What is the management plan for a 23-year-old male with weight gain, acanthosis nigricans, impaired glucose regulation, and a body mass index (BMI) of 33.5, with lab results showing hyperglycemia (HbA1C: 5.5), normal thyroid function (T3 total: 1.11 ng/mL, T4 total: 7.70 ug/dL, Thyroid-Stimulating Hormone (TSH): 2.742 uIU/mL)?

Management of a 23-Year-Old Male with Obesity, Acanthosis Nigricans, and Pre-Diabetes

The primary management for this 23-year-old male with obesity (BMI 33.5), acanthosis nigricans, and pre-diabetes (HbA1c 5.5%) should focus on intensive lifestyle modifications with metformin as first-line pharmacotherapy at an initial dose of 500 mg daily, gradually titrated to 1000 mg twice daily as tolerated. 1, 2

Assessment of Current Status

• The patient presents with significant weight gain (21 kg over 9 months), fatigue, acanthosis nigricans, and a BMI of 33.5, indicating obesity 3
• HbA1c of 5.5% indicates pre-diabetes, and acanthosis nigricans is a cutaneous marker strongly associated with insulin resistance 3, 4
• Thyroid function tests are normal, ruling out hypothyroidism as a contributing factor 5

Management Plan

First-Line Approach: Lifestyle Modifications

• Establish a goal of 7-10% weight reduction (approximately 7-10 kg) through comprehensive lifestyle changes 1
• Recommend 150 minutes/week of moderate-intensity physical activity, including aerobic, resistance, and flexibility training 1, 2
• Implement dietary modifications focusing on:
  • Nutrient-dense, high-quality foods 1
  • Reduced consumption of calorie-dense, nutrient-poor foods 1
  • Elimination of sugar-sweetened beverages 1
  • Portion control and regular meal timing 1

Pharmacotherapy

• Initiate metformin at 500 mg daily with meals, gradually increasing to 1000 mg twice daily over 4 weeks to minimize gastrointestinal side effects 1
• Metformin is the preferred first-line agent even with normal HbA1c in the presence of insulin resistance and obesity 1, 2
• Metformin works primarily by reducing hepatic glucose production and may provide modest weight benefits 1

Monitoring and Follow-up

• Schedule follow-up in 3 months to assess:
  • Adherence to lifestyle modifications 1
  • Weight loss progress 1
  • Tolerance to metformin 1
  • Repeat HbA1c 2
• If no improvement after 3 months of lifestyle changes and metformin, consider:
  • Intensifying lifestyle intervention with structured program 1
  • Evaluating for medication adherence issues 1
  • Potentially adding weight loss medication if BMI remains ≥27 kg/m² 1

Special Considerations

• Acanthosis nigricans is a strong indicator of insulin resistance and increased risk for developing type 2 diabetes, warranting aggressive intervention 3, 4, 6
• The patient's young age (23) and rapid weight gain indicate high risk for progression to diabetes if not addressed promptly 1
• Avoid medications that may contribute to weight gain 1
• Consider screening for other components of metabolic syndrome (lipid profile, blood pressure) 2

Potential Pitfalls

• Underestimating the significance of acanthosis nigricans as a marker of insulin resistance 3, 6
• Delaying pharmacotherapy in a patient with clear signs of metabolic dysfunction 1
• Failing to provide adequate education and support for lifestyle modifications 1
• Not addressing psychological aspects of rapid weight gain that may impact adherence to treatment 7