What is the correct diagnosis for a patient with the following two-hour oral glucose tolerance test results: fasting 100 mg/dL, one-hour 232 mg/dL, and two-hour 115 mg/dL. Hemoglobin (Hb) A1c was 6.1%. I diagnosed dysmetabolic syndrome and added metformin [Fortamet, Glucophage, Glumetza, Riomet].
A physician colleague disagreed and said the patient unquestionably has type 2 diabetes. My diagnosis was not based on the American Diabetes Association [ADA] guidelines, but I was under the impression that I do not have to go by ADA guidelines all the time. — Chrystyne Olivieri, FNP-BC, Manhasset, N.Y.
This patient has impaired fasting glucose (IFG), or prediabetes, according to the ADA Clinical Practice Recommendations (Diabetes Care. 2012;35 Suppl 1:S64-S71). IFG is defined as a fasting glucose of 100-126 mg/dL. Impaired glucose tolerance (as well as prediabetes) is a two-hour glucose of >200 mg/dL.
In putting this patient’s clinical picture together, the HbA1c is also consistent with prediabetes according to the ADA (HbA1c of 5.7%-6.4%). The one-hour glucose level is not considered in the formal diagnostic criteria for type 2 diabetes. Based on the above information, I would not diagnose the patient with metabolic syndrome, as the patient must have at least three of the five metabolic syndrome criteria to meet this diagnosis (BP >130/85 mmHg, HDL <50mg/dL in women or <40 mg/dL in men, triglycerides >150 mg/dL, waist circumference >35 in for women and >40 in for men, and fasting glucose 100-125mg/dL).
Your intervention was appropriate and agrees with the ADA recommendations that suggest starting metformin on a patient with prediabetes younger than age 60 years. The ADA guidelines also recommend lifestyle therapy for individuals with prediabetes. — Kathy Pereira, MSN, FNP-BC, assistant professor, co-coordinator, Family Nurse Practitioner Program, Duke University School of Nursing, Durham, N.C. (167-1)
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