제2형 당뇨병 예방과 지연 (스타틴, 피오글리타존, 고위험군 적극적 감시) ADA 2023

ADA 2023 추가 내용2​

● 스타틴은 제2형 당뇨병 발생 위험이 높은 사람에서 제2형 당뇨병 발생 위험을 높일 수 있으므로 혈당 상태를 정기적으로 감시하고 당뇨병 예방을 위한 접근법을 강화해야 한다. 스타틴 중단은 권고되지 않는다.

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● 뇌졸중 병력과 인슐린저항성/당뇨병 전단계이 사람에서 피오글리타존은 뇌졸중 또는 심근경색 위험을 더 낮추기 위해 고려될 수 있다. 그러나 이 약제의 이점은 체중 증량, 부종, 골절 위험 증가와 균형을 이룰 필요가 있다.

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● 당뇨병 발생 위험이 특히 높은 사람 (BMI 35 이상, 공복혈당 110-125 mg/dL, 2시간 경구포도당 부하검사 173–199 mg/dL, A1C ≥6.0%, 임신성 당뇨 병력)에서는 더 적극적인 예방적 접근이 고려되어야 한다.

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• 3.9 Statin therapy may increase the risk of type 2 diabetes in people at high risk of developing type 2 diabetes. In such individuals, glucose status should be monitored regularly and diabetes prevention approaches reinforced. It is not recommended that statins be discontinued. B
• 3.10 In people with a history of stroke and evidence of insulin resistance and prediabetes, pioglitazone may be considered to lower the risk of stroke or myocardial infarction. However, this benefit needs to be balanced with the increased risk of weight gain, edema, and fracture. A Lower doses may mitigate the risk of adverse effects. C
• 3.12 Pharmacotherapy (e.g., for weight management, minimizing the progression of hyperglycemia, cardiovascular risk reduction) may be considered to support person-centered care goals. B
• 3.13 More intensive preventive approaches should be considered in individuals who are at particularly high risk of progression to diabetes, including individuals with BMI ≥35 kg/m2, those at higher glucose levels (e.g., fasting plasma glucose 110–125 mg/dL, 2-h postchallenge glucose 173–199 mg/dL, A1C ≥6.0%), and individuals with a history of gestational diabetes mellitus. A

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Statins have been associated with a modestly increased risk of diabetes (100–104). In the DPP, statin use was associated with greater diabetes risk irrespective of the treatment group (pooled hazard ratio [95% CI] for incident diabetes 1.36 [1.17–1.58]) (102). In studies of primary prevention of cardiovascular disease, cardiovascular and mortality benefits of statin therapy exceed the risk of diabetes (105,106), suggesting a favorable benefit-to-harm balance with statin therapy. Hence, discontinuation of statins is not recommended in this population due to concerns of diabetes risk.

Cardiovascular outcome trials in people without diabetes also inform risk reduction potential in people without diabetes at increased cardiometabolic risk (see Section 10, “Cardiovascular Disease and Risk Management,” for more details). The IRIS (Insulin Resistance Intervention after Stroke) trial was a dedicated study of people with a recent (<6 months) stroke or transient ischemic attack, without diabetes but with insulin resistance, as defined by a HOMA of insulin resistance index of ≥3.0, evaluating pioglitazone (target dose of 45 mg daily) compared with placebo. At 4.8 years, the risk of stroke or myocardial infarction, as well as the risk of diabetes, was lower within the pioglitazone group than with placebo, though risks of weight gain, edema, and fracture were higher in the pioglitazone treatment group (107–109). Lower doses may mitigate the adverse effects, though further study is needed to confirm the benefit at lower doses (110).