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CME / ABIM MOC / CE

Is Diabetic Retinopathy an Emerging Comorbidity in Youths With Type 2 Diabetes?

  • Authors: News Author: Carolyn Crist; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 4/28/2023
  • Valid for credit through: 4/28/2024
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  • Credits Available

    Physicians - maximum of 0.25 AMA PRA Category 1 Credit(s)™

    ABIM Diplomates - maximum of 0.25 ABIM MOC points

    Nurses - 0.25 ANCC Contact Hour(s) (0 contact hours are in the area of pharmacology)

    Pharmacists - 0.25 Knowledge-based ACPE (0.025 CEUs)

    Physician Assistant - 0.25 AAPA hour(s) of Category I credit

    IPCE - 0.25 Interprofessional Continuing Education (IPCE) credit

    You Are Eligible For

    • Letter of Completion
    • ABIM MOC points

Target Audience and Goal Statement

This activity is intended for diabetologists/endocrinologists, family medicine/primary care clinicians, internists, ophthalmologists, pediatricians, public health and prevention officials, nurses, pharmacists, physician assistants, and other members of the healthcare team for youths with T2D.

The goal of this activity is for members of the healthcare team to be better able to describe estimated global prevalence of diabetic retinopathy (DR) in pediatric T2D, according to a systematic review and meta-analysis.

Upon completion of this activity, participants will:

  • Describe estimated global DR prevalence in pediatric T2D, according to a systematic review and meta-analysis
  • Identify clinical and public health implications of estimated global DR prevalence in pediatric T2D, according to a systematic review and meta-analysis
  • Outline implications for the healthcare team


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News Author

  • Carolyn Crist

    Freelance writer, Medscape

    Disclosures

    Carolyn Crist has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC

    Disclosures

    Laurie Barclay, MD, has no relevant financial relationships:

Editor/Nurse Planner

  • Stephanie Corder, ND, RN, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Stephanie Corder, ND, RN, CHCP, has no relevant financial relationships.

Compliance Reviewer

  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC

    Disclosures

    Amanda Jett, PharmD, BCACP, has no relevant financial relationships.

Peer Reviewer

This activity has been peer reviewed and the reviewer has no relevant financial relationships.


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This activity was planned by and for the healthcare team, and learners will receive 0.25 Interprofessional Continuing Education (IPCE) credit for learning and change.

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CME / ABIM MOC / CE

Is Diabetic Retinopathy an Emerging Comorbidity in Youths With Type 2 Diabetes?

Authors: News Author: Carolyn Crist; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 4/28/2023

Valid for credit through: 4/28/2024

processing....

Clinical Context

Primarily because of the obesity epidemic, many children are developing type 2 diabetes (T2D) early in life and will live with diabetes for several decades. This may increase their lifetime risk of developing diabetic retinopathy (DR), which If undetected and untreated can cause blindness.

Type 2 diabetes is more aggressive in youths than in adults. Early comorbidities and complications include hypertension, nephropathy, polycystic ovary syndrome, and dyslipidemia. Current guidelines recommend DR screening in youths with T2D at diagnosis and annually thereafter, but the global burden of DR is still unknown.

Study Synopsis and Perspective

Nearly 1 in 4 children diagnosed with T2D for 5 years or more develop DR, according to a new report. The global prevalence of DR in pediatric patients with T2D is about 7%, which appears to increase with age.

"In our clinical practice, we have seen an increase in children presenting with [T2D] over the past few years. These patients present with multiple simultaneous comorbidities and complications like hypertension, fatty liver, and other conditions," senior author M. Constantine Samaan, MD, told Medscape Medical News.

"The exact scale of diabetes-related eye disease was not clear, and we decided to quantify it," said Samaan, an associate professor of pediatrics at McMaster University and pediatric endocrinologist at McMaster Children's Hospital in Hamilton, Ontario, Canada.

