Many people with prediabetes are confused about how serious their condition is. Is it a severe problem, or likely to become one? Should you be changing your diet or exercise habits? Do you need medicine?
The answer is … it depends. Prediabetes will mean different things for different people, and your risk level will be different than someone else’s.
Most people with prediabetes take no medicine for their condition. In fact, the FDA has not approved any drugs for use with prediabetes. In certain circumstances, however, doctors will encourage their patients to take certain drugs “off-label” to help slow the progression toward full-blown type 2 diabetes.
This article is not medical advice, and it cannot tell you if you should be taking any medicine for your condition. But it should help put drug treatments for prediabetes into context, and allow you to approach the subject with your healthcare provider with more confidence.
Is Prediabetes a Dangerous Condition?
Nearly 100 million American adults have prediabetes, and the majority of them are unaware of the fact. If so many people with prediabetes go about their lives in blissful ignorance, it’s natural to wonder how serious the condition is.
Some experts wonder the same thing. For more about the controversy, check out this article from our partners at Everyday Health: Is Prediabetes a Useful Diagnosis? A New Article Revives an Old Debate.
Prediabetes is a controversial concept, and there is little international consensus on the condition:
In the United States, the American Diabetes Association (ADA) diagnoses prediabetes in people with the following blood sugar measurements:
Hemoglobin A1C level of 5.7–6.4 percent
Fasting blood glucose of 100–125 mg/dL
Oral glucose tolerance (OGTT) result of 140–199 mg/dL
If you live elsewhere, though, your doctor may be operating with different standards and terms. The World Health Organization (WHO), for example, does not even use the word “prediabetes,” and has a stricter standard: a fasting blood glucose of 110-125 mg/dL.
To put it simply, some people with “prediabetes” in the United States would be considered healthy in other countries. There’s a fierce debate among experts about how strict the standard for prediabetes should be.
Prediabetes and Risk Level
Prediabetes is not considered an especially dangerous condition, in and of itself, although it is associated with a number of bad long-term health outcomes. Most experts instead focus on the likelihood that prediabetes will progress into full-blown type 2 diabetes.
The odds that prediabetes will lead to diabetes differ between patients. Prediabetes is a more serious warning sign in younger adults than in older ones, for example. And patients with blood sugar results in the lower end of the American prediabetic range are at less risk than those with blood sugar measurements in the higher end.
A 2007 study found that 8.1 percent of individuals with a fasting glucose of 100-109 mg/dL went on to develop type 2 diabetes in the next several years. But 24.3 percent of those with a fasting glucose of 110–125 mg/dL developed the more serious condition.
You should speak to your healthcare provider to better assess how hazardous your particular case of prediabetes is. Your doctor may consider you at a higher risk — and therefore a better candidate for drug therapy — if your blood sugar is near the top of the prediabetic range, if you are a younger adult, or if you have other relevant health circumstances, such as a history of gestational diabetes.
Try Lifestyle Modifications First
Here’s one thing that all medical authorities agree on: If you have prediabetes, your first plan of attack should be lifestyle adjustments. That generally means a healthier diet and healthier physical activity habits.
The Centers for Disease Control and Prevention (CDC) helps to operate the National Diabetes Prevention Program, a hub of resources for people looking to prevent diabetes through lifestyle adjustments. The effort is based on a massive series of linked clinical studies proving that people at a high risk of type 2 diabetes can slow or halt the disease’s progression with positive lifestyle changes. The central study of this effort found that volunteers assigned to a lifestyle change program had better results than those that used medication alone.
Most doctors do not automatically prescribe medication for prediabetes, but at least one medication has been thoroughly investigated and validated as a treatment for the condition.
Metformin, the world’s most-prescribed diabetes drug, is not officially approved by the FDA for the treatment of metformin, but its “off-label” use for the condition is so common that the ADA has issued recommendations for doctors to follow.
The Diabetes Prevention Program proved that metformin significantly helps to slow the progression towards type 2 diabetes in people with prediabetes (although not as well as lifestyle modifications). After three years, participants that were assigned metformin were 31 percent less likely to develop type 2 than participants using a placebo. Real-world data also suggests that metformin has positive effects on long-term cardiovascular health.
The ADA’s latest guidance says that metformin should be “considered” for adults at high risk of type 2 diabetes, especially the following:
People between the ages of 25–59 with extreme obesity (BMI ≥35)
People with blood sugar levels on the higher end of the prediabetes spectrum (fasting plasma glucose ≥110 mg/dL; A1C ≥6.0 percent)
Women with a history of gestational diabetes
Not all experts agree. In 2020, Diabetes Care published an essay by Mayer Davidson, M.D., who believes that metformin should not be used for prediabetes. Dr. Davidson argues that most people with the condition will never develop type 2 diabetes, which means that prescribing the drug widely will cause many people to take the medication unnecessarily, perhaps for the rest of their lives.
We can’t resolve the controversy. If you think you might benefit from metformin — and especially if you are in one of the categories of “high risk” as outlined by the ADA above — please discuss the topic with your doctor.
Stronger Drugs for Prediabetes
In the near future, it may become common for doctors to prescribe even stronger drugs for prediabetes. A new generation of pricey diabetes drugs is replacing metformin as the go-to option for type 2 diabetes, and these same drugs appear to be extremely effective for people with prediabetes.
A major trial of the drug semaglutide found that after 68 weeks of use, some 84 percent of users with prediabetes returned to normal blood sugar levels. Researchers called the result “transformational.” Semaglutide is the active ingredient in three wildly popular newer drugs: Ozempic, Rybelsus, and the weight-loss medication Wegovy.
Liraglutide — a related drug that is sold as Victoza (for diabetes) and Saxenda (for weight loss) — can also significantly slow or halt the progression of type 2 diabetes.
SGLT2 inhibitors, another class of newer diabetes drugs, also show potential for people with prediabetes, perhaps especially for those with an increased risk of cardiovascular disease.
The ADA has not yet given a clear endorsement for the use of these drugs for prediabetes, and doubtless wishes to see more research before rendering an official judgment. But the organization’s latest guidance has begun to open the door for doctors to use them off-label. The newest recommendations suggest the use of “more intensive preventive approaches” than metformin, and promote the use drugs “for weight management, minimizing the progression of hyperglycemia, cardiovascular risk reduction,” a clear reference to the touted benefits of GLP-1 receptor agonists like semaglutide and liraglutide.
Many clinicians are already comfortable prescribing Ozempic and other GLP-1 receptor agonists off-label as weight loss therapies; it is likely that many will also eagerly prescribe them for patients with diagnosed prediabetes.
Insurers, however, are unlikely to cover the cost of these pricey drugs, which as of this writing can have sticker prices as high as $1,000. For the foreseeable future, these “more intensive” prediabetes therapies will too exorbitant for most Americans.
The Bottom Line
Most people with prediabetes do not take any medication for their condition, and the FDA has not approved a single medication for use with prediabetes. Nevertheless, several diabetes drugs have shown that they can help delay or prevent the development of type 2 diabetes in these patients.
The American Diabetes Association recommends that clinicians “consider” the use of metformin in patients with a higher risk of type 2 diabetes, especially younger adults with extreme obesity, patients with blood sugar levels on the higher end of the prediabetes spectrum, and women with prediabetes and a history gestational diabetes.
It is also becoming more common for clinicians to prescribe the off-label use of more advanced drugs, such as GLP-1 receptor agonists, to their patients with prediabetes.