2021 vs 2022
3.1 至少每年監測一次糖尿病前期患者的 2 型糖尿病發展情況，根據個人風險/收益評估進行修改。 E
3.1 At least annual monitoring for the development of type 2 diabetes in those with prediabetes is suggested. modified based on individual risk/benefit assessment E (2022增）
2021: vs 2022
在存在某些血紅蛋白病或影響紅細胞更新的疾病時，使用 A1C 篩查前驅糖尿病和糖尿病可能會出現問題 受到限制。
Using A1C to screen for prediabetes and diabetes may be problematic limited in the presence of certain hemoglobinopathies or conditions that affect red blood cell turnover.
2021 vs 2022 DM prevention CP值高，要提供給患者
3.4 鑑於預防糖尿病的生活方式行為改變計劃的成本效益，應向患者提供此類糖尿病預防計劃。 A 糖尿病預防計劃應由第三方支付者承保，並且應解決獲取途徑的不一致問題。
3.5 Given the cost-effectiveness of lifestyle behavior modification programs for diabetes prevention A, such diabetes prevention programs should be offered to patients. A Diabetes prevention programs should be covered by third-party payers and inconsistencies in access should be addressed.
Nutrition
2021 vs 2022:
DPP 干預 生活方式乾預組 中的減肥飲食諮詢包括減少總膳食脂肪和卡路里，以預防 BMI 超重或肥胖的 2 型糖尿病高危人群的糖尿病 (2022 刪）
The dietary counseling for weight loss in the DPP lifestyle intervention arm included a reduction of total dietary fat and calories to prevent diabetes for those at high risk for developing type 2 diabetes with an overweight or obese BMI (1,8,9)
While CDC-recognized lifestyle change programs and Medicare DPP services have the advantages of having met minimum quality standards and being reimbursed by various payers, there have been lower retention rates in such programs reported for younger adults and racial/ethnic minority populations (44). Therefore, other programs and modalities of lifestyle behavior changes for achieving the goalsbehavioral counseling for diabetes prevention may also be appropriate and efficacious based on patient preferences and availability. The use of community health workers to support DPP efforts has been shown to be effective with cost savings cost-effective (45,46)
Pharmacologic Interventions
2021 vs 2022 preDM use metformin: focus 成人> 25 ~60y/o + 還要加上 BMI>35/FBS>110/A1c>6
3.6 糖尿病前期患者的成人應考慮使用Metformin 預防 2 型糖尿病，尤其是 BMI ≥ 35 kg/m2、年齡 <60 歲
以糖尿病預防計劃為代表，尤其是 25-59 歲 BMI ≥35 kg/m2、空腹血糖較高（例如 ≥110 mg /dL) 和更高的 A1C (例如，≥6.0%)，和有妊娠糖尿病史的女性。 A
3.6 Metformin therapy for prevention of type 2 diabetes should be considered in those adults with prediabetes, especially for those with BMI ≥35 kg/m2, those aged <60 years, andas typified by the Diabetes Prevention Program, especially those aged 25–59 years with BMI ≥35 kg/m2, higher fasting plasma glucose (e.g., ≥110 mg/dL), and higher A1C (e.g., ≥6.0%), and in women with prior gestational diabetes mellitus. A
2021 vs 2022: 新增 testosterone -> reduce DM incidence.
由於僅通過飲食和運動的行為改變來減輕體重可能難以長期維持 (6)，因此如果需要，接受減肥治療的人可能會受益於支持和額外的藥物治療選擇。已經評估了用於治療糖尿病的各種藥物對糖尿病的預防。Metformin、acarbose、liraglutide、TZD、睾固酮 (61) 和胰島素已被證明可降低糖尿病前期患者的糖尿病風險 特定人群的糖尿病發病率(62-67)；而Nateglinide沒有預防糖尿病（68）。
Because weight loss through behavior changes in diet and exercise alone can be difficult to maintain long term (6), people being treated with weight loss therapy may benefit from support and additional pharmacotherapeutic options, if needed. Various pharmacologic agents used to treat diabetes have been evaluated for diabetes prevention. Metformin, α-glucosidase inhibitors, liraglutide, thiazolidinediones, testosterone (61), and insulin have been shown to lower the risk of diabetes in those with prediabetesincidence of diabetes in specific populations (62–67); whereas diabetes prevention was not seen with nateglinide (68).
