What is the first line of treatment for patients with prediabetes?

First-Line Treatment for Prediabetes

Intensive lifestyle modification is the first-line treatment for patients with prediabetes, consisting of 150+ minutes of moderate-to-vigorous physical activity weekly, healthy eating patterns, and 7-10% weight loss if overweight/obese. 1, 2

Diagnostic Criteria for Prediabetes

Prediabetes is defined by any of the following:

• Fasting glucose: 100-125 mg/dL
• 2-hour post-load glucose: 140-199 mg/dL after 75g oral glucose load
• HbA1c: 5.7-6.4% 2

First-Line Treatment Approach

Lifestyle Modification Components

1. Physical Activity

   • At least 150 minutes of moderate-to-vigorous physical activity weekly 1
   • Spread over at least 3 days with no more than 2 consecutive days without exercise 1
   • Include muscle and bone strength training at least 3 days/week 1
   • Reduce sedentary behavior 1

2. Nutrition

   • Focus on healthy eating patterns emphasizing nutrient-dense, high-quality foods 1
   • Decrease consumption of calorie-dense, nutrient-poor foods 1
   • Particularly reduce sugar-added beverages 1
   • Consider DASH-style eating pattern with reduced sodium and increased potassium 1

3. Weight Management

   • Target 7-10% weight loss if overweight/obese 1, 2
   • Either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective 1

Pharmacological Therapy

If lifestyle modification alone is insufficient or for high-risk individuals, consider adding pharmacological therapy:

Metformin

• Consider metformin for patients with:
  • A1C ≥ 6.0% 3
  • BMI ≥ 35 kg/m² 1, 2
  • Age < 60 years 1, 2
  • History of gestational diabetes 1, 2
  • Fasting plasma glucose ≥ 110 mg/dL 2

Other Pharmacological Options (in specific situations)

• GLP-1 receptor agonists for patients with obesity 1
• Pioglitazone in selected cases 1
• Acarbose as an alternative option 1, 4

Monitoring and Follow-up

• Check HbA1c every 3 months to assess glycemic response 3
• Target HbA1c < 6.5% for most patients with prediabetes 3
• Monitor for progression to diabetes
• Address cardiovascular risk factors (hypertension, dyslipidemia) 1

Clinical Considerations and Pitfalls

• Effectiveness comparison: Intensive lifestyle modification is more effective than metformin alone, reducing diabetes incidence by 6.2 cases per 100 person-years versus 3.2 cases with metformin 2
• Adherence challenges: Despite strong evidence for lifestyle interventions, implementation and adherence remain significant challenges 5
• Comprehensive approach: Address all modifiable risk factors including sleep quality, stress management, and social support 6
• Technology assistance: Consider technology-assisted goal setting to improve physical activity adherence 7
• Cardiovascular risk: Prediabetes increases cardiovascular event risk, so comprehensive cardiovascular risk management is essential 2

Risk Stratification

Higher-risk patients who may benefit from more aggressive intervention include those with:

• Multiple prediabetes criteria (IFG, IGT, and metabolic syndrome) 4
• Family history of diabetes
• Higher BMI (≥35 kg/m²)
• Higher A1C (≥6.0%)
• History of gestational diabetes

By implementing these evidence-based interventions early, progression to type 2 diabetes can be significantly delayed or prevented, reducing long-term morbidity and mortality.