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Randomized Controlled Trial
. 2015 Feb 19:350:h454.
doi: 10.1136/bmj.h454.

Improving diabetes prevention with benefit based tailored treatment: risk based reanalysis of Diabetes Prevention Program

Jeremy B Sussman  1 , David M Kent  2 , Jason P Nelson  2 , Rodney A Hayward  3
Affiliations
Randomized Controlled Trial

Improving diabetes prevention with benefit based tailored treatment: risk based reanalysis of Diabetes Prevention Program

Jeremy B Sussman et al. BMJ. .

Abstract

Objective: To determine whether some participants in the Diabetes Prevention Program were more or less likely to benefit from metformin or a structured lifestyle modification program.

Design: Post hoc analysis of the Diabetes Prevention Program, a randomized controlled trial.

Setting: Ambulatory care patients.

Participants: 3060 people without diabetes but with evidence of impaired glucose metabolism.

Intervention: Intervention groups received metformin or a lifestyle modification program with the goals of weight loss and physical activity.

Main outcome measure: Development of diabetes, stratified by the risk of developing diabetes according to a diabetes risk prediction model.

Results: Of the 3081 participants with impaired glucose metabolism at baseline, 655 (21%) progressed to diabetes over a median 2.8 years' follow-up. The diabetes risk model had good discrimination (C statistic=0.73) and calibration. Although the lifestyle intervention provided a sixfold greater absolute risk reduction in the highest risk quarter than in the lowest risk quarter, patients in the lowest risk quarter still received substantial benefit (three year absolute risk reduction 4.9% v 28.3% in highest risk quarter; numbers needed to treat of 20.4 and 3.5, respectively). The benefit of metformin, however, was seen almost entirely in patients in the top quarter of risk of diabetes. No benefit was seen in the lowest risk quarter. Participants in the highest risk quarter averaged a 21.4% three year absolute risk reduction (number needed to treat 4.6).

Conclusions: Patients at high risk of diabetes have substantial variation in their likelihood of receiving benefit from diabetes prevention treatments. Using this knowledge could decrease overtreatment and make prevention of diabetes far more efficient, effective, and patient centered, provided that decision making is based on an accurate risk prediction tool.

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Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organization for the submitted work; no financial relationships with any organizations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

Figures

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Fig 1 Calibration plot: black dots represent deciles of risk
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Fig 2 Efficacy plots
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