New Targets for Prediabetes Treatment: An Expert Interview With Cindy Lamendola, MSN, ANP-BC, FPCNA

Laurie Barclay, MD

April 30, 2010

April 30, 2010 — Editor's note: In patients with prediabetes, treatment goals should include a reduction in elevated blood glucose and improvement in other risk factors for cardiovascular disease, according to a presentation at the Preventive Cardiovascular Nurses Association 16th Annual Symposium, held April 15 to 17 in Chicago, Illinois.

To learn more about detection of prediabetes and appropriate treatment goals for these patients, Medscape Nurses interviewed presenter Cindy Lamendola, MSN, ANP-BC, FPCNA, clinical research nurse coordinator of medicine/cardiovascular at Stanford University School of Medicine and adult nurse practitioner at Stanford University Medical Center in California.

Medscape: What is the rationale for identifying people early on as being at increased risk for type 2 diabetes?

Ms. Lamendola: According to the Prediabetes Consensus Statement of the American Association of Clinical Endocrinology [Endocr Pract. 2008;14:933-946]: "Epidemiologic evidence suggests that the complications of diabetes begin early in the progression from normal glucose tolerance to frank diabetes. Early identification and treatment of persons with prediabetes have the potential to reduce or delay the progression to diabetes and related [cardiovascular] and microvascular disease."

Medscape: What laboratory values identify someone as being at increased risk for diabetes or prediabetes?

Ms. Lamendola: Hemoglobin A1C as a diagnostic tool is a new test, now approved, for identifying the patient at risk for type 2 diabetes. Besides good epidemiological evidence for using cut-off points for A1C recommended by the American Diabetes Association, the test is now standardized and offers increased convenience; this test does not require fasting.

According to the American Diabetes Association Clinical Practice Recommendations, increased risk for diabetes can be defined by an A1C value of 5.7% to 6.4%, a fasting plasma glucose level of 100 to 125 mg/dL (5.6 - 6.9 mmol/L), and an oral glucose tolerance test result of 140 to 199 mg/dL (7.8 - 11.0 mmol/L).

Medscape: What targets do you currently recommend for patients with prediabetes?

Ms. Lamendola: Patients who have prediabetes generally have elevated blood glucose, as well as other risk factors for cardiovascular disease. Goals would be a fasting glucose below 100 mg/dL, a blood pressure below 140/90 mm Hg, and a normal lipid panel, with low-density lipoprotein below 130 mg/dL (optimally below 100 mg/dL), triglycerides at 150 mg/dL, and high-density lipoprotein cholesterol above 40 mg/dL for a man and above 50 mg/dL for a woman.

Medscape: How can these targets best be achieved?

Ms. Lamendola: Lifestyle is important and can make a substantial difference in preventing type 2 diabetes and in reducing risk factors. Data from the Diabetes Prevention Trial showed that a 5% to 7% weight loss in the intensive lifestyle group reduced or delayed individuals from progressing to type 2 diabetes by 58%, compared with placebo. This was effective in all age groups and ethnicities. In fact, the number needed to treat to prevent 1 case in 3 years was 6.9. At the 10-year follow-up, the lifestyle group overall still had the lowest incidence of type 2 diabetes.

If someone is under 60 years of age and obese, and has both impaired fasting glucose and impaired glucose tolerance, then metformin 850 mg twice daily may be prescribed to prevent or delay onset of type 2 diabetes.

If other risk factors prevail despite diet and exercise, then appropriate medications and follow-up need to be prescribed to keep risk factors at goal to prevent cardiovascular disease.

Medscape: What role should the cardiovascular nurse play in managing prediabetes?

Ms. Lamendola: The nurse can be instrumental in educating the patient about their risk and helping them with lifestyle changes and adherence.

Medscape: How can the cardiovascular nurse best facilitate communication between the patient and the healthcare management team to optimize patient compliance?

Ms. Lamendola: The nurse can educate the patient about their risk, review ongoing therapies to help the patient understand their prescribed treatment, review barriers to achieving these goals, and help set up a plan of action that the whole team can follow to help the patient achieve his or her goals.

Medscape: What additional research needs to be done in this area?

Ms. Lamendola: More research needs to be done to better understand the pathophysiology of type 2 diabetes and to better identify those at risk.

Ms. Lamendola reports having received educational grants from AstraZeneca, Merck & Co. Inc., Pfizer Inc., and Abbott Laboratories.

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