What is the recommended treatment for a patient with an impaired fasting glucose level, indicated by an Hemoglobin A1c (HbA1c) of 5.7%?

Treatment Approach for HbA1c 5.7%

An HbA1c of 5.7% indicates prediabetes and should be managed with intensive lifestyle intervention as the first-line treatment, with metformin considered for specific high-risk patients, but not routine pharmacotherapy for all. 1

Diagnostic Classification

• An HbA1c of 5.7% falls within the prediabetes range (5.7-6.4%), placing the patient at significantly increased risk for developing type 2 diabetes 1
• Individuals with HbA1c 5.7-6.0% have a 5-year cumulative diabetes incidence of 12-25%, which is 3-8 fold higher than the general U.S. population 1
• This level corresponds approximately to a fasting plasma glucose of 100-110 mg/dL based on linear regression analyses 1

Primary Treatment: Intensive Lifestyle Modification

The cornerstone of treatment at this HbA1c level is intensive behavioral intervention targeting weight loss and physical activity, not medication. 1

Specific Lifestyle Targets

• Weight reduction goal: Loss of 7% of body weight through dietary modification 1
• Physical activity goal: At least 150 minutes per week of moderate-intensity physical activity (such as brisk walking) 1
• Patients should be referred to an intensive diet and physical activity behavioral counseling program to achieve these targets 1
• Follow-up counseling is important for success and should be ongoing 1

Evidence Supporting Lifestyle Intervention

• Intensive lifestyle modification programs have demonstrated a 58% reduction in diabetes onset after 3 years 1
• Long-term follow-up shows sustained benefit: 43% reduction at 20 years (Da Qing study), 43% reduction at 7 years (Finnish DPS), and 34% reduction at 10 years (U.S. DPPOS) 1
• Cost-effectiveness modeling confirms that lifestyle interventions are cost-effective and should be covered by third-party payers 1

Pharmacotherapy Consideration: Metformin

Metformin therapy for diabetes prevention may be considered, but only in specific high-risk subgroups, not as routine treatment for all patients with HbA1c 5.7%. 1

Specific Criteria for Metformin Use

Metformin should be considered specifically for patients with HbA1c 5.7-6.4% who meet all of the following criteria: 1

• BMI > 35 kg/m², OR
• Age < 60 years, OR
• Women with prior gestational diabetes mellitus

Important Caveat

• At HbA1c 5.7%, the patient is at the lower end of the prediabetes spectrum, making lifestyle intervention even more appropriate as first-line therapy before considering metformin 1
• The continuum of risk is curvilinear—as HbA1c rises toward 6.0% and above, risk increases disproportionately, and interventions should become more intensive 1

Monitoring and Follow-Up

• At least annual monitoring for the development of diabetes is recommended for those with prediabetes 1
• Screening for and treatment of modifiable cardiovascular disease risk factors should be performed 1
• Patients should be informed of their increased risk for both diabetes and cardiovascular disease 1

Additional Considerations

• Diabetes self-management education (DSME) and support programs are appropriate venues for patients with prediabetes to receive education and develop behaviors that can prevent or delay diabetes onset 1
• Interventions should be most intensive for those with HbA1c levels above 6.0%, who are at very high risk 1
• However, individuals with HbA1c below 5.7% may still be at risk depending on the presence of other risk factors such as obesity and family history 1

Common Pitfalls to Avoid

• Do not immediately start pharmacotherapy at HbA1c 5.7% without first implementing intensive lifestyle intervention, unless the patient meets specific high-risk criteria for metformin 1
• Do not neglect cardiovascular risk factor management—prediabetes is associated with increased cardiovascular disease risk, not just diabetes risk 1
• Do not assume the patient is at negligible risk simply because HbA1c is at the lower end of the prediabetes range—the risk is still 3-8 fold higher than the general population 1
• Do not fail to provide ongoing support—single counseling sessions are insufficient; follow-up counseling is critical for sustained behavior change 1