My 16 year old son has had type 2 diabetes since he was 11 years old. For the first four years, he had maintained good control with metformin, diet and exercise. His A1c was 7.0 and his fasting blood sugar average was less than 140 mg/dl [7.8 mmol/L]. During the past 12 months, he has not had good control despite an increase in his metformin dose, usual diet and exercise. His A1c went up to 8.0. The endocrinologist has a three or four month wait for appointments and our family physician is not very familiar with type 2 in an adolescent. Do you have any insight into why his blood glucose is so high or suggestions for further “detective work” to try and get to the root of the problem?

A high A1c always means high sugars for the previous four to eight weeks so, either excess food, inadequate daily exercise or running out of insulin. You did not say what was happening to his weight and this may also give you a clue. Adolescent hormone changes may also be contributing to more insulin needs. After so many years, if this is not a food or activity problem, then his medication doses may need to be increased or others added or, he needs insulin. C-peptide levels would help figure this out. You should be in touch with the diabetology office and get him on a waiting list/cancellation list. It is likely, this would get him an appointment within a few weeks rather than waiting so long. Over time, many with type 2 diabetes really do need some insulin so, this could just be the natural history of his illness. Combinations of oral agents sometimes work as do some insulin in combination with oral agents as well.

If you do a series of before and after meal (pre and postprandial) blood glucose readings for five or six days in a row, you should find out where the problems are and then be able to discuss in more detail with your doctor/team.

SB