Type II Diabetes is becoming a serious threat to healthy living in the modern world. Many are aware of it and some have regular checks of their blood sugar to make sure they are not diabetic.

A few years ago the American Diabetes Association (ADA), brought forth the term “prediabetes” to warn people that they should consider making lifestyle changes when their blood sugar level was not considered diabetic but was very close to it. The threshold for prediabetes was also lowered from a fasting glucose level of 110 mg/dl to one of 100 mg/dl.

In 2008, the American Diabetes Association (ADA) began recommending the drug metformin for prediabetes — specifically, for people under age 60 with a very high risk of developing diabetes, for people who are very obese (BMI of 35 or higher), and for women with a history of gestational diabetes. The ADA also said that health-care professionals could consider metformin for anyone with prediabetes or an HbA1c level between 5.7% and 6.4%.

However according to a recent study, metformin is still rarely prescribed for prediabetes. The study, published in April 2015 in the journal Annals of Internal Medicine, found that only 3.7% of people with prediabetes were prescribed metformin over a three-year period, based on data from a large national sample of adults ages 19 to 58. According to a Medscape article on the study, 7.8% of people with prediabetes with a BMI of 35 or higher or a history of gestational diabetes were prescribed metformin — still a very low rate for the highest-risk groups, in which evidence for the benefits of metformin is strongest. It appears that most doctors simply aren’t following the ADA’s guidelines or aren’t aware of them, as they relate to prediabetes.

Many articles now indicate that both metformin and lifestyle changes have been very effective at slowing the progression of prediabetes to Type 2 diabetes. I know many of the doctors in India do advise their patients on weight reduction if they are diabetic or in a prediabetic state. However how many would prescribe metformin if their patient's fasting blood sugar level is 100 mg/dl?

Thanks for the reminder to our other colleagues. In my practice the only difficulty I have is that some Med Aids are not prepared to put these patients on Metformin. They insist on life style changes for a few months with regular feedbacks before they consider putting the patient on chronic medicines.
The other problem is ,some of the generics of Metformin are not very effective, and there are many on the market.

Chil, Good to see you on the Forum.

Asking some one to take Metformin can be tricky. Until recently if someone had told me to take Metformin, I would have refused, strongly believing that I should take the tablet only if I was a diabetic. Many among the public will tell you the same. Many believe that a medicine should be taken only when it is absolutely necessary to take it!

Metformin
Indications in Pre Diabetes.

Adults at high risk whose blood glucose measure (fasting plasma glucose or HbA1c) shows they are still progressing towards type 2 diabetes, despite their participation in an intensive lifestyle-change programme.
Adults at high risk who are unable to participate in lifestyle-change programmes because of a disability or for medical reasons.

What action should be taken?
Doctors, non-medical prescribers and pharmacists in primary and secondary healthcare should use clinical judgement on whether (and when) to offer standard-release metformin to support lifestyle change for people whose HbA1c or fasting plasma glucose blood test results have deteriorated, if:

this has happened despite their participation in an intensive lifestyle-change programme, or
they are unable to participate in an intensive lifestyle-change programme.

They should also:
Discuss with the person the potential benefits and limitations of taking metformin, taking into account their risk and the amount of effort needed to change their lifestyle to reduce that risk.

Explain that long-term lifestyle change can be more effective than drugs in preventing or delaying type 2 diabetes.

Encourage them to adopt a healthy diet and be as active as possible. Where appropriate, stress the added health and social benefits of physical activity (for example, point out that it helps reduce the risk of heart disease, improves mental health and can be a good way of making friends).

Advise them that they might need to take metformin for the rest of their lives and inform them about possible side effects.

Continue to offer advice on diet and physical activity along with support to achieve their lifestyle and weight-loss goals.

Check the person's renal function before starting treatment, and then twice yearly (more often if they are older or if deterioration is suspected).

Start with a low dose (for example, 500 mg once daily) and then increase gradually as tolerated, to 1500–2000 mg daily. If the person is intolerant of standard metformin consider using modified-release metformin.

I prefer MR METFORMIN 250 mg to start with for atleast 3 -4 weeks, and then reassess if the drug suits them.
I am not keen on MR Metformin dose in excess of 1500mg, in South Asians.

Prescribe metformin for 6–12 months initially. Monitor the person's fasting plasma glucose or HbA1c levels at 3-month intervals and stop the drug if no effect is seen.

G Mohan.