Should a patient with a prior diagnosis of prediabetes but whose most recent two hemoglobin A1c results are below 5.7% still be labeled as having prediabetes?

Should You Continue the Prediabetes Diagnosis After Two Normal A1c Results?

No—remove the prediabetes diagnosis when two consecutive annual A1c results are below 5.7%. The patient no longer meets diagnostic criteria and should be reclassified as having normal glucose metabolism with continued surveillance. 1

Understanding Prediabetes Diagnostic Criteria

Prediabetes is defined by specific laboratory thresholds, not by historical diagnosis alone:

• A1c 5.7–6.4% (39–47 mmol/mol) 1
• Fasting plasma glucose 100–125 mg/dL (5.6–6.9 mmol/L) 1
• 2-hour glucose 140–199 mg/dL (7.8–11.0 mmol/L) during 75-g OGTT 1

Prediabetes is not a permanent clinical entity but rather a risk state—when laboratory values normalize, the diagnosis should be updated accordingly. 1

Why Two Normal Results Matter

• Test variability is inherent: A1c has the least day-to-day variability among glucose tests, making it the most reliable marker for sustained glycemic status. 1
• Biological regression occurs: Patients with borderline elevations can return to normal through lifestyle modification, weight loss, or resolution of transient metabolic stress. 1
• Two consecutive normal values (A1c <5.7%) over two annual exams strongly indicate the patient has reverted to normal glucose metabolism and no longer carries the cardiovascular and diabetes progression risk associated with prediabetes. 1

Recommended Clinical Approach

Reclassify the Patient

• Remove the prediabetes diagnosis from the active problem list when A1c is <5.7% on two consecutive annual measurements. 1
• Document the history: Note "history of prediabetes, now resolved" to maintain awareness of prior risk. 1

Adjust Surveillance Intervals

• Rescreen every 3 years if the patient has no other diabetes risk factors (normal BMI, no family history, no hypertension, no dyslipidemia). 1
• Continue annual screening if the patient retains high-risk features despite normal A1c:
  • Overweight/obesity (BMI ≥25 kg/m² or ≥23 kg/m² in Asian Americans) 1
  • First-degree relative with diabetes 1
  • High-risk race/ethnicity (African American, Latino, Native American, Asian American) 1
  • History of gestational diabetes 1
  • Hypertension (≥130/80 mmHg or on therapy) 1
  • HDL <35 mg/dL or triglycerides >250 mg/dL 1
  • Polycystic ovary syndrome 1
  • Physical inactivity 1
  • History of cardiovascular disease 1

Reinforce Lifestyle Maintenance

• Emphasize sustained behavior change: The patient's normalization of A1c likely reflects successful lifestyle intervention (diet, exercise, weight management). 1
• Counsel on continued risk: Even with normal A1c, the patient had demonstrated metabolic vulnerability and should maintain healthy habits to prevent recurrence. 1
• Address residual cardiovascular risk factors: Optimize blood pressure, lipids, smoking cessation, and weight management regardless of glucose status. 1

Common Pitfalls to Avoid

• Do not perpetuate outdated diagnoses: Continuing to label a patient as prediabetic when they no longer meet criteria can lead to unnecessary anxiety, insurance complications, and inappropriate treatment escalation. 1
• Do not assume permanent remission: A return to normal A1c does not eliminate future risk—patients with prior prediabetes remain at higher lifetime risk for diabetes than those who never had dysglycemia. 1
• Do not reduce surveillance prematurely: If multiple risk factors persist (obesity, family history, hypertension), annual screening is still warranted even with normal A1c. 1
• Do not ignore A1c trajectory: If the patient's A1c was 6.3% two years ago and is now 5.6%, this downward trend is reassuring; conversely, if A1c is rising year-over-year within the normal range (e.g., 5.2% → 5.5% → 5.6%), closer monitoring may be prudent. 2

Evidence Quality and Nuance

The most recent 2025 ADA Standards of Care 1 explicitly define prediabetes by current laboratory values, not historical diagnosis. The guidelines emphasize that prediabetes represents increased risk rather than a fixed disease state, and that risk stratification should be dynamic and based on ongoing assessment. 1

Guideline consensus is clear: When repeat testing shows normal values, the patient no longer has prediabetes. 1 The 2021 ADA guidelines 1 recommend annual retesting for those with prediabetes, implicitly acknowledging that some will revert to normal and should be reclassified accordingly.

Research evidence 3, 4 demonstrates that A1c-defined prediabetes (5.7–6.4%) does not always correlate with impaired insulin secretion or action, and that individuals in this range have heterogeneous metabolic profiles. This reinforces the importance of serial testing and dynamic reclassification rather than permanent labeling.