1. TYPE 1 DIABETES UPDATE Colorado Association for School-Based Health Care G. Todd Alonso, MD May 6, 2016

2. Disclosures No relevant financial disclosures

3. Objectives Understand the importance of timely diagnosis of type 1 diabetes (T1D) Be able to diagnose T1D Understand special considerations for teens with T1D Be aware of emerging diabetes technology

4. 1. Diabetes background Prevalence Pathophysiology Diagnostic criteria Diabetic ketoacidosis in new onset diabetes

5. Type 1 Diabetes in the US 1.25M have T1D (~200,000 youth). 40,000 people are diagnosed each year. $14B T1D-associated annual healthcare costs. Less than one-third of people with T1D are achieving target blood glucose control levels. T1D is associated with an estimated loss of life- expectancy of up to 13 years. http://jdrf.org/about-jdrf/fact-sheets/type-1-diabetes-facts/

6. T1D incidence rising 3-5% per year. Incidence per 100,000/ yr in children aged 0-14 2000 1990 1980 1970 1960 20 35 30 25 40

7. Clinical case #1 A 15 year old boy is in the school clinic with complaints of fatigue. What other history or findings would suggest that you should consider diabetes?

8. Clinical case #1 Increased thirst and urination 15 pound weight loss in the last few months Labored, rapid breathing, but a clear lung exam.

9. LOSS OF FIRST PHASE INSULIN RESPONSE DIABETES “PRE”- DIABETES GENETIC PREDISPOSITION INSULITIS BETA CELL INJURY NEWLY DIAGNOSED DIABETES MULTIPLE ANTIBODY POSITIVE GENETICALLY AT RISK TIME BETA CELL MASS STAGES IN DEVELOPMENT OF TYPE 1 DIABETES TRIGGER FBG > 125 RBG > 200

10. DKA at diagnosis of T1D is common, increasing. Rewers A, et al. Incidence of DKA at Diagnosis of Type 1 Diabetes in Colorado Youth, 1998-2012. JAMA. 2015;313(15):1570-1572.

11. Public knowledge may help prevent DKA at diagnosis of T1D. DKA (n=31)No DKA (n=30) FAMILY FACTORS Family suspected diabetes30%70% Family borrowed a glucometer10%30% Family familiar with diabetes symptoms33%87% Others in the family with diabetes70%87% Others with T1D in family23%43% Others with T2D in family60%57% Friends with T1D37%57% Looked up symptoms on Internet26%30%

12. How do we diagnose diabetes? A1c ≥ 6.5%* OR Fasting** plasma glucose ≥ 126 mg/dL OR 2 hour plasma glucose ≥ 200 mg/dL OR Random plasma glucose ≥ 200 mg/dL in a patient with classic symptoms of hyperglycemia Standards of Medical Care in Diabetes. Diabetes Care. 2012. *Using NGSP certified lab method standardized to the DCCT assay ** No caloric intake for 8 hours

13. Clinical case #1 What can I do for this child? Ask the right history questions Urine or blood sugar testing Refer him for testing

14. Special challenges in teens with diabetes 2. Special challenges in teens with diabetes

15. Clinical case #2 A 13 year old girl doesn’t like coming to the office before lunch for diabetes management. Her blood sugars are almost always in the >300 mg/dL range.

16. Our patients are not meeting glycemic goals. T1D Exchange. June 2015.

17. Risk of complications rises with HbA1c. Skyler JF. Endocrinol Metab Clin North Am. 1996;25:243-54 Relative Risk HbA 1c % 789101112 Diabetic retinopathy Nephropathy Neuropathy Microalbuminuria 15 13 11 9 7 5 3 1 6

18. Depressive symptoms are common in teens with T1D. Silverstein 2015. Diabetes Care.

19. DKA is too common in patients with established T1D. 28.3% of >12,000 patients had 1 or more DKA admissions in a 365-day period in the last 5 years. Malik et al. J Peds. April 2016.

20. Clinical case #2 How can we help her get better control during the school day? Test in office before 1 st period Carb counting (rather than sliding scale) Long acting insulin given at school Transition to greater independence once better glycemic control is established School communicates with diabetes provider (dose adjustments) Mental/behavioral health services? Other ideas?

22. 3. Emerging diabetes technology

23. Clinical case #3 A 6 th grader is using Dexcom Share with the Nightscout app. The family wants to use the school’s wifi to follow her blood sugars remotely.

24. Meal memory

25. GoCarb Project

26. Diabetes apps Meal Memory Dexcom G5

27. Closed Loop Control www.photoseed.com

30. Itrade.gov.il

31. Proportional Integral Derivative Algorithm www.wikipedia.org Current Error Current Error Accumulated Error Accumulated Error Anticipated Error Anticipated Error

32. Closed loop control

33. Itrade.gov.il

34. AP systems in development

35. Summary Timely diagnosis of T1D is critical in avoiding severe illness (and ICU stay). Have a really low threshold to check a sugar. Glucosuria Hyperglycemia (>200). Teen years are hard. Especially for a kid with diabetes. Diabetes technology is rapidly advancing.