From the Guidelines
This 69-year-old female patient with prediabetes should be considered for metformin therapy to prevent the progression to type 2 diabetes, especially given her age and potential for increased cardiovascular risk, as suggested by the standards of medical care in diabetes-2022 1. Given her history of bilateral knee replacement in 2022 with successful recovery, it is essential to prioritize her overall health and well-being to prevent any potential complications. Some key considerations for her management include:
- Regular monitoring of her blood glucose levels and HbA1c testing every 3-6 months to assess her risk of progressing to type 2 diabetes 1.
- Screening for and treatment of modifiable risk factors for cardiovascular disease, such as hypertension and dyslipidemia, as people with prediabetes are at increased risk for cardiovascular disease 1.
- Emphasis on weight management through a combination of diet and exercise, as weight loss can be difficult to maintain long-term, and support with additional pharmacotherapeutic options may be necessary if needed 1.
- A Mediterranean-style diet rich in vegetables, whole grains, lean proteins, and healthy fats, while limiting refined carbohydrates and sugars, can help manage her prediabetes and overall health.
- Regular physical activity of at least 150 minutes per week of moderate exercise, such as walking, swimming, or stationary cycling, can benefit both her metabolic health and maintain knee function.
- Continuing any prescribed physical therapy exercises to maintain strength and range of motion in her replaced knees, and annual follow-up with her orthopedic surgeon to assess the status of her knee prostheses. It is crucial to weigh the potential benefits and risks of metformin therapy in this patient, considering her age and potential for increased cardiovascular risk, as well as the potential for biochemical vitamin B12 deficiency with long-term metformin use 1.
From the Research
Patient Profile
- The patient is a 69-year-old female with no past history of major medical problems except for prediabetes and a history of bilateral knee replacement in 2022 with successful recovery.
Prediabetes Management
- According to 2, prediabetes is defined by a fasting glucose level of 100 to 125 mg/dL, a glucose level of 140 to 199 mg/dL measured 2 hours after a 75-g oral glucose load, or glycated hemoglobin level (HbA1C) of 5.7% to 6.4% or 6.0% to 6.4%.
- Intensive lifestyle modification, consisting of calorie restriction, increased physical activity (≥150 min/wk), self-monitoring, and motivational support, decreased the incidence of diabetes by 6.2 cases per 100 person-years during a 3-year period 2.
- Metformin decreased the risk of diabetes among individuals with prediabetes by 3.2 cases per 100 person-years during 3 years 2.
Treatment Options
- Metformin is most effective for women with prior gestational diabetes and for individuals younger than 60 years with body mass index of 35 or greater, fasting plasma glucose level of 110 mg/dL or higher, or HbA1c level of 6.0% or higher 2.
- Sitagliptin, an oral dipeptidyl peptidase-IV inhibitor, preserves existing beta cell function and increases beta cell mass, and has been shown to be safe and effective in improving glycemic control when added to metformin and pioglitazone combination therapy 3, 4, 5.
Glycemic Control
- Achieving glycemic control in patients with prediabetes through lifestyle and pharmacologic interventions can effectively prevent or delay the development of diabetes and its associated complications 6.
- The combination of metformin and sitagliptin may potentially slow or halt the progression from prediabetes to type 2 DM by targeting both characteristics of prediabetes (insulin resistance and progressive beta cell degeneration) 3.