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Treatments and drugs

By Mayo Clinic staff

Treatment for type 2 diabetes is a lifelong commitment of blood sugar monitoring, healthy eating, regular exercise and, sometimes, insulin or other medications — even for kids. And as your child grows and changes, so will his or her diabetes treatment plan.

If managing your child's diabetes seems overwhelming, take it one day at a time. And remember that you're not in it alone. You'll work closely with your child's diabetes treatment team — doctor, diabetes educator and registered dietitian — to keep your child's blood sugar level as close to normal as possible.

Blood sugar monitoring
Depending on what type of insulin therapy your child needs, you may need to check and record your child's blood sugar at least three times a day, but probably more. This usually requires frequent finger sticks, though some blood glucose meters allow for testing at other sites.

Frequent testing is the only way to make sure that your child's blood sugar level remains within his or her target range — which may change as your child grows and changes. Your child's doctor will let you know what your child's blood sugar target range is. The doctor may ask you to keep a log of your child's blood glucose readings, or he or she may download that information from your blood glucose meter.

Even if your child eats on a rigid schedule, the amount of sugar in his or her blood can change unpredictably. With help from your child's diabetes treatment team, you'll learn how your child's blood sugar level changes in response to:

  • Food. What and how much your child eats will affect your child's blood sugar level.
  • Physical activity. Physical activity moves sugar from your child's blood into his or her cells. The more active your child is, the lower his or her blood sugar level.
  • Medication. Any medications your child takes may affect his or her blood sugar level, sometimes requiring changes in your child's diabetes treatment plan.
  • Illness. During a cold or other illness, your child's body will produce hormones that raise his or her blood sugar level.

Healthy eating
Contrary to popular perception, there's no diabetes diet. Your child won't be restricted to a lifetime of boring, bland foods. Instead, your child will need plenty of fruits, vegetables and whole grains — foods that are high in nutrition and low in fat and calories — and fewer animal products and sweets. In fact, it's the best eating plan for the entire family. Even sugary foods are OK once in a while, as long as they're included in your child's meal plan.

Yet understanding what and how much to feed your child can be a challenge. A registered dietitian can help you create a meal plan that fits your child's health goals, food preferences and lifestyle. If your child is overweight or obese, gradual weight reduction will be a goal.

Physical activity
Everyone needs regular aerobic exercise, and children who have type 2 diabetes are no exception. Encourage your child to get regular physical activity. Sign up for a sports team or dance lessons. Better yet, get in the act together. Play catch in the backyard. Take a walk or run through your neighborhood. Visit an indoor climbing wall or local pool. Make physical activity part of your child's daily routine.

Remember that physical activity lowers blood sugar. If your child needs insulin treatment, check your child's blood sugar level before any activity. He or she might need a snack before exercising to help prevent low blood sugar.

Medication and insulin
Some children who have type 2 diabetes can control their blood sugar with diet and exercise alone, but many also need oral medication or insulin treatment.

Metformin is the only oral medication that's approved for children (age 10 and older) who have type 2 diabetes. Metformin reduces the amount of sugar a child's liver releases into the bloodstream between meals. Side effects may include nausea, upset stomach, diarrhea and, rarely, a harmful buildup of lactic acid (lactic acidosis). Metformin isn't safe for anyone who has liver failure, kidney failure or heart failure.

Because stomach enzymes interfere with insulin taken by mouth, oral insulin isn't an option for lowering blood sugar. Therefore, insulin has to be delivered under the skin. Insulin delivery options include:

  • Injections. Usually, insulin delivery means injections using a fine needle and syringe or an insulin pen — a device that looks like an ink pen, except the cartridge is filled with insulin.
  • Insulin pump. An insulin pump also may be an option for some children. The pump is a device about the size of a cell phone worn on the outside of the body. A tube connects the reservoir of insulin to a catheter that's inserted under the skin of the abdomen. A wireless pump that uses small pods filled with insulin is another option that's now available. The pump is programmed to dispense specific amounts of insulin automatically. It can be adjusted to deliver more or less insulin depending on meals, activity level and blood sugar level.

Many types of insulin are available, including rapid-acting insulin, long-acting insulin and intermediate options. Examples include regular insulin (Humulin R, Novolin R, others), NPH insulin (Humulin N, Novolin N), insulin lispro (Humalog), insulin aspart (NovoLog) and insulin glargine (Lantus). Depending on your child's needs, the doctor may prescribe a mixture of insulin types to use throughout the day and night.

The decision about which treatment is best depends on the child, his or her blood sugar level, and the presence of any other health problems. Initially, children whose blood sugar is above 200 or who have an A1C above 8.5 percent will likely be started on insulin therapy to stabilize the blood sugar. Once blood sugar levels are normalized, your child may be weaned off insulin and placed on metformin alone.

However, if blood sugar isn't well-controlled on metformin and lifestyle changes, insulin will have to be given again. A long-acting insulin, such as insulin glargine, is often used for type 2 diabetes in children.

