"As individuals and as a society, we need to address those forces which are creating the epidemic of obesity, diabetes, and prediabetes," Yehuda Handlesman MD, FACP, FACE, treasurer of AACE and medical director of the Metabolic Institute of America, said in a news release. "We understand the difficulties in implementing solutions, but as an association of endocrinologists we are committed to supporting community and national efforts in every way we can."
The new guidelines are the first comprehensive treatment regimen for patients with prediabetes recommended by a consensus of experts in diabetes and metabolic disorders. The consensus statement offers specific guidelines regarding lifestyle modification as well as pharmaceutical intervention where appropriate.
US prevalence of prediabetes, defined by elevated fasting glucose levels or impaired glucose tolerance, is greater than 56 million. However, an even greater number of individuals with prediabetes have not yet been diagnosed.
Because prediabetes increases the risk for cardiovascular disease as well as for the development of type 2 diabetes, these guidelines extend the overall effort to recognize and treat type 2 diabetes sooner and more intensively.
Because no pharmacologic therapies are currently approved by the US Food and Drug Administration (FDA) to prevent the development of diabetes in patients with prediabetes, the expert panel recommends a 2-fold approach to treating prediabetes.
The first goal is aggressive lifestyle management to prevent the progression to type 2 diabetes, following guidelines established by the Diabetes Prevention Program of the US government.
"Although lifestyle can clearly modify the progression of patients towards overt diabetes, it may not be sufficient," said Alan J. Garber, MD, PhD, FACE, professor of medicine, Baylor College of Medicine in Houston, Texas, and chairman of the Consensus Conference. "Medications may well be required, particularly in high risk groups."
The second goal is to avoid cardiovascular complications, with use of pharmacotherapy for those patients whose prediabetes is refractory to lifestyle modifications. In addition to medications for glycemic control, this strategy involves use of medications for hypertension and hypercholesterolemia when appropriate. High-risk individuals with levels of blood glucose approaching those seen in diabetes, hypertension, or hyperlipidemia should consider closer clinician monitoring of their risk factors.
"The data show that there is a spectrum of severity, with the most severely affected approaching the risks of people with diagnosed type 2 diabetes," said Daniel Einhorn, MD, FACP, FACE, vice president of AACE and medical director of the Scripps Whittier Institute for Diabetes in La Jolla, California. "In these highest risk individuals, who represent a minority, pharmacologic strategies may be appropriate if intensive lifestyle therapies fail. Regardless, all individuals at risk for diabetes should be aware of the level of their risk factors and be prepared to take action."
Specific questions and pertinent comments addressed in the Consensus Statement are as follows:
1. What is the spectrum between normal glucose tolerance, prediabetes, and diabetes, and what criteria should be used to diagnose each of these?
Normal glucose levels are defined as a fasting blood glucose level of less than 100 mg/dL and a postchallenge level of less than 140 mg/dL. Those considered diagnostic for diabetes are a fasting blood glucose level of 126 mg/dL or more and a postchallenge level of 200 mg/dL or more; the spectrum in between is poorly defined. In some individuals, these intermediate levels of glucose (fasting glucose level of 100 - 125 mg/dL; 2-hour levels of 140 - 199 mg/dL) may be a harbinger of overt type 2 diabetes, cardiovascular disease, and microvascular complications.
2. What clinical risks ensue if prediabetes is not treated?
In the large DECODE Study, risks for all-cause mortality increased linearly as the 2-hour blood glucose level increased from 95 to 200 mg/dL. In the Diabetes Prevention Program, approximately 8% of patients with impaired glucose tolerance had diabetic retinopathy as did nearly 13% of those whose condition progressed to diabetes. The STOP NIDDM trial showed an increase in hypertension (> 140/90 mm Hg) in the placebo-treated patients with impaired glucose tolerance during a 3-year period, with an increase in clinical cardiovascular disease (CVD) events by approximately 5% during 4 years. The Honolulu Heart Study showed that postchallenge hyperglycemia was associated with an increase in sudden death during a 23-year follow-up.
作者:admin@医学,生命科学 2011-09-08 05:14