Friday, 15 May 2009

Prediabetes Aggressive Treatment

Prediabetes is defined as impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Some of these people with prediabetes already have microvascular changes which are characteristic of the condition diabetes mellitus itself.

The American Association of Clinical Endocrinologists (AACE) have recently released recommendations for prediabetes (here). Important recommendations are:
  • Lifestyle modification should be the cornerstone of treatment.
  • Persons with prediabetes should reduce weight by 5% to 10%, with long-term maintenance at this level.
  • A program of regular moderate-intensity physical activity for 30 to 60 minutes daily, at least 5 days weekly, is recommended.
  • A diet that includes calorie restriction, increased fiber intake, and possible limitations in carbohydrate intake is advised.
  • There is strong evidence from randomized multicenter interventional trials that metformin or acarbose reduce the progression of prediabetes to diabetes.
  • The committee believes that persons with prediabetes should have the same lipid goals as those with established diabetes.
  • The committee ecommends that prediabetic patients achieve the same target blood pressure currently recommended for persons with diabetes—that is, a systolic pressure less than 130 mm Hg and a diastolic pressure less than 80 mm Hg.
  • Low-dose aspirin is recommended for all persons with prediabetes for whom there is no identified excess risk for gastrointestinal, intracranial, or other hemorrhagic condition.
The AACE also identified areas of future research needed to further clarify the diagnosis and management of the prediabetic state?
  • Recommendation 1. We recommend that a retrospective analysis of data from previous long-term prevention studies be performed to determine whether there are unique characteristics that might distinguish with greater clarity the determinants of different levels of risk for conversion to diabetes.
  • Recommendation 2. To determine if there are specific characteristics that predict the development of cardiovascular outcomes in persons with prediabetes, we recommend that the retrospective analysis include assessment of the metabolic risk profiles of those persons who have developed CVD vs those who have not.
  • Recommendation 3. Since there are no conclusive studies to date that show that lowering of fasting or postprandial glucose prevents CVD in prediabetes, werecommend a clinical trial in which intensive control of all cardiovascular risk factors plus pharmacologic glucose lowering is achieved in prediabetic participants. The primary outcomes would be major cardiovascular events, microvascular complications, and death.
  • Recommendation 4. We recommend a clinical outcomes study that would test the hypothesis that simultaneous use of intensive lifestyle modification plus preventive pharmacotherapy results in the greatest degree of diabetes prevention in prediabetic participants, taking into account safety and cost-effectiveness.
  • Recommendation 5. We encourage further development of noninvasive methods of analyzing β-cell mass and more sensitive assessments of β-cell function in humans.
  • Recommendation 6. We encourage the identification of novel therapeutic agents for preservation of β-cell function.
  • Recommendation 7. We encourage further research in identifying unique genetic markers to specify unique β-cell therapeutic targets.
  • Recommendation 8. Diagnostic tests should be developed to better distinguish patients who will progress to diabetes from those who will not.
  • Recommendation 9. Greater understanding of the role of insulin resistance (eg, liver and/or fatty liver insulin resistance, mitochondrial dysfunction) in the conversion of prediabetes to diabetes is needed.

Aspirin -
β-cell - Diabetes Mellitus - Fasting Glucose - Hyperglycaemia - Insulin Resistance - Microvascular Disease - Prediabetes - Treatment
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