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AACE consensus conference brings attention to prediabetes
Experts call for a comprehensive treatment regimen for patients with prediabetes using a two-pronged approach.
A panel of diabetes and metabolic disorder experts have recommended a comprehensive treatment regimen for patients with prediabetes that calls for specific guidelines on both lifestyle and pharmaceutical intervention where appropriate.
The recommendations were made recently by the American Association of Clinical Endocrinologists and the American College of Endocrinology, following a two-day consensus conference held in Washington, D.C.
“The issue we are confronting is not a stranger to any of you. There has been an explosion of obesity and obesity-related diseases in the United States, chief among those is the explosion of diabetes,” Alan J. Garber, MD, PhD, Endocrine Today Chief Medical Editor, said during a press conference.
“Although lifestyle can clearly modify the progression of patients towards overt diabetes, it may not be sufficient. Medications may well be required, particularly in high risk groups,” added Garber, professor of medicine at Baylor College of Medicine in Houston and chairman of the consensus conference.
More than 56 million Americans have prediabetes, according to CDC estimates. These individuals are at risk for progression to type 2 diabetes, as well as cardiovascular, microvascular and macrovascular complications.
“Data show that there is a spectrum of severity, with the most severely affected approaching the risks of people with diagnosed type 2 diabetes. In these highest-risk individuals, who represent a minority, pharmacologic strategies may be appropriate if intensive lifestyle therapies fail. Regardless, all individuals at risk for diabetes should be aware of the level of their risk factors and be prepared to take action,” said Daniel Einhorn, MD, vice president of AACE and medical director of the Scripps Whittier Institute for Diabetes in La Jolla, Calif.
He said these recommendations were not made to create a new illness but rather bring attention to the gap between prediabetes and diabetes.
Two-pronged approach
The expert panel recommended a two-pronged approach; one method is intensive lifestyle management to prevent progression to type 2 diabetes.
“We all agree that lifestyle intervention is the first way to go. Yet we also recognize that in high risk groups lifestyle intervention will not be enough to stop them from progressing to diabetes,” said Yehuda Handelsman, MD, treasurer of AACE and medical director of the Metabolic Institute of America.
The second approach is to prevent the development of cardiovascular complications, and to help those patients where lifestyle modifications have been insufficient to modify cardiovascular risk factors. This requires cardiovascular risk reduction medications for abnormal blood pressure and cholesterol independent of glucose control medications.
People are considered high risk if they have near-diabetic levels of blood glucose, hypertension or abnormal lipid profiles. Until now, there has been no consensus about when patients with prediabetes become at risk for the complications of diabetes, such as myocardial infarction, retinopathy, congestive heart failure and chronic kidney disease. Further, no pharmacologic therapy is approved by the FDA to treat prediabetes.
“We all get hung up on labels and specific numbers, but cut points [for prediabetes] are arbitrary,” said Einhorn. “We should be looking less at numbers and more at the evaluation of the people.”
The guidelines are the first comprehensive treatment regimen for patients with prediabetes. The final document consensus statement will be published in Endocrine Practice later this year. – by Katie Kalvaitis
The question is: What should one do about people who have abnormalities of blood glucose that are in between normal and diabetic? This state has been referred to by a number of terms, including the current one, 'prediabetes.' It is prediabetes in the sense that anyone who was normal and then becomes diabetic must at some point go through an intermediate stage. But it is not prediabetes in the sense that a substantial number of persons who have blood glucose in the intermediate range do not progress to develop diabetes. How should one categorize and then treat these people? Certainly, glycemic treatment is appropriate for diabetes. Lifestyle modification with focus on diet and exercise always makes sense. It is not clear that glycemic treatment before the time of diabetes is beneficial in preventing adverse events. Additionally, treatment of blood pressure and lipids with the more aggressive approach we currently use for treating patients with diabetes appears reasonable for prediabetes, recognizing that data are not 100% clear that the very strict blood glucose, blood pressure and cholesterol targets we establish are absolutely necessary, even for diabetes. If we did have definite answers to these questions, of course, we would not need a consensus conference. In the judgment of the many experts who contributed to the panel, these seem to be reasonable approaches.
– Zachary T. Bloomgarden, MD
Endocrine Today Editorial Board member