465 - Prediabetes/T2D Screening in Youth, Asthma 2022, “The Great Rē___”
Take 3 – Practical Practice Pointers©
From the USPSTF
1) Screening for Prediabetes/T2D in Children and Adolescents
Diabetes (both type 1 and type 2) is the third most common chronic disease in childhood. Approximately 10% of children with diabetes have type 2 diabetes (T2D). T2D is much more common in older than in younger children, often presenting at the onset of puberty. Approximately 18% of adolescents (12 to 18) have prediabetes. Studies indicate that between 22-52% of children and adolescents with prediabetes return to normal glycemia or normal glucose tolerance without intervention over 6 months to 2 years. Obesity and excess adipose tissue, especially when centrally distributed, are the most important risk factors for T2D in younger persons.
Compared with non-Hispanic White youth, the T2D rate in Black, American Indian/Alaska Native, and Hispanic/Latino youth has been shown to be 4, 5, and 8 times higher, respectively. Causes of these differences are not well understood, but structural factors that disproportionately affect non-White populations, as well as cultural and environmental influences and quality of and access to health care, may contribute significantly to differences by race and ethnicity.
The USPSTF recently published a recommendation regarding screening for prediabetes and T2D in asymptomatic children and adolescents younger than 18. They concluded that there is insufficient evidence to assess the balance of benefits and harms of screening for either (I Recommendation).
In 2017, the USPSTF recommended that children and adolescents > 6 years old should be screened for obesity and offered or referred to a comprehensive, intensive behavioral intervention to promote improvements in weight status (B Recommendation). This recommendation is presently undergoing review and a draft is expected soon. It should be noted that in 2021, the USPSTF did recommend screening adults aged 35-70 who have overweight or obesity for prediabetes and T2D (B Recommendation).
The American Diabetes Association (ADA) recommends risk-based screening for T2D after onset of puberty or age 10 years in children who have overweight (defined as a BMI ≥85th percentile) or obesity (defined as a BMI ≥95th percentile) and 1 or more additional risk factors for diabetes. A family history of diabetes (including gestational diabetes) would be considered a risk factor. In children at high risk, the ADA recommends screening every 3 years if tests are normal or more frequently if BMI increases.
When looking at the numbers, it seems imperative to do all we can to attenuate the impact of insulin resistance in those younger than 18. Aggressive lifestyle intervention for the entire family seems the most prudent approach. There are no medications presently approved for treatment of prediabetes in this population. It is important to note that pediatric T2D diabetes appears to take a very different and more aggressive course compared with adult T2D, resulting in more rapid beta cell failure and insulin dependence often within the first 12 months of diagnosis.
· USPSTF. Screening for Prediabetes and Diabetes in Children and Adolescents. September 13, 2022. Link
· USPSTF. Screening for Obesity in Children and Adolescents. June 20, 2017. Link
From the Global Initiative for Asthma (GINA)
2) GINA 2022 Asthma Guidelines
Just as with COPD, there is an international guideline committee for asthma. We covered the US-based National Heart, Lung, and Blood Institute (NHLBI)’s 2020 guideline update in Take 3 #383. That update to their 2016 guidelines was restricted to only a few key areas of new evidence. GINA meets and updates their guidelines yearly. The guidelines are detailed and comprehensive, so we will look only at the most primary care relevant parts of the 2022 guidelines and focus on the changes.
First (naturally), we should review the methods. GINA has a science committee made up of “asthma experts” internationally. It looks like there may be one or two members (out of the 20-member science committee) from a primary care academic department.
All but three of the members disclosed funding (mainly grants and “personal fees”) from pharmaceutical companies, and all but one declared that they had avoided tobacco company funding in the last 5 years. The group searches for existing literature and systematic reviews (preferentially those reviews done with GRADE methodology) and appraises them for inclusion. They use an evidence rating process similar to that of the NHLBI (which, unfortunately, rates randomized controlled trials, systematic reviews and “consistent observational evidence” all as level A). The guideline was sent for external review by primary care and specialty physicians.
Highlights of New Recommendations/Changes in 2022:
· Because 30% of asthma deaths are in patients with infrequent symptoms, and short acting beta-agonists (SABAs) alone increase the risk of death, GINA now recommends:
o For adults/adolescents - inhaled corticosteroid (ICS)-formoterol combinations for “mild” asthma as a reliever medication. SABA use is an alternative approach only if accompanied by ICS use as a reliever.
o For children (6-11y), an ICS (used as either maintenance or reliever, depending on severity) with a prn SABA is recommended.
· When patients are using an ICS-formoterol combination inhaler for symptoms, assessing their symptoms with frequency of use greater than twice/week (as is recommended for SABA reliever medications) does not work. The group recommends evaluating the dose of ICS-formoterol combinations based on an average weekly use over a month until more evidence is available.
