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Experts debate role of metformin in management of prediabetes
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PHILADELPHIA — During an academic debate held here, two physicians argued the issue of whether lifestyle changes and metformin are adequate for the management of prediabetes.
Richard F. Hamman, MD, DrPH, founding dean and professor of epidemiology at the Colorado School of Public Health, took the “pro” side, arguing that lifestyle changes and metformin are adequate, using data from the Diabetes Prevention Program (DPP), the Finnish Diabetes Prevention Study (DPS) and other research to bolster his position. Opposite Hamman, Ralph A. DeFronzo, MD, professor of medicine and chief of the diabetes division at the University of Texas Health Science Center and the Audie L. Murphy Memorial VA Hospital in San Antonio, said lifestyle changes are not effective enough for the long-term treatment of patients with diabetes in which metformin is not optimal.
“I’m sure Dr. DeFronzo will look at these data and tell us that weight re-gain means that lifestyle [change] is difficult to achieve. And there’s no question [that’s true] … but these weight loss data have also [demonstrated that a] reduction in diabetes incidence over 10 years is still substantially lower in the lifestyle group,” Hamman said.
He said the DPP and the DPS data showed lifestyle changes reduced the incidence of diabetes by 58% at 3 years after randomization. Additionally, the 10-year DPPOS follow-up demonstrated that diabetes incidence gradually increased among those without diabetes and at high risk for the disease at the start of the trial. In the placebo group, diabetes incidence increased the most.
“This is over the entire 10 years, cumulative,” Hamman said, adding that diabetes incidence was “reduced by 18% over 10 years by metformin and by 34% in the lifestyle group.” He said these reductions were both substantial, and risk reduction among different groups yielded an 86% reduction in diabetes incidence among the lifestyle group, and a 62% and a 69% reduction among the metformin and placebo groups, respectively.
“So, not surprisingly, maybe comfortingly, if you meet the weight goal and you maintain it over a long period of time, you very substantially reduce your risk,” he said.
In response, DeFronzo said early interventions at the prediabetes stage are essential to prevent type 2 diabetes. However, he recommended using other medications, including glucagon-like peptide 1 analogues and the thiazolidinedione agent pioglitazone (Actos, Takeda Pharmaceuticals), to improve insulin sensitivity and beta-cell function.
DeFronzo said the issue is not whether diet and exercise work, but that, “on a long-term basis, it doesn’t work in many individuals, and there is consistent weight gain. If you happen to be among the people who continue to lose weight and you keep the weight off, of course you have a good effect; that’s a no-brainer. The problem is it’s very difficult to get people to lose weight and keep it off on a long-term basis, particularly in the real-world situation.”
Ronald T. Ackermann, MD, MPH, FACP, director for Northwestern University’s Community Engaged Research Center and associate professor in medicine-general internal medicine and geriatrics, spoke neutrally on the topic when both presentations concluded, but went on to discuss the topic of payment for prevention.
“The evidence is strong for prevention effectiveness using metrics that employers, public payers and purchasers in the United States value. But there is some individual market, meaning some people will pay for prevention in terms of paying for things like Weight Watchers,” Ackermann said.
He also said, today in the United States, third-party purchasers have an expectation that they will pay for and receive wellness benefits.
“In more than half of individuals that includes weight management programs, and third-party payers are already paying for obesity management, Medicare and, in some cases, the DPP specifically, and have considered payment models like pay-for-performance to maximize cost and effectiveness over time,” Ackermann said.
For more information:
Ackermann RT. CT-SY14. Who will pay for prevention?
DeFronzo RA. CT-SY14. Lifestyle changes and metformin are not adequate.
Hamman RF. CT-SY14. Lifestyle changes and metformin are adequate.
All were presented at: The Role of Pharmacology in Managing Prediabetes Symposium. The American Diabetes Association’s 72nd Scientific Sessions; June 8-12, 2012; Philadelphia.
Ratner RE. Poster #1309. Presented at: The American Diabetes Association’s 72nd Scientific Sessions; June 8-12, 2012; Philadelphia.
Disclosure: Dr. DeFronzo reports being on advisory panels for and receiving research support from Amylin Pharmaceuticals, Eli Lilly and Company, and Takeda Pharmaceutical Company. He also reports being on the advisory panel for Boehringer Ingelheim Pharmaceuticals and the speakers’ bureau for Novo Nordisk. Dr. Ackerman reports consultancy for UnitedHealth Group/i3 Drug Safety. Dr. Hamman reports no relevant financial disclosures. Dr. Hamman participated in the planning, design and implementation of the DPP/OS and serves as the current national vice chair.