April 28, 2016

Physicians Passing on Treating Prediabetes

I am not sure the ADA actually said this. “According to the ADA, if A1C is between 5.7-6.4%, the patient is considered prediabetic and should be treated with lifestyle modifications and possibly metformin therapy.” But this is what the author of the article stated and I hope it is true, as a prediabetes diagnosis is a last call for patients to take action to possibly prevent a lifelong battle with diabetes.

As I explained in this blog, many doctors won't treat prediabetes in the hopes that they will soon have a patient with type 2 diabetes that they can treat. They use words like, “watch what you eat, as your blood sugar is elevated.” We know this is code for prediabetes and these doctors are licking their chops knowing they will soon have a captive patient to treat. I must state that not all doctors are this callus and do diagnosis prediabetes, but then fail to help the patient.

A new article published in Journal of the American Board of Family Medicine (JABFM) states that only 23% of prediabetes patients were diagnosed by their healthcare providers and started on appropriate therapy. Researchers looked at the data from the 2012 National Ambulatory Medical Care Survey, which included adults over 45 years of age with no diabetes and their A1C tested within the last 90 days. A1C results were categorized as normal, prediabetes, or diabetes and were broken down based on age, sex, race, payer type, body mass index, and prediabetes treatment.

A total of 518 visits were analyzed. The survey found that 54.6% of participants had a normal A1C, 33.6% had prediabetes, and 11.9% had diabetes. Only 23.0% of patients categorized as having prediabetes received treatment; the most common was counseling on lifestyle modifications. Rates of prediabetes were similar between men (36.5%) and women (40.0%). The most frequent primary diagnosis was hypertensive disease (16.3%). There were no noticeable differences in applied treatments based on HbA1c level range whether patients had an HbA1c level of 5.7% or 6.4%.

This proves the doctors don't have the best interests of their patients in mind and are afraid of diabetes and prediabetes. Why they won't prescribe metformin is unknown. This is a generic diabetes medication, very inexpensive, and many endocrinologists do prescribe it “off-label.” It is the safest diabetes drug available and while not FDA approved for prediabetes, it still needs to be prescribed.

Primary care physicians (PCPs) should play an active role in the lives of their patients who have prediabetes and diabetes. The increasing prevalence of diabetes is a major health problem and the American Diabetes Association recommends screening for prediabetes in all individuals over 44 years of age and children who are obese.

When patients do have elevated A1C, PCPs must intervene. By providing them counseling and medication therapy, and following up with them, PCPs can influence patients’ lives by delaying the onset of diabetes, or perhaps even preventing patients from transitioning to diabetes. Prevention is the most effective strategy to treat diabetes that we have so far, and can greatly improve the overall quality of life of an affected patient as well as help lower the total cost of healthcare for all of us.

In the last ten days, I have been in email correspondence with three individuals that actually asked for and received copies of their lab reports. All three had A1c's in the prediabetes range and asked what they should be doing. All stated that the doctor had made a statement like the one in the second paragraph above. I asked if they had insurance and explained that metformin would probably not be covered, but they should check this and testing supplies. If insurance would not cover any of this, they should investigate purchasing testing supplies from a pharmacy that was low cost and known for this. They needed to talk to their doctor about prescribing metformin ER (extended release) or even just metformin as it was a low cost generic.

Two of the individuals said their doctor would not prescribe metformin and I suggested they get a referral to an endocrinologist or lacking this, getting an appointment with one. Then they should talk to the endocrinologist about a prescription for metformin. They said they would and I have told all three that I would work with them on “eating to their meter” and learning what the meter readings were telling them.

This is one reason I promote obtaining your lab reports so that you will know what the results are and if there is need for concern and action on your part. I would suggest reading this article in Diabetes-in-Control.

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