Options for managing type 2 diabetes in children

Liraglutide (Victoza) is the first new non-insulin medication approved to treat type 2 diabetes in children in almost 20 years. Children often don't get enough from metformin (Glucophage) alone since they have less insulin secretion and more insulin resistance at diagnosis. Plus kids may not stick with insulin because of weight gain. Victoza and other GLP-1 agonists can be "insulin sparing" and promote weight loss in adults with diabetes. But it's too soon to say if this is the case with Victoza in kids with type 2 diabetes. 

          Emphasize lifestyle changes. For example, suggest the 5-2-1-0 approach, 5 or more fruits and veggies, 2 hours max screen time, 1 hour or more of physical activity, 0 sugary drinks, and more water every day. Stick with metformin first for most kids with type 2 diabetes. It's weight neutral, low-cost, and has a long safety and efficacy track record. Then weigh pros and cons (advantages and disadvantages) of adding injectable Victoza or insulin.

In kids 10 and older, using Victoza for about 6 months only lowers A1C by about 0.6% when added to metformin with or without insulin. Suggest Victoza for kids close to A1C goal who want to minimize weight gain from insulin. But point out Victoza is very expensive. Recommend starting with 0.6 mg/day and titrating up to 1.8 mg/day to limit nausea and vomiting. Or consider adding insulin, especially if A1C isn't close to goal. Some kids can start with one daily dose of insulin (glargine, NPH, etc).

Explain there's not much evidence for other diabetes medications in kids. In general, aim for an A1C below 7% in kids, but individualize the goal, since evidence for this target is limited. See additional topics Management of diabetes mellitus in primary care AND Pharmacotherapy of Type 2 Diabetes.

REFERENCES

• Tamborlane, and others (2019). Liraglutide in Children and Adolescents with Type 2 Diabetes. New England Journal of Medicine, 381(7), pp.637–646. Available at: https://www.nejm.org/doi/full/10.1056/NEJMoa1903822

  Zeitler, P., and others (2018). ISPAD Clinical Practice Consensus Guidelines 2018: Type 2 diabetes mellitus in youth. Pediatric Diabetes, 19, pp.28–46. Available at: https://pubmed.ncbi.nlm.nih.gov/29999228

  Arslanian, S., Bacha, F., Grey, M., Marcus, M.D., White, N.H. and Zeitler, P. (2018). Evaluation and Management of Youth-Onset Type 2 Diabetes: A Position Statement by the American Diabetes Association. Diabetes Care, 41(12), pp.2648–2668. Available at: https://care.diabetesjournals.org/content/41/12/2648