What are the management options for prediabetes?

Management Options for Prediabetes

Intensive lifestyle modification is the first-line treatment for prediabetes, targeting 7-10% weight loss through caloric reduction and at least 150 minutes of moderate-intensity physical activity per week, with metformin recommended for high-risk individuals who don't achieve goals with lifestyle changes alone. 1

Diagnostic Criteria for Prediabetes

Prediabetes is diagnosed when one of the following criteria is met:

• Fasting plasma glucose: 100-125 mg/dL
• 2-hour glucose during OGTT: 140-199 mg/dL
• A1C: 5.7-6.4% 1

First-Line Treatment: Lifestyle Modification

Dietary Recommendations

• Target 7-10% weight loss through caloric restriction
• Create a 500-750 kcal/day deficit 1
• Focus on Mediterranean or DASH eating patterns
• Emphasize whole grains, legumes, nuts, fruits, and vegetables 1
• Consider referral to a registered dietitian/nutritionist for individualized medical nutrition therapy 1

Physical Activity

• At least 150 minutes/week of moderate-intensity physical activity
• Combine aerobic and resistance training exercises
• Break up prolonged sitting time with short activity breaks 1
• Recent evidence shows that structured exercise programs significantly improve metabolic parameters 2

Pharmacological Management

Metformin

• Recommended for high-risk individuals who don't achieve goals with lifestyle changes alone
• Most effective for:
  • Individuals with BMI ≥35 kg/m²
  • Age <60 years
  • Women with prior gestational diabetes mellitus
  • Fasting plasma glucose ≥110 mg/dL
  • A1C ≥6.0% 1, 3
• Reduces diabetes risk by approximately 31% over 3 years 1
• Monitor vitamin B12 levels in patients on long-term metformin 1

Other Medication Options

When lifestyle modification fails and in high-risk patients, consider:

• GLP-1 receptor agonists
• Pioglitazone
• SGLT2 inhibitors
• Acarbose
• Phentermine 1, 4

Structured Diabetes Prevention Programs

• Refer patients to CDC-recognized Diabetes Prevention Programs (DPP)
• Programs should include interaction with a coach and use an approved curriculum
• Both in-person and virtual programs are effective based on patient preference
• Medicare DPP coverage available for eligible individuals (BMI ≥25 kg/m² or ≥23 kg/m² if Asian) 1
• Group delivery in community or primary care settings can reduce program costs while still producing weight loss and diabetes risk reduction 1

Cardiovascular Risk Management

• Screen for and treat modifiable cardiovascular risk factors
• Manage hypertension and dyslipidemia with the same treatment goals as for the general population
• Regularly monitor blood pressure, lipids, and other risk factors 1, 4
• Consider lipid-lowering and blood pressure-reducing therapies as indicated 1

Monitoring and Follow-up

• Test for progression to diabetes at least annually
• Regular weight checks
• Monitor cardiovascular risk factors 1
• Recent evidence shows that structured multidomain interventions can lead to remission of prediabetes in approximately 20% of patients within 12 months 2

Common Pitfalls to Avoid

• Underutilization of metformin in high-risk individuals
• Inadequate implementation of lifestyle modification programs
• Insufficient monitoring of vitamin B12 levels in patients on long-term metformin 1
• Lack of consistent follow-up and reinforcement of lifestyle changes
• Failure to recognize the importance of addressing both glycemic control and cardiovascular risk factors 4

The most recent evidence from 2023 confirms that lifestyle modification is associated with a larger benefit than metformin, with intensive lifestyle modification decreasing diabetes incidence by 6.2 cases per 100 person-years compared to 3.2 cases with metformin during a 3-year period 3.