Dr. Sanjay Kalra offers key practice points on the diagnosis, clinical evaluation, and pharmacological and non-pharmacological treatment interventions for halting the progression of pre-diabetes.

Diagnosis and classification

Prediabetes is a well-defined syndrome, with clear cut criteria for diagnosis. A fasting plasma glucose of >100mg% and/or a 2-hour post 75g glucose load value of >140mg%, and/or an HbA1c >5.7%, confirmed at least once, confirm the diagnosis of prediabetes. Values in the diabetic range (fasting >126%, post-load >200mg%, HbA1c >6.4%) preclude a label of prediabetes.

Prediabetes can be classified as impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). In general, IGF is more closely linked to impaired insulin secretion, while IGT is associated with insulin resistance.

Clinical impact

Both IFG and IGT are independent risk factors for progression to type 2 diabetes, and for the development of a chronic vascular complication. At times, prediabetes itself may be associated with the macrovascular and microvascular manifestation of diabetes. Dysglycaemia can also predispose to acute complications such as infections and impair their resolution.

Need for intervention

Prediabetes represents a window of opportunity to prevent diabetes. Active intervention, whether pharmacological or non-pharmacological, can help arrest the progression of the disease and long-term complications and may achieve euglycaemia. Indians in general, have a more rapid trajectory of worsening of glycaemia and onset of a complication. Hence, it makes sense to manage prediabetes in a proactive manner.

Clinical evaluation

Persons with prediabetes should be evaluated for aetiology (symptoms and signs suggestive of insulin deficiency/autoimmune disorders of insulin resistance/metabolic syndrome); current status (symptoms and signs directly attributable to hyperglycaemia), comorbid condition (acute infection, inflammation, invasion, chronic- endocrine, medical, surgical), vascular complications (macrovascular, microvascular), concomitant therapy (immunosuppressives, complementary therapy), and psychosocial status (personal distress).

Dietary, physical activity, sleep and substance abuse patterns should be reviewed. Relevant investigations should be ordered if they have the potential to influence therapeutic decision making or counselling.

Non-pharmacological management

Lifestyle modification is the preferred choice of management in prediabetes. Diabetes prevention studies from across the world have shown encouraging results with intensive behavioural modification and lifestyle therapy. All persons should be advised a balanced diet to help achieve and maintain a healthy weight. Regular exercise should be instituted. Optimisation of stress management (coping skills) and sleep patterns, as well as avoidance of substance abuse, is helpful. Basic hygiene should be followed to prevent communicable disease, including COVID 19.

Pharmacological therapy

Drug therapy can be instituted in persons with diabetes if there is:

• High risk of developing diabetes or its complications, e.g., multiple risk factors
• Unwillingness or inability to modify lifestyle, e.g., osteoarthritis
• Presence of symptoms directly attributable to hyperglycaemia, e.g., weight loss, asthenia
• Presence of comorbid conditions which can be resolved by euglycaemia, e.g., foot ulcer

Metformin remains the first drug of choice. Sustained-release preparations offer good efficacy with tolerability and safety. GLP1 receptor agonists and alpha-glucosidase inhibitors may be used, if the main target is obesity and postprandial hyperglycaemia, respectively.

Monitoring

There are no standardised guidelines for monitoring persons with prediabetes. If drug therapy has been instituted, a monthly assessment of glycaemia should suffice. However, enhanced glucovigilance is mandatory if variability in glucose levels is anticipated, suspected, or experienced. Examples include sudden onset febrile illness, or the initiation of concomitant therapy known to alter glucose metabolism (corticosteroid).

Pragmatic practice

1. In our practice, we encourage relative of persons with type 2 diabetes to get themselves screened for prediabetes.
2. We also opportunistically screen persons with infectious diseases such as acute febrile illness, hepatitis, tuberculosis, STDs; endocrine diseases like hypothyroidism and PCOS; metabolic diseases like NAFLD, dyslipidaemia, hypertension and CAD, and dysglycaemia.
3. Screening of antenatal women and women planning conception is done as per standard protocol.
4. We have begun screening post-COVID-19 survivors at regular intervals, based upon their overall metabolic risk profile.
5. All persons diagnosed to have prediabetes are, encouraged to modify their lifestyle, stop tobacco, avoid free sugars and ghee, exercise regularly, and learn how to relax. They are requested to return after 3 months.
6. Persons with obesity are counselled about medical nutrition therapy, orlistat and liraglutide, with final treatment based on shared decision-making. Those with intercurrent illness such as resistant, refractory or recurrent urogenital or skin and soft tissue infection are sometimes offered low dose metformin and DPP4 inhibitors to hasten healing.
7. Management of comorbid metabolic and endocrine conditions, such as dyslipidaemia, hypertension and hypothyroidism is done as per standard of care.

Doctors should counsel all persons to view prediabetes as a window of opportunity, rather than a reason to despair. Timely screening, diagnosis and intervention can prevent diabetes and can change the trajectory of this pandemic.

Disclaimer- The views and opinions expressed in the article and videos are those of the speakers and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. Sanjay Kalra is a leading Endocrinologist from India.