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Richard Pratley Part 2, Diabetes Prevention

In part 2 of this Exclusive Interview, Richard Pratley talks with Diabetes in Control Publisher Steve Freed during the AACE meeting in Austin, Texas about prediabetes intervention and options for prediabetes treatment outside of metformin.

Richard E. Pratley, MD serves as the Medical Director of the Florida Hospital Diabetes Institute. He is also a senior scientist at the Florida Hospital /Sanford-Burnham Translational Research Institute for Metabolism and Diabetes.

Transcript of this video segment:

Steve Freed: I see one of the things that you work with is preventing diabetes and nowadays that’s considered fairly important because of the cost to treat someone is so expensive. Where do you fit in when it comes to preventing diabetes because that’s probably one of the most important things when it comes to our whole healthcare system and that is preventing people from having all the complications that are very expensive with diabetes. So what kind of things can you tell us in your research that may be coming out, new technology and things, whatever you found to be very successful. I mean technically, the ADA doesn’t approve drug for prediabetes even though AACE recommends metformin. So where do you stand in that whole field and especially how do you determine a person even has prediabetes because 90% don’t know they have it?

Richard Pratley: That’s absolutely true. Prediabetes is epidemic just like diabetes. We have 86 million people with prediabetes in our country. Most people don’t know that they have it. Only about 7% or so the people with prediabetes know that they have it. Only less than 3% who are eligible for treatment with metformin are actually prescribed metformin. So we need to do better in identifying patients and talking to patients about prediabetes and the risk of diabetes. Now, prediabetes interventions are difficult in primary care practice because it involves weight loss and exercise interventions that most primary care practices are not well equipped to deliver. Unfortunately, there are a number of community resources such as the YMCA that we can call upon. So, become familiar with your local resources and refer patients to your local resources. But most of all have the conversation with your patients about prediabetes. I do recommend the use of metformin in patients with diabetes. It is most effective in obese and younger patients; not so effective in our older patients, so choose your patience carefully, but I think that it makes sense to treat patients with metformin because we know that in addition to the benefits of preventing diabetes may be other benefits in terms of long-term cardiovascular risk, so we really need to focus on identification and treatment of patients with prediabetes so that we can prevent this epidemic from worsening.

Steve Freed: At what A1c level for person with prediabetes, and that’s A1c is 5.7 to 6.4, at what point would you start to treat them with the only drug that we really have right now, although there’s talk about SGLT-2 for preventing diabetes and some of the GLPs. So, there’s a lot of drugs out there that can help lose weight and prevent them from getting diabetes that are even better than metformin.

Richard Pratley: That’s right. The evidence that we have for the pharmacologic treatment is pretty broad. I’ll go over that in just a second. But as a general rule of thumb is if somebody’s A1C is above 6% and particularly if they have not responded or have difficulty complying with diet and exercise then I think they are a good candidate for pharmacologic treatment. The US diabetes prevention program focused on metformin use I saw that decreases incident diabetes by 31%. However, we have other trials, including trials with thiazolidinediones that decrease incidence of diabetes anywhere from 40-60% and drug like liraglutide, which has been studied for the treatment of obesity. In that study, the number of patients who progressed to diabetes on treatment with liraglutide was remarkably small and more importantly a large number of patients regressed to have a perfectly normal glucose tolerance. It is also data with some of the other obesity agents and so I think we should think about prediabetes as a condition, which medications that alter body weight, decrease body weight, would be particularly useful for decreasing risk.

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