"What we found was that in pediatric patients with [T2D], [DR] is present in 1 in 14 youth. The risk of retinopathy increased significantly 5 years after diagnosis to almost 1 in 4," he noted.

"While we acknowledged that the number of [DR] cases was relatively small and there was heterogeneity in studies, we were surprised that retinopathy rates rose so fast in the first few years after diabetes diagnosis," Samaan indicated.

The findings signal that the increase in the prevalence of DR is emerging decades earlier among children compared with adults with T2D, the authors wrote in their article published March 1 in JAMA Network Open.

"While the guidelines for eye care in children with [T2D] recommend screening at diagnosis and annually afterward, these recommendations are not followed in almost half of these patients," Samaan said. "There is a need to ensure that patients get screened to try and prevent or delay retinopathy onset and progression."

Analyzing Prevalence Rates

Diabetic retinopathy is the leading cause of blindness in patients with T2D. Between 21% and 39% of adults have DR at diagnosis, with rates subsequently increasing, the authors wrote.

Samaan and colleagues conducted a systematic review and meta-analysis to estimate the global prevalence of DR in pediatric patients with T2D. They included studies that had a study population of at least 10 participants diagnosed at age 21 years and younger, an observational study design, and prevalence data on DR.

Among the 29 studies included, 6 were cross-sectional, 13 had a retrospective cohort design, and 10 had a prospective cohort design. Patients were diagnosed between the ages of 6.5 and 21 years, and the diabetes duration ranged from 0 to 15 years after diagnosis.

The overall global prevalence of DR in 5924 pediatric patients was 7%. Prevalence varied by study design, ranging from 1.1% in cross-sectional studies to 6.5% in prospective cohort studies and 11.3% in retrospective cohort studies.

In the 9 studies that reported DR classification based on criteria, the prevalence of minimal to moderate nonproliferative DR was 11.2%, the prevalence of severe nonproliferative DR was 2.6%, the prevalence of proliferative DR was 2.4%, and the prevalence of macular edema was 3.1%.

In the 5 studies that reported DR diagnosis using fundoscopy, the prevalence was approximately 0.5%. In the 4 studies that used 7-field stereoscopic fundus photography, the prevalence was about 13.6%.

In the pooled analysis of 27 studies, the prevalence of DR was about 1.8% less than 2.5 years after diabetes diagnosis but more than doubled to 5.1% in years 2.5 to 5 and jumped to 28.8% more than 5 years after diagnosis.

Differences by Sex and Ethnicity

"We were also surprised that there was very limited evidence to understand the sex and race differences in retinopathy risk," said Samaan. "Further research is warranted, considering that more girls develop [T2D] than boys, and the risk of [T2D] is higher in some racial groups."

In addition, older age, longer diabetes duration, and higher hypertension prevalence were associated with [DR] prevalence. There were no associations with obesity prevalence or mean age at diabetes diagnosis; however, patients who developed [DR] had a higher mean glycated hemoglobin [HbA1c] level of 1.4% compared with patients without retinopathy.

Samaan and colleagues are continuing to research the comorbidities and complications that children with T2D face as well as mechanisms that drive diabetes outcomes among children and adolescents.

For now, the findings highlight the importance of retinopathy screening and personalized diabetes treatment to protect vision, Samaan reiterated.

No funding source for the study was reported. The authors have reported no relevant financial relationships.

JAMA Netw Open.2023;6:e231887.[1]

