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Consensus statement on prediabetes confirms proper management
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On July 23 the American College of Endocrinology released a consensus statement on the diagnosis and management of pre-diabetes.
Approximately 57 million people in the United States have prediabetes, defined as either impaired fasting glucose or impaired glucose tolerance. Many of these individuals will eventually go on to develop overt diabetes mellitus. Some experience complications associated with diabetes, even before they meet criteria for formal diagnosis. However, when relying on fasting glucose alone, the diagnosis of prediabetes can be missed. Performing a two-hour oral glucose tolerance test in those patients considered to be at high risk, may increase the number of new cases indentified.
The committee accurately pointed out that prediabetes should never be considered to be benign. Besides being at risk to develop diabetes mellitus, individuals with prediabetes are more likely to have metabolic syndrome, hypertension and other comorbidities. Prediabetes is associated with greatly increased risk of future cardiovascular events.
The statement reiterated the importance of aggressive lifestyle modification. Even modest amounts of weight loss of 5-10 lbs have been shown to reduce the risk of developing diabetes. Weight loss can improve the control of hypertension and dyslipidemia. In addition to dietary modification, regular physical activity of about 30-60 minutes a day five days a week was recommended.
Because prediabetes is associated with increased cardiovascular risk, blood pressure and dyslipidemia should also be aggressively managed. The statement echoed the same targets for prediabetes as for overt diabetes: blood pressure of 130/80, LDL of 100 mg/dL, non-HDL cholesterol of 130 mg/dL and apolipoprotein of 90 mg/dL.
Although there is no FDA-approved pharmacotherapy for the treatment of prediabetes, the consensus statement did mention metformin and acarbose as possible options in those who fail lifestyle modification alone. Thiazolidinediones have also been shown to reduce the development of type 2 diabetes. However, because of concerns about potential risks of weight gain, CHF and fractures, there was no recommendation for this class to be used for routine treatment of prediabetes. The newer agents such as DPP-IV or glucagon-like peptide 1 agonists were also not recommended because of lack of safety and efficacy data.
None of this comes as any surprise to those of us involved in the care of people with prediabetes. We have already been attempting to manage our patients aggressively. Despite the success seen in clinical trials, initiating and maintaining lifestyle modification is met with variable success in the real world. Some of our patients do better than others. Many of us have already been using medications off-label for those who fail lifestyle modification. I am glad that the experts have finally reached a consensus to recommend pharmacotherapy as an additional option.