Signs of trouble
Short-term complications of type 2 diabetes require immediate care, including:

  • Low blood sugar (hypoglycemia). If your child's blood sugar level drops below his or her target range, it's known as low blood sugar. Your child's blood sugar level can drop for many reasons, including skipping a meal, getting more physical activity than normal or injecting too much insulin. Watch for early signs and symptoms of low blood sugar, including sweating, shakiness, drowsiness, hunger, dizziness and nausea. Later signs and symptoms include behavior changes, confusion, and passing out.

    If your child has signs or symptoms of low blood sugar, give him or her fruit juice, glucose tablets, hard candy, regular (not diet) soda or another source of sugar, and then recheck the blood sugar levels in 15 minutes. If the blood sugar reading is still low, give your child another fast-acting source of sugar, and retest again in 15 minutes. Once the blood sugar reaches a normal level, give your child a mixed food snack, such as peanut butter and crackers, to stabilize the blood sugar levels.

    If your child loses consciousness, he or she may need an emergency injection of glucagon — a hormone that stimulates the release of sugar into the blood. This is a medical emergency.

  • High blood sugar (hyperglycemia). Likewise, your child's blood sugar can rise for many reasons, including eating too much, not taking enough insulin or illness. Watch for frequent urination, increased thirst, dry mouth, blurred vision, fatigue and nausea. If you suspect hyperglycemia, check your child's blood sugar. You might need to adjust your child's meal plan or medications. If your child's blood sugar is dangerously high, call your child's doctor right away or seek emergency care.
  • Increased ketones in your child's urine (diabetic ketoacidosis). If your child's cells are starved for energy, your child's body may begin to break down fat — producing toxic acids known as ketones. Although this condition is more common in children with type 1 diabetes, it can occur in children with type 2. Watch for loss of appetite, nausea, vomiting, fever, stomach pain and a sweet, fruity smell on your child's breath. If you suspect ketoacidosis, check your child's urine for excess ketones with an over-the-counter ketones test kit. If your child has excess ketones in his or her urine, call your child's doctor right away or seek emergency care.
Coping and support Tests and diagnosis
References
  1. Laffel L, et al. Epidemiology, presentation, and diagnosis of type 2 diabetes mellitus in children and adolescents. http://www.uptodate.com/home/index.htm. Accessed Jan. 6, 2009.
  2. Am I at risk for type 2 diabetes? National Institute of Diabetes and Digestive and Kidney Diseases. http://diabetes.niddk.nih.gov/DM/pubs/riskfortype2/. Accessed Jan. 9, 2009.
  3. Standards of medical care in diabetes — 2008. Alexandria, Va.: American Diabetes Association. http://care.diabetesjournals.org/content/vol31/Supplement_1/. Accessed Jan. 6, 2009.
  4. McCulloch DK, et al. Pathogenesis of type 2 diabetes mellitus. http://www.uptodate.com/home/index.htm. Accessed Jan. 6, 2009.
  5. Laffel L, et al. Comorbidities and complications of type 2 diabetes mellitus in children and adolescents. http://www.uptodate.com/home/index.htm. Accessed Jan. 6, 2009.
  6. McCulloch DK, et al. Glycemic control and vascular complications in type 2 diabetes mellitus. http://www.uptodate.com/home/index.htm. Accessed Jan. 6, 2009.
  7. Kidney disease (nephropathy). American Diabetes Association. http://www.diabetes.org/type-2-diabetes/kidney-disease.jsp. Accessed Jan. 9, 2009.
  8. Prevent diabetes problems: Keep your eyes healthy. National Institute of Diabetes and Digestive and Kidney Diseases. http://diabetes.niddk.nih.gov/dm/pubs/complications_eyes/index.htm. Accessed Jan. 6, 2009.
  9. Why taking care of your diabetes is important. National Diabetes Information Clearinghouse. http://www.diabetes.niddk.nih.gov/dm/pubs/type1and2/care.htm. Accessed Jan. 9, 2009.
  10. Prevent diabetes problems: Keep your feet and skin healthy. National Diabetes Information Clearinghouse. http://diabetes.niddk.nih.gov/dm/pubs/complications_feet/. Accessed Jan. 9, 2009.
  11. Estimated Average Glucose, eAG. American Diabetes Association. http://professional.diabetes.org/GlucoseCalculator.aspx. Accessed Jan. 6, 2009.
  12. Laffel L, et al. Management of type 2 diabetes mellitus in children and adolescents. http://www.uptodate.com/home/index.htm. Accessed Jan. 6, 2009.
  13. The basics of insulin. American Diabetes Association. http://www.diabetes.org/utils/printthispage.jsp?PageID=TYPE1DIABETES3_263601. Accessed Jan. 6, 2009.
  14. Hypoglycemia. American Diabetes Association. http://tracker.diabetes.org/hypoglycemia.php. Accessed Jan. 9, 2009.
  15. Hyperglycemia. American Diabetes Association. http://tracker.diabetes.org/hyperglycemia.php. Accessed Jan. 9, 2009.
  16. Ketoacidosis. American Diabetes Association. http://www.diabetes.org/type-1-diabetes/ketoacidosis.jsp. Accessed Jan. 6, 2009.
  17. International Expert Committee. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care. 2009;32:1.

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June 13, 2009

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