User login

We offer our registered users tailored information, free online courses and exclusive content.

You have an old EXCEMED account ...

Our platform has been renewed. All users registered at any of the old websites are kindly requested to reset their password. Why is this?

... or you lost your password?

Management of Pre-diabetes in the Asia-Pacific region

Management of Pre-diabetes in the Asia-Pacific region

Over half of the global diabetic population resides in Asia-Pacific creating a high regional disease burden. Increasing evidence shows that without targeted intervention, the progression from impaired glucose tolerance (IGT) to type 2 diabetes occurs more frequently in Asians compared with Caucasians. Furthermore, IGT is independently associated with an increased risk of cardiovascular disease and should be managed as early as possible. Because diabetes is now a major public health issue, strategies aimed at prevention and treatment are urgently required.

Screening and diagnosis of pre-diabetes

Screening and treatment of IGT can delay or prevent the development of type 2 diabetes, providing a window of opportunity for primary prevention of diabetes and cardiovascular disease. Targeted screening is for patients aged ≥35 years and/or high risk individuals, and comprises laboratory tests (i.e., fasting blood glucose [FPG], HbA1c and/or 75 g oral glucose tolerance test [OGTT]). High risk individuals include those who are overweight or obese (country-specific), those with high blood pressure, dyslipidemia, a history of large babies or gestational diabetes or a family history of diabetes. Pre-diabetes is diagnosed if the FPG ≥100 mg/dL (5.5 mmol/L), 2-hour OGTT is 140–99 mg/dL (7.8–11.0 mmol/L), and HbA1c is >5.7%.

If the initial screening for pre-diabetes is negative, patients should be rescreened every 1 to 3 years, depending on their risk factors, and based on clinical judgment and local resource availability.

The optimal cut-offs for diagnosing pre-diabetes in Chinese patients are an HbA1c of 5.6% (38 mmol/mol) in the young and middle-aged and 5.7% (39 mmol/mol) in the elderly.1 The basis for including age for routine screening with the cut-off of ≥35 years was reports from Bangladesh and Eastern Uganda of individuals with abnormal glucose regulation but a normal body mass index (BMI).2,3 The HbA1c threshold for pre-diabetes was set at 5.7% and was based on a previously published cost-effectiveness strategy.4

Treatment of pre-diabetes

Most countries within the region do not have country-specific guidelines but follow the American Diabetes Association (ADA) or the International Diabetes Federation (IDF) recommendations.5,6 The IDF consensus guidelines on the prevention of type 2 diabetes recommends the following three steps to prevent development of diabetes7:

  1. Identification of individuals at high risk of developing diabetes
  2. Assessment of risk levels by measuring plasma glucose levels
  3. Initiation of lifestyle interventions with or without pharmacological therapy

Once individuals with pre-diabetes have been identified, they are advised to undergo structured lifestyle modifications, with the aim of achieving gradual and sustained weight loss and maintaining a healthy body composition through physical activity and change of dietary habits.7 The World Health Organization (WHO) and IDF also recommends addressing other risk factors, including smoking.8 In addition, the WHO highlights the need for a global approach to reduce the growing worldwide burden of diabetes.8

The ADA recommends the referral of patients with IGT, impaired fasting glucose (IFG) or an HbA1c of 5.7–6.4% to an ongoing support program targeting weight loss of 7% of body weight and moderate exercise of ≥150 minutes per week.5 The ADA states that metformin therapy for prevention of type 2 diabetes may be considered in individuals with IGT, IFG or an HbA1c of 5.7–6.4%, especially for those with a BMI >35 kg/m2, individuals aged <60 years, and women with prior gestational diabetes.5 In addition, the ADA guidelines recommends follow-up counselling for successful lifestyle interventions, annual monitoring of individuals with pre-diabetes for the development of diabetes, as well as screening for and treatment of modifiable risk factors for cardiovascular disease.5

In Asia-Pacific countries, lifestyle modifications remain the mainstay of recommended first-line interventions for patients with pre-diabetes. In Malaysia, lifestyle interventions, such as diet and physical therapy, are the pillars for pre-diabetes therapy.7 In addition, the 2015 Ministry of Health (MOH) guidelines state that metformin (as the preferred first-line oral anti-diabetic agent) should be considered for patients at very high risk of progressing to diabetes (combined IFG and IGT, IGT plus other risk factors, or failed lifestyle intervention after 6 months).9 Off-label metformin may be initiated at the discretion of the prescribing physician.

In Thailand, there are no area-specific guidelines available for the management of pre-diabetes. The majority of physicians follow the IDF recommendations, the ADA guidelines or findings from randomized controlled trials on pre-diabetes prevention.5,6 Likewise, given a lack of country-specific guidelines in the Philippines, physicians generally follow the ADA recommendations. However, in the Philippines, metformin is approved for the treatment of pre-diabetes after failed lifestyle intervention.