· For pre-school children with intermittent viral wheezing, consider short course ICS use, but monitor appropriate use given the side effects.
· Long-acting muscarinic antagonists (LAMAs) should only be used with severe asthma to be added on to at least medium-dose ICS-LABA combinations.
· Chronic oral corticosteroids are a last resort when all other measures have been exhausted.
· Written asthma action plans are recommended over verbal plans.
· The keys to asthma diagnosis are typical symptoms (wheezing, shortness of breath, chest tightness, cough) AND demonstration of airflow limitation (e.g., reduced FEV1) that is reversible with bronchodilators.
· Patients with well-controlled mild-moderate asthma are not at significant risk of severe COVID-19. Patients needing steroids for control and those who are hospitalized, however, are at increased risk.
· Consider strongyloides infection when asthma is difficult to control, blood eosinophils levels are greater than 300 cells/ul, and the patient lives in rural/agricultural setting, goes barefoot a lot, and/or is around sewage.
· To confirm the diagnosis of asthma in patients already on controller medications – use their symptom pattern together with documentation of airflow limitation (e.g., FEV1):
|Airway Symptoms||Airflow limitation||Next steps|
|Variable||None||Reduce controller, repeat spirometry with/without bronchodilator (BD)|
|Few||None||Reduce controller, repeat spirometry with/without BD|
|Persistent||---||Refer for specialty evaluation. Consider COPD overlap.|
John’s Comments: Based on the evidence and converging guideline recommendations, we should be moving away from SABA use and toward the ICS-formoterol combinations for both reliever and maintenance therapy, even in “mild asthma.” I didn’t include information about severe asthma treatment options (biologics, etc.) or the more globally oriented recommendations. If you want a clear picture of the whole guideline, I recommend the pocket guide or the slide set, at the GINA website.
· Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. Published online 2022. Link
From PeerRxMed ( www.PeerRxMed.org )
3) It’s Time for “The Great Rē_____”
Taking time for rēcovery, rēflection, rēcalibration, and rēprioritization is not selfish, but rather sanity and ultimately good stewardship of your life energy. Me
Last year it was called “The Great Resignation,” a phenomenon of the pandemic workplace where people chose to vacate their jobs rather than just resume the “old normal” of slogging to the office every day. The Gallop organization called it the “Great Discontent.” I’m calling it the “Great Rēprioritization” (of values), the “Great Rēduction” (in desired work hours) and in some cases, the “Great Rēlocation” (pursing a better job). Whatever you want to call it, it seems that the sentiment of many is, “I can’t/won’t go back to ‘the way it was’ prior to the pandemic.”
Indeed, after many years of working long hours and sacrificing other priorities while being dedicated to a noble but demanding and seemingly insatiable profession, the past 30 months of the pandemic has caused many who work in healthcare to ask an important but often disorienting question: “Is this worth it?!” And the answer that many are hearing is, “not in its present form.” Which leads to an all-important follow-up question: “What then do I want?”
Part of the inspiration for the PeerRxMed process was the recognition that the work we do in healthcare will regularly create conditions that can cause us to become “off-course” and potentially drain us of the energy we need to establish and maintain our personal and professional well-being. Under such circumstances, we risk becoming distanced from identity, from meaning, from priorities, from perspective, and from each other. That is why we need to schedule regular time for rēcovery, rēflection, rēcalibration, and rēprioritization and also why we need to regularly rēconnect with others who can help provide input, encouragement, and accountability.
A vital component of the PeerRxMed process (what I call PRx90) is the quarterly “up to 90 minutes every 90 days” check-in intended to provide a deliberate space for that rēconnection with ourselves and our PeerRxMed partner. Here’s a rēminder of that Process . As September comes to an end, it’s time to schedule that quarterly meeting once again. To help guide that time, here are some questions to consider for dialogue together:
· What would you say are your top 3 priorities presently and how are you incorporating them deliberately into your life?
· What have you learned about yourself over the past 3 months?
· What are your personal/professional goals over the next three months? What is one that will cause disappointment if you have not accomplished it when we meet again in 3 months?
· What are your dreams both personally and professionally? How are you taking action to move toward them?
· When’s your next vacation / adventure / break? What will you do that will be fun for you?
Regularly rēenergizing is often neglected by those who are always “on the go” and/or perpetually “needed by others.” Rēfuse to be one of them! Rēsolve to schedule some time alone and with your PeerRxMed partner in the next 3 weeks for a “life check-up” to ensure you’re on target to be living the life you want to be living using the questions above as a guide. Doing so regularly will be an important investment in “rēgret prevention.” It’s time for your “Great Rē_____.” Choose wisely.
Mark and John
Carilion Clinic Department of Family and Community Medicine
Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.