2021 vs 2022 prevent DM: 將vit D 另外討論。
In addition, several weight loss medications like orlistat and phenteramine-topiramate have also been shown in research studies to decrease the incidence of diabetes to various degrees in those with prediabetes (69,70). Studies of other pharmacologic agents have shown some efficacy in diabetes prevention with valsartan but no efficacy in preventing diabetes with ramipril or anti-inflammatory drugs (71–74).with ramipril, anti-inflammatory drugs, or vitamin D in preventing diabetes (71–75). 將vit D 另外討論。
儘管維生素 D 和 2 型糖尿病 (D2d) 前瞻性隨機對照試驗顯示，維生素 D 與安慰劑相比對高危個體進展為 2 型糖尿病沒有顯著益處 (75)，但事後分析和薈萃分析表明， 在特定人群中受益（75-78）。 需要進一步研究以確定補充維生素 D 可能有益的患者特徵和臨床指標 (61)。
Although the Vitamin D and Type 2 Diabetes (D2d) prospective randomized controlled trial showed no significant benefit of vitamin D versus placebo on the progression to type 2 diabetes in individuals at high risk (75), post hoc analyses and meta-analyses suggest a potential benefit in specific populations (75–78). Further research is needed to define patient characteristics and clinical indicators where vitamin D supplementation may be of benefit (61). (2022 新增)
然而，美國食品和藥物管理局尚未批准專門用於預防糖尿病的藥物。 必須權衡每種藥物的風險與收益。 Metformin 具有最強的證據基礎 (1)，並證明作為預防糖尿病的藥物治療具有長期安全性 (76)。 對於其他藥物，需要考慮成本、副作用、治療目標和持久療效。
However, no pharmacologic agent has been approved by the U.S. Food and Drug Administration specifically for diabetes prevention. The risk versus benefit of each medication must be weighed. Metformin has the strongest evidence base (1) and demonstrated long-term safety as pharmacologic therapy for diabetes prevention (76). For other drugs, cost, side effects, treatment goals, and durable efficacy require consideration.
2021 vs 2022: DPPOS subgroup benefit more to metformin
在 DPP 中，Metformin總體上不如生活方式改變有效，儘管在 DPPOS (7) 中組間差異隨著時間的推移而下降，並且Metformin可能在 10 年內節省成本 (34)。 在 DPP 的初始隨訪期間，Metformin在 BMI ≥ 35 kg/m2 的參與者和 25-44 歲的年輕參與者中與生活方式改變一樣有效 (1)。 在 DPP 中，對於有 GDM 病史的女性，Metformin和強化生活方式改變使糖尿病風險降低了 50%（77），並且在 10 年的隨訪期間，這兩種干預措施仍然非常有效（78）。 到 15 年隨訪 (DPPOS) 時，探索性分析表明，基線空腹血糖較高的參與者（≥110 mg/dL 對 95-109 mg/dL）, A1C 較高的參與者（6.0- 6.4% vs. <6.0%） 和有 GDM 病史的女性（對 . 沒有 GDM 病史的女性）使用Metformin降低了更高的風險（與安慰劑組相比） , 這些是特別從 metformin 中獲益最多的參與者亞組（79）。
Metformin was overall less effective than lifestyle modification in the DPP, though group differences declined over time in the DPPOS (7), and metformin may be cost-saving over a 10-year period (34). During initial follow-up in the DPP, metformin was as effective as lifestyle modification in participants with BMI ≥35 kg/m2 and in younger participants aged 25–44 years (1). In the DPP, for women with a history of GDM, metformin and intensive lifestyle modification led to an equivalent 50% reduction in diabetes risk (77), and both interventions remained highly effective during a 10-year follow-up period (78). By the time of the 15-year follow-up (DPPOS), exploratory analyses demonstrated that participants with a higher baseline fasting glucose (≥110 mg/dL vs. 95–109 mg/dL), those with a higher A1C (6.0–6.4% vs. <6.0%), (2022增) and women with a history of GDM (vs. women without a history of GDM) experienced higher risk reductions with metformin , identifying subgroups of participants that benefitted the most from metformin (compared with the placebo arm)(82).(79).
