Treating Patients with PRE- DIABETES David Doriguzzi, PA-C First Valley Medical Group. Learning Objectives. Background

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1 Treating Patients with PRE- DIABETES David Doriguzzi, PA-C First Valley Medical Group Learning Objectives To accurately make the diagnosis of pre-diabetes/metabolic syndrome To understand the prevalence of this disorder To understand the risk that pre-diabetes poses to the patient To know the treatment options available to manage pre-diabetes To understand the benefits and efficacy of lifestyle modification vs medication in management To motivate patients to actively participate in the treatment plan Background Type 2 Diabetes diagnostic criteria (ADA) 1 Fasting blood glucose greater than or equal to 126 mg/dl on more than one occasion 2-hour glucose tolerance test greater than or equal to 200 mg/dl Hemoglobin A1c measurement greater than or equal to 6.5%

2 Background Pre-Diabetes diagnostic criteria (ADA) 1 Fasting blood glucose between 100 and 125 mg/dl on more than one occasion 2-hour glucose tolerance test between 140 and 199 mg/dl Hemoglobin A1c measurement between 5.7 and 6.4% Diagnostic criteria (ADA) 1 Background Importance of Recognition Pre-Diabetes is a direct risk factor for Type 2 Diabetes 1/3 of pre-diabetics will progress into full diabetes Pre-diabetes (whether the patient progresses to DM2 or not) carries an increased risk of cardiovascular complications and cancer Pre-diabetes appears to be closely associated with Metabolic Syndrome (abdominal obesity, elevated BP, impaired fasting blood glucose, elevated triglycerides, and low HDL)

3 Epidemiology Diabetes incidence is increasing at alarming rates M US persons with diabetes in 1980 has increased to 20.9 M in 2011 Incidence of Type 2 Diabetes has increased by 40% between 2007 and 2012 Incidence of Pre-Diabetes has increased by 70% between 2007 and 2012 Epidemiology Diabetes prevalence is expected to rise to 1/3 of the general population by the year % OF GENERAL POPULATION Pre-diabetes Prevalence Approximately 1/3 of all US adults have Pre-Diabetes (86 Million) 5 About 56% of US adults over 65 are Pre-Diabetic 16% of adolescents age have either impaired fasting glucose or impaired glucose tolerance 6 Only 11% of people with pre-diabetes are aware of the condition

4 The Key Early identification of pre-diabetes is key ADA recommends screening all adults with BMI >25 if there are additional risk factors for diabetes 7 If no other risk factors, consider screening adults with BMI > 25 starting at age 45. Repeat in 3 years if normal. Test A1c [at least] yearly if a patient is confirmed to have pre-diabetes Identifying patients at risk Understanding diabetes risk factors helps to identify patients at risk of pre-diabetes. Diabetes Risk Factors Family history of DM (first degree) Previous A1c > 5.7% Physical inactivity High-risk race/ethnicity Hypertension History of cardiovascular disease Dyslipidemia History of gestational diabetes or delivery of a baby weighing more than 9 lbs. Severe obesity Other conditions related to insulin resistance (eg. PCOS or acanthosis nigrans)

5 So we have a diagnosis. Now What? Appropriate approach to patients with pre-diabetes isn t as clearly laid out as recommendations for Type 2 diabetes The Goal Intervention of prediabetes aims to influence the inertia of the disease state, to prevent progression into Type 2 Diabetes and, ideally, revert to a normal metabolic state Management AGGRESSIVE management of pre-diabetes can have a significant impact on preventing progression into Type 2 Diabetes Developing an appropriately aggressive management is an individualized process that requires understanding your patients on an individual level, a solid understanding of the diabetes disease process, and a fair amount of dedication from the both the patient and the provider

6 Diabetes Disease Process But what IS pre-diabetes?? Diabetes Normal Pre-Diabetes? But what IS pre-diabetes??

7 Management Diabetes Prevention Program Research Group is one of the best known studies evaluating treatment strategies in pre-diabetes. 8 3,234 pre-diabetics were randomized to Placebo, Metformin (850 mg BID), or intensive lifestyle modification. Patients on placebo and metformin were provided with information about diet and exercise, but did not get intensive guidance Management Lifestyle modification group had very clear and intense guidelines Patients were to exercise 150 minutes per week at moderate-tovigorous intensity Goal was at least 7% weight loss, compared to baseline Patients had regular interactions with dieticians and personal trainers Management

8 Lifestyle Recommendations Exercise at least 150 minutes per week, spread over at least 3 days per week Don t go more than 2 consecutive days without exercise Incorporate resistance/weight training at least twice per week Avoid prolonged (>90 minutes) of sedentary time Be sure to individualize the plan for a patient s age, physical limitations (eg. OA), and previous level of activity Working one s way up gradually is acceptable Counsel patients in detail regarding dietary changes Management The Da Qing study 9 and the Finnish DPS 10 studies have also shown significant improvement of outcomes with rigorous lifestyle modification Metformin, Alpha-glucosidase inhibitors (acarbose), orlistat, and Thiazolidinediones have all been studied in pre-diabetes and have been shown to be 20-80% effective in preventing progression to DM2, depending on the medication and the study ADA position is that metformin has the strongest evidence base and is recommended first line Medically-Assisted Weight Loss Lorcaserin (Belviq), Phentermine/Topiramate (Qsymia), Naltrexone/Bubroprion (Contrave), and Liraglutide (Saxenda) are FDA approved medications for treatment of obesity in combination with lifestyle modification. Bariatric surgery can also be considered in patients with BMI>40 kg/m 2 without risk factors or BMI>35 kg/m 2 with at least one obesity-related comorbidity

9 Choosing the Right Approach Developing a treatment plan requires truly understanding the patient Recommending a lifestyle modification plan requires truly understanding the exercise Choosing a medication plan involves truly understanding the diabetes process Pre-diabetes is the earliest stages of the diabetes process Summary Early identification and early intervention of pre-diabetes is key in managing the condition Medication therapy offers a valid improvement of the disease state Intensive lifestyle modification offers a greater impact on interrupting the disease inertia The health care provider s approach and level of dedication in guiding the patient through effective lifestyle modification can greatly impact the patient s adherence and ultimate outcome

10 Citations 1. American Diabetes Association (2012) Diagnosis and classification of diabetes mellitus. Diabetes Care, 35(Suppl 1): S64-S71 2. Center for Disease Control and Prevention; 3. Boyle, JP, et al. Popul Health Metr 2010; 8: Diabetes Care 2014; 37: CDC. MMWR Morb Mortal Weekly Report 2013; 62: Li C, et al. Diabetes Care. 2009; 32: ADA. Diabetes Care. 2015: 38 (suppl 1): S8-S16 8. Knowler, et al. N Eng J Med 2002; 346: Diabetes Care 1997;20: N Eng J Med;2001;