(P76) Why Am I Gaining Weight? Developing a Standardized Intervention for Insulin Resistance in Children with Acute Lymphoblastic Leukemia

Abstract Section 1: Basis of inquiry: Children treated for acute lymphoblastic leukemia (ALL) are at risk for developing insulin resistance due to the prolonged exposure of therapeutic corticosteroids. Supraphysiologic doses of steroids are beneficial in the treatment of ALL; however, they have profound effects on insulin sensitivity through decreased glucose uptake in skeletal muscle, increased hepatic glycolysis and gluconeogenesis, and increased lipolysis and protein catabolism. Steroids also alter insulin synthesis at the level of the beta cell and induce beta cell apoptosis. Symptoms of insulin resistance seen in children with ALL include unexplained weight gain, increased hunger, increased fatigue, and acanthosis nigricans (darkening in skin folds). Metformin is an insulin sensitizing drug that improves insulin-mediated suppression of hepatic glucose production and enhances insulin-stimulated glucose disposal in peripheral tissues.

Abstract Section 2: Purpose/Objectives: The purpose of this clinical practice project was to develop and implement a treatment algorithm for the identification of insulin resistance and subsequent treatment with metformin in children during and after ALL therapy.

Abstract Section 3: Methods: We formed an interdisciplinary team within our pediatric cancer program to create a treatment guideline to manage children with ALL, who met criteria for insulin resistance, within the institution’s oncology program. Pediatric specialty team members included an endocrinologist, oncologists, oncology nurse practitioners, an oncology pharmacist, and the dietitian for the oncology program. After multiple meetings, the team developed and vetted an evidence-based algorithm and implemented its use by publishing it on the program’s website as a clinical guideline. This algorithm will be part of the poster.

Health care providers completed guideline education through a regularly scheduled weekly tumor conferences with additional one on one consultations as needed between team members and providers as needed. The program dietitian meets with each identified family to complete nutritional counseling. Evaluation of individual patient outcomes occurred during routine visits through monitoring of growth curves, BMI z scores, and laboratory assessments. Data gathered on patient outcomes since implementation include patient age, gender, stage of treatment upon entry to the algorithm (maintenance/off therapy), length of time receiving metformin, and change in BMI z score.

Abstract Section 4: Findings or Outcomes: Each year there are approximately 90 children and adolescent in maintenance for ALL or in their first year off therapy in our cancer program. Seven patients met criteria for insulin resistance and started on metformin with routine follow-up measurements; an additional 3 patients have recently started on metformin. Among the 7 patients with follow up measurements, 4 are in maintenance therapy and 3 are in their first year off therapy. There are 2 females and 5 males with a mean age of 10.0 years. The mean time of receiving medformin is 17.8 months and BMI z scores have decreased by .49 from a mean of 2.19 to a mean of 1.71.

Additionally, the program dietitian anecdotally observed that families shared their concern over their child’s weight and health wellbeing and often expressed relief over the team’s intervention to address it. This familial perception and assessment was not statistically evaluated in this report, but is certainly worthy of formal evaluation in subsequent studies.