Type-1 Diabetes and Pediatric Glycemic Control: How Early is Retinopathy a Concern?

Reem Gebrekidan, Mercer University College of Pharmacy

Retinopathy is a neurovascular complication which could lead to various eye disorders including blindness, glaucoma, cataracts, and others. An A1C of under 7% is recommended for non-pregnant adults without co-morbidities (53 mmol/mol) and may be reasonable for nonpregnant adults without comorbidities. However, less stringent A1c levels between 7- 8% (64 mmol/mol) could be considered in patients with a history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes in which lower goals are more difficult to achieve. [1]

Long term risk of severe retinopathy in childhood-onset type 1 diabetes: a data linkage study [2]
Design Retrospective, cohort, data linkage; N= 503
Objective To examine the impact of childhood glycaemic control on the future risk of complications in people with type 1 diabetes
Study Groups Stable (n= 143); low improving (n= 82); worsening (n= 96); stable high (n= 182)
Methods Adults with type 1 diabetes with data transferred from the paediatric diabetes clinic, and at least one specialist adult diabetes clinic attendance were included. Patients who were lost to follow-up at the time of care transition from the paediatric clinic or who died were excluded. Glycemic control was defined as mean HbA1c 66 mmol/mol with the values calculated for paediatric (pre-transition), adult (post-transition, as an adult), and life course (level from diagnosis to end of study).

Trajectory groups used for analysis of mean HbA1c were: stable low (mean paediatric and adult HbA1c ≤ 66 mmol/mol); improving (mean paediatric HbA1c > 66 mmol/mol, mean adult HbA1c ≤ 66 mmol/mol); worsening (mean paediatric HbA1c ≤ 66 mmol/mol, mean adult HbA1c > 66 mmol/mol); or stable high (paediatric and adult mean HbA1c > 66 mmol/mol).

Duration Data from 1975- 2013
Primary Outcome Measure Record of severe diabetic retinopathy
Secondary Outcome

Measure

Record of other complications such as chronic kidney disease, ulceration/amputation, and death
Baseline Characteristics  

Stable low Improving Worsening Stable high
Women, n 58 46 44 102
Mean age at diagnosis, years (SD) 10.7 (4.1) 9.1 (3.9) 10.3 (4.2) 9.5 (3.9)
Mean duration of paediatric observation, years (SD) 7.8 (4.1) 9.2 (4.1) 8.1 (4.6) 8.9 (4.1)
Mean duration of adult observation, years (SD) 18.5 (0.8) 18.3 (0.8) 18.4 (1.1) 18.4 (1.2)
Mean duration of type 1 diabetes, years (SD) 7.8 (5.3) 10.0 (6.9) 9.2 (5.5) 9.4 (5.8)
*Mean HbA1c level, mmol/mol (SD)
    Pedatric 57 (6.6) 74 (9.8) 60 (5.5) 78 (5.5)
Adult 57 (6.6) 60 (5.5) 77 (10.9) 85 (10.9)
   Life long 58 (3.3) 67 (8.7) 65 (6.6) 79 (6.6)

*Differences between groups: p< 0.001

Results  

n (%) Stable low Improving Worsening Stable high **p-value
Severe     retinopathy 0 3 (4) 1 (1) 12 (7) 0.004
Renal disease 0 0 4 (5) 2 (2) 0.07
Ulceration/amputation 1 (1) 1 (1) 0 4 (2) 0.76
Death 0 0 1 (1) 4 (2) 0.18

**Difference between all four groups  

Adverse Events Common Adverse Events: N/A
Serious Adverse Events: N/A
Percentage that Discontinued due to Adverse Events:N/A
Study Author Conclusions Severe retinopathy was associated with uncontrolled pediatric glucose levels, independent of glycemic control during adulthood.

These results challenge the belief that glycemic control in young adults with type 1 diabetes can wait until  adolescence is surpassed and reinforce implementation of early glycemic control in pediatric diabetes care. Mediation interference may have been overlooked as comorbidities such as hypertension, hyperlipidemia, and obesity are associated with increased risk of retinopathy but were not recorded. Further, any history of pregnancy, which has been linked with a rapid progression of diabetic retinopathy, was not provided by women participants. With the A1c threshold for the groups being higher than what is recommended by ADA guidelines, the definition of controlled glucose level from this study was less valid.

 

References

[1] ADA, American Diabetes Association. Standards of medical care in diabetes—2017.
Diabetes Care. 2017;39(suppl 1):S1-S106.

[2] White M, Sabin MA, Magnussen CG, O’connell MA, Colman PG, Cameron F. Long term risk of severe retinopathy in childhood-onset type 1 diabetes: a data linkage study. Med J Aust. 2017;206(9):398-401.

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