Children and teens with type 2 diabetes should be treated initially with a combination of metformin and lifestyle changes, much like adults, a new practice guideline from the American Academy of Pediatrics indicated.

Most pediatric patients newly diagnosed with type 2 diabetes should receive metformin along with a program of lifestyle modification covering diet and physical activity, according to the guideline, authored by an AAP committee headed by Kenneth Copeland, MD, and Janet Silverstein, MD.

The committee made two exceptions: children and teens presenting with ketosis or diabetic ketoacidosis and “in whom the distinction between types 1 and 2 ... is unclear,” and those with blood sugar levels of at least 250 mg/dL or glycated hemoglobin (HbA1c) higher than 9%.

Such patients should be started immediately on insulin therapy, the panel recommended.

The American Diabetes Association, the Pediatric Endocrine Society, the American Academy of Family Physicians, and the Academy of Nutrition and Dietetics contributed to the guidelines, billed as the first ever for this population and published in the February issue of Pediatrics.

Reviewing literature published between 1990 and 2008, the AAP committee concluded that “the practicing physician is likely to be faced with the need to provide care for children with type 2 diabetes mellitus.”

Yet, the members found, nonspecialist clinicians have too little data to consult when treating these cases, especially as the numbers accelerated.

The recommendation of metformin and lifestyle changes for most cases was based on an evidence review contained in a separate, 18-page “technical report.” The bottom line was improved outcomes and preponderance of benefits over harms in published studies.

The guideline cautioned against prescribing more than 500 mg daily at the onset because of metformin’s gastrointestinal adverse affects. But such effects “are often transient and often disappear completely if medication is continued,” the authors wrote. Use of extended-release metformin with evening dosing is also an option.

More than 2,000 mg dose a day has not provided additional benefits, the committee warned.

Metformin was preferred over insulin for several other reasons, the guidelines stated. These include weight loss, less risk of hypoglycemia, fewer finger sticks, improved insulin sensitivity, and ease and patient preference of oral medication over injections.

But, the committee cautions, physicians should be aware of recent trials in the TODAY (Treatment Options for type 2 Diabetes in Adolescents and Youth) program showing that metformin does not sustain glycemic control in most youths with diabetes. Adding rosiglitazone (Avandia) to metformin alone improved the outcomes, but rosiglitazone is not FDA-approved for children and is now restricted even for adults.

Other anti-diabetic drugs for adults such as pioglitazone (Actos) and incretin-type agents are also not approved in children, although evidence suggests that they are sometimes prescribed off-label in teens, the committee indicated.

While metformin should be the first-line treatment for most cases, the guideline indicated that insulin achieves metabolic control more quickly. Also, insulin use may have another, more indirect benefit, the committee speculated—the necessity of frequent injections may send the message to patients and their families that diabetes has to be taken seriously.