Recommendations

• Monitor type 2 diabetes (T2D) development in people with prediabetes at least every year; assess individual risk to modify testing frequency.
• Consider HbA1c every six months and a 75-g oral glucose tolerance test every year to monitor disease progression in individuals with presymptomatic T2D; assess individual risk to modify testing frequency using age, glycemic metrics, and type and number of autoantibodies.
• Adults with overweight or obesity who are at high T2D risk should be referred to an intensive lifestyle behavior change program to attain and maintain a weight loss of ≥7% of initial body weight.
• Eating patterns, which are effective in T2D prevention, should be prescribed to individuals with prediabetes. Benefits have been reported with intermittent fasting, Mediterranean-style, and low-carbohydrate diets.
• As lifestyle behavior modification programs for preventing diabetes are cost-effective, offer these programs to adults with high T2D risk.
• Diabetes prevention programs (DPPs) assisted with certified technology are effective in T2D prevention and should be considered based on individual preference.
• Consider metformin for T2D prevention in adults at high T2D risk, especially those aged 25–59 years with higher fasting plasma glucose, BMI ≥35 kg/m², and higher A1C, and those with a history of gestational diabetes mellitus (GDM).
• Long-term metformin use may be linked to vitamin B12 deficiency. Assess vitamin B12 periodically in patients on metformin, especially those with peripheral neuropathy or anemia.
• There is an association between prediabetes and higher cardiovascular (CV) risk; screen and treat modifiable risk factors for CV disease.
• Statin therapy may enhance T2D risk in those with a high risk of T2D development. Regularly monitor glucose levels and consider diabetes prevention approaches in these individuals; do not avoid or discontinue statin therapy for this adverse effect.
• Consider pioglitazone to reduce the risk of myocardial infarction or stroke in people with a history of stroke and evidence of prediabetes and insulin resistance; however, balance this benefit with a higher risk of edema, weight gain, and fractures. Lower dose, although it reduces adverse effects, may be less effective.
• Care goals should be minimizing hyperglycemia progression, weight loss and maintenance, and attention to CV risk in adults with overweight or obesity at high T2D risk.
• Consider pharmacotherapy options, such as minimizing hyperglycemia progression, weight loss and maintenance, and CV risk reduction, to support individual care goals.
• Consider more intensive preventive approaches in those at high risk of progression to diabetes, such as individuals with higher glucose levels, BMI ≥35 kg/m², and A1C ≥6.0, and those with a history of GDM.
• Discuss teplizumab-mzwv with selected individuals of ≥8 years of age with stage 2 T2D to delay the onset of symptomatic T2D. The treatment site should have appropriately trained personnel.