Prediabetes

Description:

The prediabetes — the life period preceding a disease of a diabetes mellitus, a condition of predisposition is often diagnosed retrospectively.

Reasons of a perdiabet:

Risk factors for a prediabetes are:
- unioval twins whom one of parents is ill a diabetes mellitus or - are patients with a diabetes mellitus in a family tree of other parent;
- the women who gave birth to the living child weighing 4,5 kg and more;
- mothers of children with malformations, women with a glucosuria during pregnancy, and - also after an abortion or the birth of the dead child;
- the persons having obesity, a giperlipoproteinemiya, atherosclerosis, a hypertension, a hyperuricemia, gout;
- diseases of a liver, bile-excreting channels, pancreas, persistent infections of urinary tract and respiratory organs, chronic damages of kidneys;
- persons with a renal and alimentary glucosuria;
- persons with the incidental glucosuria and a hyperglycemia revealed in stressful situations;
- patients with a persistent paradontosis and fununkulyozy;
- persons with neyropatiya of not clear genesis;
- persons with spontaneous gipoglikemiya;
- persons of advanced and senile age.

The risk of incidence of a diabetes mellitus considerably increases at a combination of several factors: obesity + increase in diastolic arterial pressure + increase in level of triglycerides in a blood plasma, concentration of lactic acid, bilirubin, a lactate, activity of a glutamatpiruvattransaminaza in the circulating blood. At the correct way of life, normalization of the body weight adequate to therapy of above-mentioned states and diseases at the majority predisposition to development of a diabetes mellitus remains hidden and is not implemented in a manifest form.

Diagnosis:

Laboratory determination of level of a glycemia on an empty stomach and in two hours after meal (a postprandialny glycemia), or carrying out the glyukozotolerantny test (indicators serve as differential and diagnostic criteria between the norm broken by tolerance to glucose and a diabetes mellitus).

Preclinical diagnosis of a diabetes mellitus.
Definition of existence of autoantibodies to beta cells of pancreatic islands.
Determination of level of S-peptide.

Prediabetes symptoms:

The prediabetes is shown by the following states:
1. Disturbance of tolerance to glucose.
The broken tolerance to glucose (on old classifications "a latent diabetes mellitus") clinically, as a rule, is not shown and characterized:
normoglikemiya on an empty stomach (a glucose indicator in peripheral blood 3,3 … 5,5 mmol/l);
the glucosuria is absent (glucose in urine is not defined);
comes to light at test of tolerance to glucose.

Quite often at persons with the broken tolerance to glucose paradiabetic symptoms nabyudatsya:
furunculosis,
bleeding of gums,
early shaking and dedentition, paradontosis,
skin and genital itch,
xeroderma,
it is long not healing injuries and diseases of skin,
sexual weakness, disturbance of a mentstualny cycle up to an amenorrhea,
angioneyropatiya of various localization and expressiveness, up to a proliferating retinopathy or the expressed obliterating atherosclerosis (obliterating endarteritis).
Identification of these states is the cause for test of tolerance of glucose.

2. Disturbance of a glycemia on an empty stomach.

State at which the defined glycemia indicators on an empty stomach exceed norm, but not so to correspond to criteria of a diabetes mellitus. The glucosuria, usually, is not defined.

Treatment of a prediabetes:

The following strategy of correction of a prediabetes are possible.

1. Basic strategy — modification of a way of life: a low-calorie diet plus physical exercises not less than 150 minutes a week.

2. Influence on insulin resistance and toshchakovy hyperglycemia. In researches efficiency of two drugs is proved.
Metforminum in a dose of 1700 mg/days. Suppresses products of glucose in a liver, reducing a toshchakovy hyperglycemia; improves sensitivity of peripheral fabrics to insulin. Is choice drug in the presence of abdominal obesity.
Rosiglitazon in a dose of 8 mg/days. Exerts impact on activity of the genes participating in regulation of exchange of glucose and lipids.

3. Influence on a postprandialny hyperglycemia.
- Acarbose in a dose of 150 mg/days. By inhibition of enzyme prevents splitting poly-and oligosaccharides, thereby causing stable decrease in a postprandialny glycemia.
- Glinida? Treat group of prandialny regulators, promote recovery of the first phase of secretion of insulin. Efficiency at a prediabetes is not proved. Studying of a nateglinid continues in the research NAVIGATOR (Nateglinide And Valsartan in Impaired Glucose Tolerance Outcomes Research).

4. "Normoglikemiya at any cost" — early purpose of an insulin therapy? Expediency of use of insulin at a stage of a prediabetes is not established. Studying of a glargin continues in the research ORIGIN (Outcome Reduction with Initial Glargine Intervention).

One of the most indicative researches showing possibilities of modification of a way of life is the research Diabetes Prevention Program which included 3 234 patients with obesity (IMT on average of 34 kg/sq.m) and disturbance of tolerance to glucose.

In this research compared efficiency of intensive modification of a way of life (a diet, exercise stresses — decrease in body weight by 7% + 150 minutes of physical exercises a week) and therapies by Metforminum (850 mg two times a day). The control group was made by the patients accepting placebo against the background of a standard diet and physical activity. In 2,8 years the risk of transition of the broken tolerance to glucose to a diabetes mellitus in group of modification of a way of life decreased by 58%, and in group of Metforminum — for 31% in comparison with control (frequency of a diabetes mellitus made 4.8, 7.8 and 11.0% respectively).

