Guideline stress lifestyle changes for prediabetes

Prediabetes is widespread in the United States, but little guidance is available for physicians who want to treat it. A recent consensus conference convened by the American College of Endocrinology (ACE) and the American Association of Clinical Endocrinologists (AACE) aimed to assist physicians by developing guidelines for managing prediabetes.

According to the medical director of Scripps Whittier Institute for Diabetes in La Jolla, Calif., and vice president of the AACE, prediabetes occurs in the gap between normal glucose levels and levels meeting the current criteria for diabetes. Patients whose lab values fall into the gap can be carrying a risk of complications approaching the association with full-blown diabetes.

In terms of numbers, the currently accepted definition of prediabetes is an impaired fasting glucose (100-125 mg/dL), an impaired glucose tolerance (a 2-hour post-glucose load of 140-199 mg/dL), or both. More than 50 million adults in the United States meet the criteria for prediabetes, according to the Centers of Disease Control and Prevention in Atlanta.

The consensus conference “has been in the works for over a year,” the chair of the consensus conference program committee said. “We felt we had to come out with some type of recommendation for how to treat these patients.”

In the draft consensus document developed at the conference, the group emphasized that patients considered prediabetic “should be treated for the same cardiovascular goals as diebetic patients, including blood pressure and lipid goals.” The consensus statement is the first to recommend that people with prediabetes make a specific effort to improve their blood pressure and cholesterol profiles.

The recommendations, which will be finalized and published later in 2008, also emphasize that signs of metabolic syndrome should prompt primary care physicians to do glucose tests and check patients for prediabetes, noted an endocrinologist on the voluntary faculty at the University of Miami. Then they can focus on reducing cardiovascular risk factors while patients are still in prediabetes state.

The recommendations emphasize intensive lifestyle management for anyone who meets the criteria for prediabetes. “Nothing else matches lifestyle in reducing the complications of diabetes.”

If lifestyle modification is not enough, or if someone is at increased risk for cardiovascular problems or progression to diabetes, the recommendations call for adding medications to manage blood pressure and cholesterol, in addition to glucose control medications if necessary.

The recommendations also state that “monitoring of patients with prediabetes to assess for worsening of glycenic status should include annual glucose tolerance tests and testing for microalbuminuria.” In addition, fasting plasma glucose, hemoglobin A1c, and lipids should be checked twice a year. If hyperglycemia or cardiovascular risk factors are getting worse, more intense lifestyle modifications and pharmacotherapy may be needed.

One of the challenges in deciding whether to treat prediabetes is that although it is not benign condition, it is essentially asymptomatic, an epidemiologist at the University of Texas at San Antonio.

“These people are completely well,” who spoke at the consensus conference about the challenges of predicting disease outcomes in persons who meet criteria for prediabetes. “It needs to be demonstrated that early intervention is superior to delayed intervention.”

Cost-effectiveness must be considered, too. Any treatment incurs costs, but not everyone who meets criteria for treatment will progress to poor clinical outcomes, he noted.

Data from recent studies presented at the consensus conference suggest that the beginnings of the characteristic complications of diabetes can appear in individuals who meet criteria for prediabetes. It is based on these findings that recommendations state that persons with prediabetes should focus on reducing their risk of diabetes by taking action to improve risk factors such as high blood factors, high cholesterol, and excess weight.

Although most of the consensus committee members were endocrinologists, the recommendations are aimed more at primary care physicians. That’s because the number of prediabetes patients outscripts the capability of the endocrinology community, and primary care physicians are most likely to see prediabetes patients initially.