Guidelines in Singapore indicate that lifestyle modification should be the first-line treatment of choice.10 Metformin may be considered for individuals with a very high risk of progressing to diabetes, particularly patients with IFG, IGT, <60 years of age, or BMI ≥35 kg/m2.10 Hong Kong has country-specific pre-diabetes management guidelines aimed at the primary care sector.11 The emphasis is mainly on lifestyle modifications using dietary or behavioural interventions to reduce and maintain body weight and practice a healthy lifestyle. Pharmacological therapy is not routinely recommended presently.11

The 2009 Indonesian guidebook on the management of pre-diabetes and prevention of type 2 diabetes (Buku Panduan - Pengurus Besar Persatuan Diabetes Indonesia [PB Persadia]) states that the diabetes prevention strategy should encompass a three-step process:12

  1. Identification of high-risk individuals
  2. Risk calculation
  3. Intervention

Step 3 involves lifestyle changes, body weight management (reduction by 5–7% of baseline body weight, 0.5–1 kg/week), physical activity and pharmacologic intervention. The latter involves either metformin 250–850 mg twice daily in individuals ≤60 years, with BMI >25 kg/m2 and fasting blood sugar >110 mg/dL (6.1 mmol/L) if no contraindications are present; or acarbose 50–100 mg three times daily.12

Within the region, despite the lack of formal recommendations, metformin is often used off-label for certain patient populations. For example, there are no pre-diabetes guidelines in India, but metformin is used off-label by physicians if pre-diabetes patients require pharmacotherapy. Pakistan also has no formal guidelines for pre-diabetes treatment. In view of long-standing safety information about metformin, this drug is prescribed to individuals who are noncompliant with lifestyle interventions. For other potential drugs, further long-term studies are needed on safety and vascular outcomes before lifelong treatment can be safely recommended.

Conclusions

Pre-diabetes represents a window of opportunity to prevent or delay the progression to diabetes and its associated complications, underscoring the critical need for screening at the primary care level. Lifestyle modification, including weight loss, dietary changes and increased physical activity play a major role in controlling the disease. Furthermore, significant evidence supports the effectiveness of combining lifestyle modification and pharmacological therapy in certain patient populations to delay the onset of diabetes. A cost-effectiveness analysis of lifestyle intervention and metformin therapy for the prevention of diabetes in Singapore concluded that both lifestyle modification and metformin are likely to be cost-effective and worth implementing in Singapore to prevent or delay the onset of type 2 diabetes.  Although the importance of lifestyle interventions is well recognized throughout Asia, many countries do not have formal recommendations to guide the diagnosis and management of individuals at risk of progression to diabetes.


References

  1. Yan ST, et al. The cutoffs and performance of glycated hemoglobin for diagnosing diabetes and prediabetes in a young and middle-aged population and in an elderly population. Diabetes Res Clin Pract. 2015;109(2):238-45.
  2. Akter S, et al. Prevalence of diabetes and prediabetes and their risk factors among Bangladeshi adults: A nationwide survey. Bull World Health Organ. 2014;92(3):204-13,213A.
  3. Mayega RW, et al. Diabetes and pre-diabetes among persons aged 35 to 60 years in Eastern Uganda: Prevalence and associated factors. PLoS One. 2013;8(8):e72554.
  4. Zhuo X, et al. Alternative HbA1c cutoffs to identify high-risk adults for diabetes prevention: a cost-effectiveness perspective. Am J Prev Med. 2012;42(4):374-81.
  5. American Diabetes Association. Standards of Medical Care in Diabetes—2015. Diabetes Care. 2015;38(Suppl 1):S1-89.
  6. International Diabetes Federation Clinical Guidelines Task Force. Global Guideline for Type 2 Diabetes. Brussels, Belgium: International Diabetes Federation, 2012. http://www.idf.org/e-library/guidelines/79-global-guideline-for-type-2-d.... Accessed: September 22, 2016.
  7. Alberti KG, et al. International Diabetes Federation: A consensus on type 2 diabetes prevention. Diabet Med. 2007;24(5):451-63.
  8. World Health Organization. “Diabetes Fact Sheet No. 312.” Reviewed November 2016. http://www.who.int/mediacentre/factsheets/fs312/en/.
  9. Ministry of Health Malaysia. Clinical practice guidelines—Management of type 2 diabetes mellitus, 5th ed. Putrajaya, Malaysia: Ministry of Health Malaysia, 2015. http://www.acadmed.org.my/index.cfm?&menuid=67#Endocrine_Disease.
  10. Ministry of Health Singapore. Diabetes Mellitus—MOH Clinical Practice Guidelines 1/2014. Singapore: Ministry of Health, Singapore, 2014. https://www.moh.gov.sg/content/dam/moh_web/HPP/Doctors/cpg_medical/curre....
  11. Task Force on Conceptual Model and Preventive Protocols, Working Group on Primary Care, Food and Health Bureau. Hong Kong Reference Framework for Diabetes Care for Adults in Primary Care Settings, 2013. http://www.pco.gov.hk/english/resource/files/RF_DM_full.pdf.
  12. Buku Panduan - Pengurus Besar Persatuan Diabetes Indonesia (PB Persadia). 2009.

Chaicharn Deerochanawong

Professor of Medicine
Dept. of Medicine
Diabetes and Endocrinology Unit
Rajavithi Hospital
Bangkok, Thailand
Regional
Asia Pacific
Guidelines
impaired glucose tolerance
metformin