So, modification of a way of life brought even big benefit, than therapy by Metforminum reducing insulin resistance. Unfortunately, as professor of Paul Zimmet told (the center of joint WHO researches in Melbourne, Australia): Despite accurate proofs of decrease in risk of a disease of diabetes and cardiovascular pathologies as a result of control of weight and high physical activity, many people live, without listening to useful tips.

Preventive opportunities of acarbose were studied in the research STOP-NIDDM at 1 429 patients of white race with disturbance of tolerance to glucose. Development of a diabetes mellitus (concentration of glucose ≥ 11,1 mmol/l after loading glucose) was primary final point of a research. Randomized patients within on average 3,3 years accepted acarbose or placebo. Acarbose appointed in a dose 50 mg/days which was gradually increased to 100 mg by three times a day or the most tolerable dose (at the end of a research it averaged 194 mg/days).

During the specified term transition of the broken tolerance to glucose to a diabetes mellitus was observed at 32,4% of patients in group of active therapy and at 41,5% of patients in group of placebo. Besides, at treatment by acarbose in 35% of cases noted recovery of normal tolerance to glucose. And the effect of drug did not depend on age, sex or an index of body weight.
After the research STOP-NIDDM started talking also about positive influence of acarbose on reduction of risk of cardiovascular complications.

So, M. Hanefeld and соавт. received interesting results when studying dynamics of thickness erotic-medii of carotid arteries by means of an ultrasonic method at 132 patients participating in the research STOP-NIDDM. In 3,3 years in group of acarbose annual increase in thickness erotic-medii was slowed down approximately for 50% and made (0,07 mm/year), and in group of placebo — 0,013 mm/year. To estimate this effect, it is necessary to tell that the thickening erotic-medii of carotid arteries reflects progressing of atherosclerosis and is associated with increase in risk of cardiovascular complications. At healthy people thickness erotic-medii increases approximately by 0,006 mm a year. Despite some restrictions of this research, it is possible to agree that acarbose contributes to "normalization" of dynamics of atherosclerotic processes in carotid arteries.

But the declared figures of decrease in risk of a myocardial infarction for 91% in the research STOP-NIDDM or for 74% in meta-analysis, the carried-out M. Hanefeld against the background of treatment by acarbose look absolutely improbable.

Such result was not achieved even by statines. For example, симвастатин in a research 4S-extended (n=483, secondary prevention) the risk of an ischemic heart disease at patients with a diabetes mellitus lowered by 42% and without diabetes for 32%. Lovastatin in the research AFCAPS/TexCAPS (n=239, primary prevention) reduced risk of an ischemic heart disease at patients with a diabetes mellitus by 43% and without diabetes for 37%.

Without belittling an acarbose role in correction of disturbances of carbohydrate metabolism at all, it is necessary to tell about need of the critical relation to the published articles when manipulations with selection can distort the true situation.

It is necessary to realize that the drugs intended for correction of carbohydrate metabolism can influence really prevention of cardiovascular risks only through delay of development of a diabetes mellitus. And especially are hardly capable to divide an efficiency pedestal with statines.

By the way, also the return assumption was not confirmed that cardiovascular means (in particular APF inhibitor ramiprit) are able to prevent development of a diabetes mellitus in patients with a prediabetes.

In the research DREAM which results were published in September, 2006 ramiprit, though contributed to normalization of carbohydrate metabolism (in comparison with placebo), however did not show decrease in risk of development of diabetes.

In this research (5 269 people with a toshchakovy hyperglycemia or with the broken tolerance to glucose, but without diabetes mellitus or cardiovascular pathology) to patients randomizirovanno appointed росиглитазон (8 mg/days) or placebo, and also ramiprit (up to 15 mg/days) or placebo. The average time of observation made 3 years.

Frequency of development of a diabetes mellitus and lethal outcomes was primary combined final point. It was registered in group of a rosiglitazon less often: 11,6% against 26,0% in group of placebo. At the same time distinctions between groups of a ramipril and placebo were practically not: 18,1% and 19,5%, respectively.

Frequency of cardiovascular events was similar in groups of a rosiglitazon and placebo though heart failure was registered in the first group more often: 0,5% against 0,1%, respectively.

Great interest is attracted by the continuing researches NAVIGATOR and ORIGIN which will allow to receive the answer to a question: Whether "The motto "normoglikemiya at any cost" even at prediabetichesky stages of disturbance of carbohydrate metabolism is really lawful?"

The research NAVIGATOR includes patients with the broken tolerance to glucose who are distributed in groups of therapy valsartany, nateglinidy, by their combination or placebo. A research objective is check of ability of a nateglinid as a result of control of a postprandialny glycemia to reduce quantity of cases of conversion of the broken tolerance to glucose in a diabetes mellitus 2 types and to reduce cardiovascular incidence and mortality. Also the hypothesis of ability of the antagonist of receptors to angiotensin II (valsartan) to prevent development of a diabetes mellitus 2 types is checked.

The research ORIGIN is directed to studying of effects of early purpose of an insulin therapy (in particular, a glargina). The research, along with patients with a diabetes mellitus, also included groups of patients with the broken tolerance to glucose and the broken glycemia on an empty stomach that will allow to answer a question of expediency of use of a glargin at a prediabetes stage.