Under Treatment of Pre-diabetes Has Future Costs

This is another great topic presented at the AACE 2015 meeting. Pre-diabetes is an underserved segment of the diabetes population and gets no respect. Even the ADA who called the expert gathering for this in 2003 has taken no action to promote treatment of people with pre-diabetes.

At least the AADE says it may be time to rethink management of pre-diabetes, according to some experts and clinicians may need to do more to address pre-diabetes. Unfortunately, there are no agents approved by the Food and Drug Administration (FDA) for treating pre-diabetes. Yet, an estimated 79 million people in the USA have pre-diabetes and 40% to 50% of those will progress to type 2 diabetes.

Consequently, endocrinologists and other health care providers may want to be more aggressive in managing pre-diabetes once it is diagnosed, researchers said at AADE 2015, the annual meeting of the American Association of Diabetes Educators.

This attitude of managing pre-diabetes once it is diagnosed is the crux of the problem. Many doctors and clinicians don't take pre-diabetes seriously and refuse to diagnose it especially in light of no FDA approved medications for pre-diabetes.

“We have interacted with many providers in the past who did not see management of prediabetes as a patient-care priority. They felt that there wasn't much to do until the formal diagnosis of diabetes was made. It is important to appreciate the continuum of diabetes,” clinical pharmacist Jeremy Johnson, PharmD, MBA, of the Southwestern Oklahoma State University College of Pharmacy in Waterford, said during a presentation.

Once a patient has pre-diabetes, the pathophysiologic process that builds to what we have defined as ‘diabetes' has begun. Prevention or the delay of disease progression is the goal.”

“With prediabetes, many of the pathophysiologic abnormalities already exist,” clinical pharmacist Katherine O'Neal, PharmD, MBA, BCACP, CDE, BC-ADM, AE-C, of the University of Oklahoma College of Pharmacy and School of Community Medicine in Tulsa said, “and upon diagnosis, approximately 10% to 15% of patients show signs of microvascular complications.”

Currently, the American Diabetes Association (ADA) recommends lifestyle changes as first-line therapy for pre-diabetes.

“While lifestyle modifications are extremely important, at times, drug therapy may be of benefit or necessary,” Johnson told Endocrinology Advisor. “While many providers may be familiar with lifestyle recommendations and use of metformin as recommended by the American Diabetes Association, other options are often needed.”

Johnson and O'Neal presented a review of the current literature on the effectiveness of non-traditional agents in the management of pre-diabetes. They said it is now the responsibility of health care providers to share with patients who have pre-diabetes all available options to help delay the progression to diabetes.

“Under diagnosing and under treating pre-diabetes is having an enormous economic, clinical and humanistic impact,” Johnson said.

There was more to the report, but the concern needs to be education of doctors to the importance of treating patients with pre-diabetes to slow or prevent the progression to full diabetes. The following is important to the discussion:

Eventually, the beta cells can no longer compensate and hyperglycemia is the result.

Johnson said pre-diabetes is often not diagnosed until complications present and approximately one-fourth are undiagnosed. Therefore, he suggests that clinicians should consider screening asymptomatic adults if they are overweight (BMI of at least 25) or have one or more risk factors.

He also recommends women be screened if they delivered a baby weighing more than 9 lb, had gestational diabetes or have polycystic ovary syndrome (PCOS).

At present, the ADA recommends weight loss if necessary, increasing physical activity to at least 150 minutes per week of moderate physical activity and the addition of metformin if the patient:

• Has impaired glucose tolerance or impaired fasting glucose
• Has an HbA1c between 5.7% and 6.4%
• Has a BMI greater than 35
• Is younger than 60 years old
• Is a woman over the age of 60
• Has had gestational diabetes

In some aspects of the discussion, I have to wonder the purpose of the medications promoted and would question possible conflicts of interest. The two speakers were promoting some heavy-duty oral medications. You can read the article here.