Prediabetes: How can we prevent the progression to type 2 diabetes?

prediabetes
Average A1C and blood glucose values in the pre-diabetic range

What is prediabetes?

Prediabetes describes a condition in which blood glucose levels are higher than normal, but not high enough to be diagnosed as diabetes. If you have prediabetes, you are at a high risk of developing type 2 diabetes within 10 years unless you take preventative measures.

How can you prevent prediabetes from becoming diabetes?

Lifestyle Changes

In 2002, the Diabetes Prevention Project (DPP) studied people with prediabetes who underwent intensive lifestyle intervention: 30 minutes of exercise per day, dietary changes, and at least 7% weight loss.

lifestyle intervention for prediabetes includes exercise

After these lifestyle changes, 58% of the study participants prevented (or significantly delayed) the development of type 2 diabetes. As a result of that study, Centers for Medicare and Medicaid Services recently announced that they will provide funding programs that help people achieve these kinds of lifestyle modifications.

biggest loserHowever, as we all know, it’s not easy make these permanent lifestyle changes — we are all creatures of habit. Take a look at some of the contestants on “The Biggest Loser” — they lost 50, 100, even 150 pounds! But after 6 years, most of them have gained most of it back. So, losing weight through diet and exercise is not the complete answer. It works for some people, but not for others.

Metformin

With all of the focus on lifestyle intervention, many people have lost sight of the fact that the DPP study included another approach – using metformin, a type 2 diabetes medication. People treated with metformin were 31% less likely to have their prediabetes develop into diabetes. It was not quite as effective as lifestyle modification, BUT a 31% reduction in the rate of progression to diabetes is still significant.

Since lifestyle modifications and metformin are both somewhat effective in preventing diabetes, but neither is 100% effective, it seems logical to combine them.

Results of DPP Study on Prediabetes & Diabetes prevention
Results of DPP Study (2002)

So, why aren’t we using Metformin to prevent diabetes?

metformin for prediabetesMany medical experts have recommended that metformin, as well as other diabetes drugs, be approved for people with prediabetes. Metformin has several advantages over the other drugs: it’s very safe and inexpensive, with the ‘co-pays’ at around $4 per month. It’s also associated with lower mortality, lower rates of heart disease, and lower rates of cancer. Metformin has even been shown to increase the lifespan of animals, and the FDA has now given the go ahead for a trial to see if it has the same effect on humans.

However, despite experts’ recommendations, the FDA has not approved any medication for the treatment of prediabetes.

OK… what about using it off-label?

Whenever doctors prescribe metformin to people who don’t have diabetes, they’re often told that the medication will not be approved by a pharmacy or insurance company. Doctors need to fight for an exception to the “diabetes only” rule. 

What’s the upshot?

Prediabetes is common condition — 86 million cases in the US, and 192 cases worldwide — and if not treated, many millions of people will develop type 2 diabetes. There are already nearly 500 million people with diabetes worldwide — we need to curb this epidemic. Lifestyle changes are one solution, but they are not the only solution, and they do not work for everyone.  Metformin is safe, effective and even has benefits that extend far beyond preventing diabetes. Why not use it? 

In light of the circumstances we face, we can’t afford to let any resources go unused. The FDA needs to approve medications for treatment of people with prediabetes, especially metformin, as soon as possible.

 

NOTE: Metformin should not be taken by people with kidney disease.  It should be discontinued when someone becomes dehydrated, when they have surgery, or if they get certain types of X-rays with a contrast agent. There is a very small chance – about 1 in 30,000  that metformin can cause a serious condition called lactic acidosis.

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David Rodbard MD
David Rodbard MD

David Rodbard MD is President of Biomedical Informatics Consultants, based in Washington DC, and is a specialist in diabetes and clinical endocrinology. Prior to consulting, David spent 30 years as a clinician, researcher, and computer scientist for the National Institutes of Health.