Study Highlights

  • Investigators searched Medline, Embase, Cumulative Index to Nursing and Allied Health Literature, Cochrane Library, Web of Science, and gray literature from database inception to April 4, 2021, with updated searches on May 17, 2022.
  • 3 teams of 2 reviewers each independently screened for observational studies with ≥ 10 participants that reported DR prevalence.
  • Of 1989 screened articles, 27 met inclusion criteria for pooled analysis (N = 5924).
  • For systematic reviews and meta-analyses, 2 independent reviewers performed risk for bias and level of evidence analyses.
  • Researchers pooled results using a random-effects model and reported heterogeneity using χ2 and I2 statistics.
  • Age range at T2D diagnosis was 6.5 to 21 years.
  • Global DR prevalence in pediatric T2D was 6.99% (95% CI: 3.75%, 11%) overall, 1.1% in cross-sectional studies, 6.5% in prospective cohort studies, and 11.3% in retrospective cohort studies.
  • Among 9 studies reporting criteria- based DR classification, prevalence was 11.2% for minimal to moderate nonproliferative DR, 2.6% for severe nonproliferative DR, 2.4% for proliferative DR, and 3.1% for macular edema.
  • Fundoscopy was less sensitive than 7-field stereoscopic fundus photography in detecting retinopathy (0.47% [95% CI: 0, 3.3%] vs 13.55% [95% CI: 5.43%, 24.29%]).
  • DR prevalence increased over time and was 1.11% (95% CI: 0.04%, 3.06%) at < 2.5 years after T2D diagnosis, 9.04% (95% CI: 2.24%, 19.55%) at 2.5 to 5 years after T2D diagnosis, and 28.14% (95% CI: 12.84%, 46.45%) at > 5 years after T2D diagnosis.
  • DR prevalence increased with age, with no significant differences by sex, race, or obesity.
  • Overall pooled DR prevalence in Middle Eastern or White patients was 24.07% (95% CI: 6.26%, 47.91%) and in Asian patients was 13.31% (95% CI: 2.49%, 30.05%).
  • Meta-regression analysis revealed that older age (P < .001), longer diabetes duration (P = .02), and hypertension prevalence (P = .03), but not obesity prevalence, glycemic control, or mean age at diabetes diagnosis, were associated with DR prevalence.
  • Patients with T2D who developed DR had a higher HbA1c level than patients without retinopathy (mean HbA1c difference, 1.37 [95% CI: 0.95, 1.79]; P < .001).
  • The investigators concluded that DR prevalence in pediatric T2D continues to increase over time and rose significantly at > 5 years after diagnosis, suggesting that retinal microvasculature is an early target of T2D in children and adolescents.
  • Hyperglycemia can cause structural and functional retinal abnormalities in pediatric patients with T2D as early as 2 years after diagnosis, warranting early DR screening and detection to prevent impaired vision and blindness.
  • The increase in DR in children with pediatric T2D is emerging decades earlier than in adults with T2D.
  • Annual screening with fundus photography beginning at T2D diagnosis, which is more sensitive in diagnosing early DR than fundoscopy, offers the best assessment method for early DR detection and treatment to preserve vision and improve long- term outcomes in pediatric patients.
  • To meet current clinical practice guideline standards for eye care in children with T2D, which recommend screening at diagnosis and annually afterward, the number of children with T2D who undergo regular DR screening must increase, as these recommendations are not followed in almost half of these patients.
  • Benefits of early DR identification include increased focus on improving glycemic control to minimize microvascular disease, maintaining blood pressure, and facilitating monitoring of DR progression.
  • Further research is urgently needed to discover mechanisms underlying DR pathogenesis in children with T2D.
  • As evidence was very limited regarding sex and race differences in DR risk, further research is needed, given greater prevalence of T2D in girls than in boys and in some racial groups.
  • Longitudinal studies are warranted to assess long-term outcomes of DR in children, which are still unknown because of the relative novelty of the condition.
  • Equitable access to health care for DR detection and treatment is a global priority warranting increased attention.
  • Study limitations include small number of DR cases and high heterogeneity across studies.

Clinical Implications

  • Diabetic retinopathy prevalence in pediatric T2D continues to increase over time and rose significantly at > 5 years after diagnosis.
  • This suggests that retinal microvasculature is an early target of pediatric T2D, with DR emerging decades earlier than in adults with T2D.
  • Due to rising rates of diabetic retinopathy in children diagnosed with T2D, members of the healthcare team should recommend annual screening with fundus photography for this patient population.

 

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