Patient-Centered Care Goals
2022 新增：
以患者為中心的護理目標 for preDM (IGT/IFG)
推薦
3.9 在患有 2 型糖尿病高風險的超重/肥胖成人中，護理目標應包括減輕體重或預防體重增加、盡量減少高血糖的進展，以及注意心血管風險和相關的合併症。B
3.9 In adults with overweight/obesity at high risk of type 2 diabetes, care goals should include weight loss or prevention of weight gain, minimizing progression of hyperglycemia, and attention to cardiovascular risk and associated comorbidites. B
在預防或延遲 2 型糖尿病及相關合併症的篩查、干預和監測中應考慮個體化風險/益處。包括年齡、BMI 和其他合併症在內的多種因素可能會影響進展為糖尿病的風險和並發症的終生風險 (96,97)。
- DPP 招募了糖耐量受損、空腹血糖升高和 BMI 升高的高風險個體，安慰劑組的糖尿病粗發病率為每 100 人年 11.0 例，累積 3 年糖尿病發病率28.9% (1)。
- 在基於社區的社區動脈粥樣硬化風險 (ARIC) 研究中，觀察性隨訪老年人（平均年齡 75 歲）有糖尿病前期的實驗室證據（基於 A1C 5.7-6.4% 和/或空腹血糖 100-125 mg/ dL) 但不符合特定的 BMI 標準發現在 6 年內進展為糖尿病的機率要低得多：9% 的患者患有 A1C 定義的前驅糖尿病，8% 的患者空腹血糖受損 (97)。
因此，個體化干預的風險/收益並考慮以人為本的目標很重要。風險模型已經探索了基於風險的收益，總體上發現對風險最高的人進行干預的收益更高（9）。糖尿病預防和觀察性研究強調了幾個關鍵原則，這些原則可以指導以患者為中心的目標。 DPP 招募了符合超重/肥胖標準的高危人群，體重減輕是糖尿病預防或延遲的重要調節因素，通常隨著體重減輕而增加代謝益處 (9,98)。在 DPP/DPPOS 中，進展為糖尿病、糖尿病病程和平均血糖水平是微血管並發症發生的重要決定因素 (7)。此外，在 DPP 期間實現正常血糖調節的能力（即使一次）與糖尿病風險降低和微血管並發症風險降低相關（99）。對大慶研究的觀察性隨訪還表明，在為期 6 年的干預試驗結束時，從葡萄糖耐量受損恢復到正常糖耐量或保持糖耐量受損而不是進展為 2 型糖尿病，導致心血管疾病風險顯著降低30 年以上的疾病和微血管疾病 (100)。糖尿病前期與心血管疾病和死亡率增加有關（88），強調了關注這一人群心血管風險的重要性。
Individualized risk/benefit should be considered in screening, intervention, and monitoring for the prevention or delay of type 2 diabetes and associated comorbidities. Multiple factors, including age, BMI, and other comorbidities, may influence risk of progression to diabetes and lifetime risk of complications (96,97). In the DPP, which enrolled high-risk individuals with impaired glucose tolerance, elevated fasting glucose, and elevated BMI, the crude incidence of diabetes within the placebo arm was 11.0 cases per 100 person-years, with a cumulative 3-year incidence of diabetes of 28.9% (1). In the community-based Atherosclerosis Risk in Communities (ARIC) study, observational follow-up of older adults (mean age 75 years) with laboratory evidence of prediabetes (based on A1C 5.7–6.4% and/or fasting glucose 100–125 mg/dL) but not meeting specific BMI criteria found much lower progression to diabetes over 6 years: 9% of those with A1C-defined prediabetes, 8% with impaired fasting glucose (97).
Thus, it is important to individualize the risk/benefit of intervention and consider person-centered goals. Risk models have explored risk-based benefit, in general finding higher benefit of intervention in those at highest risk (9). Diabetes prevention and observational studies highlight several key principles, which may guide patient-centered goals. In the DPP, which enrolled a high-risk population meeting criteria for overweight/obesity, weight loss was an important mediator of diabetes prevention or delay, with greater metabolic benefit generally seen with greater weight loss (9,98). In the DPP/DPPOS, progression to diabetes, duration of diabetes, and mean level of glycemia were important determinants of development of microvascular complications (7). Furthermore, ability to achieve normal glucose regulation, even once, during the DPP was associated with a lower risk of diabetes and lower risk of microvascular complications (99). Observational follow up of the Da Qing study also showed that regression from impaired glucose tolerance to normal glucose tolerance or remaining with impaired glucose tolerance rather than progressing to type 2 diabetes at the end of the 6-year intervention trial resulted in significantly lower risk of cardiovascular disease and microvascular disease over 30 years (100). Prediabetes is associated with increased cardiovascular disease and mortality (88), emphasizing the importance of attending to cardiovascular risk in this population.