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Endo’s Issue Consensus Statement on Pre-Diabetes

It is good to see that there is more concern for those at risk for diabetes. The treatment of pre-diabetes requires intensive lifestyle modification and the use of metformin and acarbose for controlling glycemia for high-risk patients, declared a consensus statement issued by the American College of Endocrinology task force.

The statement was meant to fill the void in recommendations for treating pre-diabetes by defining specific goals and targets for glucose levels, weight, blood pressure, and lipids, according to Alan Garber, M.D., Ph.D., of Baylor College of Medicine in Houston, who chaired the 17-member task force.

 

The CDC estimates that about 57 million U.S. adults have pre-diabetes, defined as impaired fasting glucose of 100 to 125 mg/dL, impaired glucose tolerance of 140 to 199 mg/dL, or both. (See: Number of Patients with Diabetes Climbs to 24 Million, this week Item# )

About 6% to 10% of patients with impaired glucose tolerance will develop diabetes each year, and among patients with both impaired fasting glucose and glucose tolerance, about 60% will have diabetes in six years. Also, half of all patients with impaired glucose tolerance meet the criteria for metabolic syndrome, according to the task force report.

"The preferred treatment approach for all the abnormalities of persons in this group is intensive lifestyle management, given its safety and the strong evidence of efficacy of this approach in improving glycemia and reducing cardiovascular risk factors," the report said.

The task force recommended that patients with pre-diabetes lose 5% to 10% of their body weight assisted by self-monitoring, the setting of realistic goals, stimulus control, cognitive strategies, social support, and appropriate reinforcement.
Pre-diabetics should get at least 150 minutes of moderate-intensity exercise – such as walking or biking — per week, the task force said, and should limit total and saturated fat and transfatty acids.

For patients at a particularly high risk — for example, those with worsening glycemia, cardiovascular disease, or nonalcoholic fatty liver disease — complementing lifestyle modification with medication should be considered, the task force said.

Doctors should consider drugs to lower glucose, cholesterol and blood pressure.  Asprin is recommended. 

"Although lifestyle can clearly modify the progression of patients towards overt diabetes, it may not be sufficient," Dr. Garber said.  The task force recommended metformin and acarbose for controlling glycemia on the basis of their efficacy in reducing the transition from pre-diabetes to diabetes and their safety.

The authors cited safety concerns with thiazolidinediones as well as insufficient evidence to recommend new agents such as glucagon-like peptide 1 (GLP-1) receptor agonists, dipeptidyl peptidase-4 (DPP4) inhibitors, and meglitinides.

In addition, pre-diabetics should meet the same lipid and blood pressure targets as diabetics using statins, ACE inhibitors, and angiotensin Ireceptor blockers as first-line treatments, according to the report. The authors made similar recommendations for lifestyle modification and medication use for children and adolescents with pre-diabetes.

However, they said, the "emphasis must be placed on lifestyle change which can be beneficial in improving glycemic and cardiovascular risk parameters."

In addition to the treatment recommendations, the task force outlined measures for monitoring patients with pre-diabetes for a worsening of the condition.  These included an annual glucose tolerance test and testing for microalbuminuria and twice-yearly evaluation of fasting plasma glucose, hemoglobin A1c, and lipids.

The authors said that "the costs of diabetes prevention can be balanced against cost savings realized from fewer patient-years of the disease, a reduction in complications, and decreased need for hospitalization."

They also stressed that health insurance should start providing better coverage for lifestyle intervention programs.
"Healthcare systems that emphasize acute care to the exclusion of disease prevention or chronic disease management will fail patients with diabetes and patients at high risk of diabetes," they said.

Practice Pearl:
Explain to interested patients that the authors of this consensus statement stressed the importance of lifestyle modification in treating pre-diabetes, although they said that medications should be considered in high-risk patients.
American College of Endocrinology Task Force on Pre-Diabetes "Consensus statement on the diagnosis and management of pre-diabetes in the continuum of hyperglycemia — when do the risks of diabetes begin?" 2008.

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