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Prediabetes Diagnosis Guidelines Changed from 110 to 100mg/dL

A blood glucose reading of 100mg/dL is Prediabetes. The newer threshold or cut-off point for fasting plasma glucose will increase those with Prediabetes to 5 million more with Prediabetes.

October 25th: An international expert committee on the diagnosis and classification of diabetes mellitus has published revised guidelines, which incorporate new data since the last report of 1997, in the November issue of Diabetes Care.

"Lowering the threshold should help pick up more people who are at increased risk for developing diabetes," Committee Chair Saul Genuth, MD, from Case Western Reserve University in Cleveland, Ohio, says in a news release. "What’s important about that is that we now know — through studies such as the Diabetes Prevention Program (DPP) and the Finnish Diabetes Study — that we can prevent or delay the progression to diabetes from impaired glucose tolerance, the original component with the term pre-diabetes, through intensive lifestyle treatment, such as exercise and diet therapy. We hope, but don’t yet know, that intervening earlier might also reduce the risk of diabetic complications, including cardiovascular complications."

Modest weight loss and regular exercise can prevent or delay the development of type 2 diabetes by up to 58%, based on results of the DPP and other studies.

Criteria for the diagnosis of diabetes remain unchanged, and the committee recommended against using the HbA1C as a routine diagnostic test for diabetes. Although clinical evidence is currently inadequate for superiority of either the fasting plasma glucose (FPG) test or the oral glucose tolerance test (OGTT), the committee prefers the FPG because of its greater convenience and lower cost.

The American Diabetes Association (ADA) recommends that individuals aged 45 years or older, especially those who are overweight or obese, be screened for diabetes/prediabetes and retested every three years if normal. Individuals at increased risk because of obesity, family history, gestational diabetes, or other recognized risk factors for diabetes should be considered for screening every few years, according to Dr. Genuth.

Unanswered questions mandating further research include defining the best approach to diabetes detection, understanding the pathophysiology and risks of IPG and glucose tolerance, and determining to what extent cardiovascular risk can be lowered by starting treatment of glycemia earlier.

"The answers to these and other questions will necessitate regular surveillance and reconsideration of new data that may lead to appropriate revisions to the diagnostic and classification criteria for diabetes over time," the authors write. Diabetes Care. 2003;26:3160-3167

Pearls for Practice
The cut point for FPG has been reduced from 110 to 100 mg/dL, which will increase the number of individuals diagnosed with prediabetes.

There is inadequate evidence to choose between the FPG and 2-hour PG tests, and judgment may be based on test feasibility, reliability, and reproducibility. Both may be performed in any one patient to confirm diabetes diagnosis. More Information
 

Most patients who’ve had a heart attack or stroke should take aspirin…to prevent a SECOND one. But should patients take aspirin to prevent a cardiovascular event even if they’ve never had a FIRST one? It’s a judgment call.

Aspirin can decrease the risk of a first heart attack. But it also increases the risk of GI bleeding and hemorrhagic stroke. Consider aspirin for patients most likely to benefit…men over 40…postmenopausal women…and younger patients with risk factors such as high cholesterol, hypertension, diabetes, smoking.

Think twice before recommending aspirin for patients at risk for bleeding due to gastric ulcers…uncontrolled hypertension…or if they are taking NSAIDs or anticoagulants. Cardiologists are debating the proper dose of aspirin.

Guidelines aren’t specific. They recommend 81 mg to 325 mg/day. But now experts are recognizing that 81 mg/day is at least as effective as higher doses…and likely safer.

Doses over 200 mg/day seem to almost double the bleeding risk. And, higher doses might actually be LESS effective than lower doses. High aspirin doses seem to inhibit prostacyclin, and lead to vasoconstriction…and possibly a paradoxical INCREASE in clotting.

Tell patients who need aspirin that 81 mg/day is usually best. Explain that a higher dose ISN’T more effective…and can increase the chance of serious side effects. Tell people that enteric-coated aspirin works just as well as non-enteric coated. But enteric coating doesn’t eliminate GI bleeding.

Keep in mind that taking 325 mg is still recommended during a heart attack…to prevent reinfarction or ischemic stroke. The higher dose is needed for a quick antiplatelet effect.

What about those with diabetes? There is growing consensus that people with diabetes mellitus are at particularly high short-term risk for the development of CHD.6,15 In fact, guidelines by the AHA and National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III [ATP III]) consider patients with diabetes to have an equal risk of developing vascular events as individuals with known CHD.6,15 For this reason, the ATP III risk assessment tables do not take diabetes into account when calculating risk. The ATP III considers people with diabetes to be at such high risk that secondary preventative strategies are necessary for cholesterol lowering regardless of other risk factors.15

At this time the American Diabetes Association (ADA) recommends aspirin therapy as secondary prevention in all diabetics with known CHD and as primary prevention in some diabetics at high risk for CHD [Evidence level C, Consensus].16 Factors identified by the ADA to increase CHD risk and warrant aspirin therapy include family history of CHD, smoking, hypertension, obesity (>120% desirable weight, body-mass-index [BMI] >27.3 kg/m2 in women and >27.8 kg/m2 in men), albuminuria (micro or macro), hyperlipidemia (cholesterol > 200 mg/dL, LDL > 100 mg/dL, HDL < 45 mg/dL in men and < 55 mg/dL in women, triglycerides > 200 mg/dL), and age > 30 years.16

For years there has been debate in the medical community regarding when to use aspirin for vascular prevention and what is the best dose to use. Randomized-controlled trials and established guidelines recommend the use of once-daily aspirin in most patients with known vascular disease [Evidence level A, RCT].2,3 Primary prevention trials and expert consensus also advocate the use of aspirin in high-risk patients [Evidence level A, RCT].1,4-6 Aspirin should be used cautiously in patients with uncontrolled hypertension or in combination with NSAIDs or anticoagulants, due to an increase risk of bleeding.4,5
Based on data from recent trials, lower doses of aspirin are at least as effective as higher doses for the primary or secondary prevention of vascular events2,8 and may be associated with a lower risk of bleeding.8,9 In most cases, 81 mg of aspirin daily should be sufficient to provide maximal antiplatelet effects with minimal risk of bleeding. In acute settings (e.g., MI), a higher initial loading dose of aspirin (e.g., 325 mg) is warranted to ensure complete immediate blockade of thromboxaneA2.2 Further evaluation of aspirin in large, randomized trials is needed to better clarify the optimum dose of aspirin in different patient populations and clinical situations such as aspirin resistance.

Circulation 2002;106:388-91; JAMA 2001;285:2486-97: Diabetes Care 2003;26:S87-8.

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