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Canadian Diabetes Association 2013 Clinical Practice Guidelines Reducing the Risk of Developing Diabetes

Chapter 5 Thomas Ransom, Ronald Goldenberg, Amanda Mikalachki, Ally PH Prebtani, Zubin Punthakee

Key Points

2013

1. At this time, there are no safe and effective strategies to prevent T1DM 2. Intensive lifestyle modification with weight loss can reduce the risk of progression from pre-diabetes to T2DM by almost 60% 3. Progression from pre-diabetes to T2DM can be reduced by Metformin or Acarbose by approximately 30%

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

No Safe and Effective Strategies to Prevent T1DM at this Time

T1DM is a chronic autoimmune condition with destruction of pancreatic beta cells Ongoing or completed trials

ENDIT: High-dose nicotinamide Not effective DPT-1: Low-dose insulin in high risk relatives Not effective overall TRIGR: Exclusion of cows milk protein to infants until 6-8 months of age Trial ongoing

Alternate strategy to use immunosuppression / modulation at the time of diagnosis but significant side effects and ethical considerations

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Diabetes Prevention Program (DPP)


Benefit of diet and exercise or Metformin on diabetes prevention in at-risk patients N = 3234 with IFG and IGT, without diabetes 40 Placebo
30

Cumulative incidence of diabetes 20 (%) 10 0 0 1.0 2.0 Years 3.0 4.0

Metformin 31% Lifestyle 58%

P* < 0.001

< 0.001

*vs placebo IFG = impaired fasting glucose, IGT = impaired glucose tolerance

Diabetes Prevention Program (DPP) Research Group. N Engl J Med 2002;346:393-403.


guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

STOP-NIDDM Study
Effects of Acarbose on the risk of T2DM N = 1429 people with IGT, BMI 25-40, 40-70 yrs, 3.3 years follow up
1.00 0.95 0.90 0.85 Acarbose Placebo

Cumulative probability

0.80 0.75 0.70 0.65 0.60 0.55 0.50 0.45 0.40 P = 0.0022

Acarbose 25%

Days after randomization


guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Chiasson JL, et al. Lancet 2002;359:2072-77. Copyright 2013 Canadian Diabetes Association

Pharmacology to Reduce Progression to T2DM

Metformin has been shown to reduce the incidence of T2DM by approximately 30% in the Diabetes Prevention Program (DPP) Acarbose has been shown to reduce the risk of progression to diabetes by approximately 30% in the Study to Prevent Non-Insulin Dependent Diabetes (STOP-NIDDM) study

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

Recommendation 1 and 2

2013

1. A structured program of lifestyle modification that includes moderate weight loss and regular physical activity should be implemented to reduce risk of T2DM in individuals with IGT [Grade A, Level 1A] or IFG [Grade B, Level 2] or A1C 6.0-6.4% [Grade D, consensus]. 2. In individuals with IGT, pharmacologic therapy with Metformin [Grade A, Level 1A] or Acarbose [Grade A, level 1A] may be used to reduce the risk of T2DM.

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association

CDA Clinical Practice Guidelines


http://guidelines.diabetes.ca for professionals 1-800-BANTING (226-8464) http://diabetes.ca for patients

guidelines.diabetes.ca | 1-800-BANTING (226-8464) | diabetes.ca Copyright 2013 Canadian Diabetes Association