Rene Rodriguez-Gutierrez, MD; Victor M. Montori, MD, MSc
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L15-0352.
Rodriguez-Gutierrez R., Montori V.; Metformin Prescription for Insured Adults With Prediabetes From 2010 to 2012. Ann Intern Med. 2015;163:482-483. doi: 10.7326/L15-5136
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Published: Ann Intern Med. 2015;163(6):482-483.
TO THE EDITOR:
Moin and colleagues (1) show that the use of metformin in patients with prediabetes is infrequent (3.7%). They suggest that this rate should be higher and call for more research on how to achieve this goal. Although their methods are rigorous, we believe that their article promotes a notion that is highly problematic: that patients with prediabetes benefit from metformin.
The case for metformin use for diabetes prevention is based on the results of the DPP (Diabetes Prevention Program) study that found metformin to be effective in delaying the diagnosis of diabetes (2) and on metformin's track record of safety. Moin and colleagues, along with some endocrine guidelines, assume that delaying the diagnosis of diabetes with an antihyperglycemic agent offers a net benefit to at-risk patients. Yet, several studies have neglected to show that metformin prevents diabetes—that is, that its use interrupts the pathophysiologic path to type 2 diabetes (3). The main mechanism responsible for delaying the diagnosis of diabetes, therefore, results from metformin's glucose level–lowering effect. This amounts to treating prediabetes as diabetes. Thus, the diagnosis of diabetes is delayed, but not its treatment. And, to our knowledge, no evidence is available showing that premature treatment leads to better patient outcomes. Indeed, one could imagine patients in whom the diagnosis of diabetes was delayed being worse off: Consider the de-emphasis on lifestyle changes now that a pill takes care of the problem or how the implementation of protocols linked to a diabetes diagnosis—for example, consideration of statin use and foot and eye examinations—may be delayed along with the diagnosis of this condition.
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