnosed diabetes. For example, Dr. Bowlby worries that some hypertension in youth with type 2 diabetes may not be recognized and thus is undertreated. Remberto C. Paulo, Jr, M.D., Assistant Professor in the Division of Pediatric Endocrinology and Diabetes, is currently studying this hypothesis. If diabetes can be caught early, proper treatment regimens can be instituted that can prevent further worsening of chronic complications.