First consensus statement on T2DM in young adults released

Matt Woodley

20/04/2022 1:35:04 PM

The statement contains recommendations that differ from typical management guidelines, but also fails to acknowledge the role of GPs.

Person checking blood sugar levels
The number of young people with type 2 diabetes is increasing.

The first Australian consensus statement on the management of type 2 diabetes in young adults has been released.
Produced by the Australian Diabetes Society Expert Consensus Development Group, the statement considers areas where existing type 2 diabetes guidance, which are directed mainly towards older adults, may not be appropriate or relevant for the young adult population.
A summary of the statement published in the Medical Journal of Australia earlier this week, features management recommendations specific to young adults, including:

  • screening for diabetes in young adults with overweight or obesity and additional risk factors, including in utero exposure to type 2 diabetes or gestational diabetes
  • more stringent glucose targets, eg glycated haemoglobin (HbA1c) ≤6.5% (≤48 mmol/mol)
  • in the context of obesity or higher cardio-renal risk, glucagon-like peptide-1 receptor agonists and sodium glucose co-transporter 2 inhibitors are preferred second-line agents
  • β-cell decline is more rapid, so frequent review, early treatment intensification and avoidance of therapeutic inertia are indicated
  • a blood pressure target of <130/80 mmHg, as the adult target of ≤140/90 mmHg is too high
  • absolute cardiovascular disease risk calculators are not likely to be accurate in this age group; early statin use should therefore be considered
  • a multidisciplinary model of care including an endocrinologist and a certified diabetes educator.
To develop the guidelines, a working group reportedly examined the body of evidence and provided advice on screening, diabetes type, psychological care, lifestyle, glycaemic targets, pharmacological agents, cardiovascular disease risk management, comorbidity assessment, contraception and pregnancy planning, and patient-centred education.
Chair of RACGP Specific Interests Diabetes Dr Gary Deed told newsGP the new consensus statement should raise primary care awareness of increasing rates of type 2 diabetes in people aged 18–30, by identifying overweight or obesity and additional risk factors, including in utero exposure to type 2 diabetes or gestational diabetes.
Dr Deed also notes that the specific heightened risks for Aboriginal and Torres Strait Islander people are ‘well elaborated’. 
‘For GPs it reminds us that the criteria for glycaemic levels for diagnosis are no different to adult patients,’ he said.
‘However, the goals for glycaemia tend to be “tighter” than for other groups set at HbA1c <6.5% versus 7% in adult type 2 diabetes.
‘Care also needs to be exercised to exclude type 1 diabetes and genetic forms of diabetes such as monogenic diabetes.’
However, while Dr Deed says the statement is timely, he believes it is ‘disappointing’ that the role of general practice in screening, diagnosis and diabetes-specific team care coordination is not specifically explained.  
‘Due to complexities in identification, diagnosis and management choices, GPs play an essential role in supporting patients through team care planning and timely referral to specialist and allied health support,’ he said.
According to the authors, led by Professor Jencia Wong from the University of Sydney, the new statement is necessary as type 2 diabetes is becoming more prevalent in younger age groups in Australia and worldwide.
‘Type 2 diabetes with onset in young adulthood [nominally, 18–30 years of age] is a more aggressive condition than that seen in older age, with greater risks of major morbidity and early mortality,’ they wrote.
‘It is estimated that onset in young adulthood comprises 16% of the adult type 2 diabetes population globally.’
Of note to GPs, Dr Deed says, is that the statement emphasises preventing complication development in this cohort.
But he also points out that cardiovascular disease risk calculators do not provide accuracy for clinical advice, and the management of long-term risk reduction may need specialist advice on risks versus benefits.
Another area for GPs to be aware of is contraception and family planning for type 2 diabetes patients in this cohort.
‘Diabetes-related medications suggested for management have potential reproductive effects that needs careful patient-centric explanation and management,’ Dr Deed said.
‘As many young people are in reproductive years, the consensus statement gives important advice to plan for possible pregnancy, and also how to provide adequate contraceptive advice.’
Meanwhile, the authors suggest more research into this specific cohort is necessary to improve treatment and management.
‘Despite a growing understanding of the excess risks and the more aggressive phenotype of type 2 diabetes in young adults compared with older adults, there is still a great need to develop a rigorous evidence base for young adults with type 2 diabetes,’ they state.
‘This will further inform management recommendations and models of care for this high-risk group, from which more definitive guidelines can be developed.’
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