|
||||||
|
|
|
|
|||||||||||
|
|||||||||||||
| ||||||||||||||||||||||||||||||||||||
The morbid signs are clear: Excessive weight among children is a burgeoning public health menace. In 25 years, the prevalence of obesity increased fourfold among children 6–11 years of age and doubled among teenagers.1 More than 30% of children are at risk of overweight, and 16% are overweight.2
Growing numbers of clinicians are reporting conditions in pediatric patients that were once mainly adult diseases, including impaired glucose tolerance (IGT), type 2 diabetes, cardiometabolic risk, and sleep apnea.
Children get the same diseases as adults, but should they be treated similarly? Should drugs be considered along with behavioral interventions for children with pre-diabetes? That was the subject of a debate in a session at The Endocrine Society's annual meeting last summer in Boston, but gained national relevance late in 2005 following a study linking pre-diabetes to an estimated 2 million youths.3
According to pediatric endocrinologists, three drugs are considered most often for young patients at risk for pre-diabetes: metformin, orlistat (Xenical, Roche), and sibutramine (Meridia, Abbott).
For adults, nobody would think twice if a drug were added to a therapeutic regimen when exercise, diet, and behavioral changes failed to bring risks under control. But the choice is not clear when the patient is a teenager or younger.
Some health professionals, including Silva Arslanian, MD, a pediatric endocrinologist at Children's Hospital of Pittsburgh, are dead set against prescribing drugs to children with pre-diabetes in the absence of clinical studies showing safety and efficacy.
"There are no properly designed long-term studies that show medication delays diabetes in children," Arslanian says. "A lot of people are using metformin in simply obese children as if it's a weight-loss medication. This just isn't supported by studies."
Representing the other side is pediatric endocrinologist Sonia Caprio, MD, of Yale University. Drugs are "something that should be considered, given the rise we've seen in type 2 diabetes in children and teenagers," Caprio says. "Teenagers, particularly African Americans, are moving very fast from pre-diabetes to diabetes. The tempo of progression is rapid; the window of intervention is short."
Caprio says she would consider prescribing medication to an adolescent who keeps gaining weight, has a strong family history of type 2 diabetes, or has other risk factors in the family.
"Impaired glucose tolerance should be considered as a disease leading to diabetes," she says. "We treat prehypertension and we treat precancerous conditions. Impaired glucose tolerance has to be taken seriously."
|
Caprio is involved in a clinical trial of rosiglitazone (Avandia, GlaxoSmithKline) in teens. So far, about two dozen patients have been recruited for the 4-month study, she says.
IS THE DANGER REAL TODAY?
Although she doesn't dispute the problem of obesity and the problems it may cause down the line, Arslanian questions whether the situation is as dire as some authorities contend. Despite the growing epidemic of pediatric obesity, Arslanian says the anticipated increased incidence of IGT or diabetes has not materialized.
"A majority of studies that have looked at obese [pediatric] populations are clinic referrals" of selected patients rather than a sample of the general population, she says. "We don't see the high rates that were reported. The same is true if you look at the TODAY study [Treatment Options for type 2 Diabetes in Adolescents and Youth—now under way] or STOPP-T2D [Studies to Treat Or Prevent Pediatric Type 2 Diabetes]."4
Giving medications to children and adolescents can cause near- and long-term problems. Orlistat is unpopular with pediatric patients because of the unpleasant side effects, Arslanian says.
"They don't like orlistat because they poop in their pants because they don't change their diet," she says. "If you look at the studies with orlistat, it isn't popular with adolescents at all. These kids already have terrible self-esteem. You add to it flatulence or an incident, and it's terrible."
As for the other drugs, Arslanian notes that they have not been tested for safety and efficacy in children.
But very few drugs used in pediatrics have been tested in children, points out Francine Ratner Kaufman, MD, professor of pediatrics at the University of Southern California's Keck School of Medicine, who moderated the debate.
"There are no data in children, but [the drugs] are approved, on the market, and being used," Kaufman says.
Arslanian says more research is needed before medications can be used
widely in children with prediabetes. "I'm not against drugs," she
says. "But we need the right drug with the right testing to show that it
is safe and effective. Drug companies need to work on this, and they are
because they see the dollar signs." 
Footnotes
For a list of treatment centers participating in the TODAY study, go to http://www.niddk.nih.gov/patient/today/centers.htm.
Information on STOPP-T2D can be accessed at http://maillists.uci.edu/mailman/listinfo/stopp-t2d.
References
2. Hedley AA, Ogden CL, Johnson CL, et al.: Prevalence of overweight
and obesity among U.S. children, adolescents, and adults, 1999–2002.
JAMA 291:2847–2850, 2004.
3. Williams D, Cadwell B, Cheng Y, et.al.: Prevalence of impaired
fasting glucose and its relationship with cardiovascular disease risk factors
in U.S. adolescents, 1999–2000. Pediatrics 116: 1122–1126, 2005.
4. Baranowski T, Cooper DM, Harrell J, et al. for the STOPP-T2D
Prevention Study Group: Presence of diabetes risk factors in a large U.S.
eighth-grade cohort. Diabetes Care 29: 212–217, 2006.
CiteULike 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||
|
||||||
|
| DOC News | Diabetes | Diabetes Care | Clinical Diabetes | Diabetes Spectrum |
