Treating type 2 diabetes in youth: a depressing picture

There is an increase in type 2 diabetes (T2D) in children, yet little evidence to guide management. The TODAY study aimed to assess the impact of three treatment interventions in this demographic group.1 In this study 927 children were converted from their current medication to metformin monotherapy. This run-in phase proceeded to randomisation if an HbA1c <8% (64 millimoles per mole [mmol/mol]) was achieved with adherence to medication >80% for at least six weeks. The randomisation cohort consisted of 699 children, aged between 10 and 17 years with T2D diagnosed within the past two years and a body mass index (BMI) >85th percentile. The ethnicity split was 41% Hispanic, 31.5% non-Hispanic Black, and 20% non-Hispanic White. The children were randomly assigned to stay on metformin alone, to have rosiglitazone added to their regime, or to continue on metformin and undergo a family based behavioural weight loss programme. This consisted of weekly visits for the first six months, then biweekly for six months, then bimonthly for the remainder of the study. The primary endpoint was either an HbA1c >8% for more than six months, or sustained insulin treatment for more than three months. Treatment failure was observed in 45.6% of children; 50% by 11.5 months after randomisation. Treatment failure was seen less in those with rosiglitazone added (38.6%) compared to those who stayed on metformin alone (51.7%, p=0.006). Intensive lifestyle intervention had an intermediate result (46.6% failure) but this did not differ significantly from those taking metformin alone. The authors conclude that whatever the intervention, progression of diabetes is rapid in this age group and that multiple oral treatments or insulin will be required within a few years for the majority of this group.