Monday, March 22, 2021

Increasing clarity about benefits and harms of screening for diabetes

 - Kenny Lin, MD, MPH

Affecting about 6 percent of pregnancies in the United States, gestational diabetes increases risks of preeclampsia, shoulder dystocia, and macrosomia, and is associated with a 10-fold greater risk of developing type 2 diabetes mellitus in later life. In a recent draft statement, the U.S. Preventive Services Task Force (USPSTF) affirmed its previous recommendation to screen pregnant persons for gestational diabetes at or after 24 weeks of gestation. Historically, there have been two screening options: a non-fasting 50 gram oral glucose challenge test followed by a fasting 100 gram glucose tolerance test if the first test result exceeds a threshold value (typically 130-140 mg/dL), or a single fasting 75 gram glucose tolerance test. Although two-step screening is more commonly used in the U.S., until recently the comparative outcomes of these approaches were uncertain. This evidence gap is important because the diagnosis is associated with increased psychological and emotional burden; labeling more persons as having gestational diabetes with the one-step screening approach would only be justified if doing so resulted in better pregnancy outcomes than the two-step approach.

A pragmatic, randomized trial recently compared the one-step and two-step approaches in more than 23,000 women who received prenatal care at Kaiser Permanente Northwest and Kaiser Permanente Hawaii. Researchers evaluated five primary outcomes: "diagnosis of gestational diabetes, large-for-gestational-age infants, a perinatal composite outcome (stillbirth, neonatal death, shoulder dystocia, bone fracture, or any arm or hand nerve palsy related to birth injury), gestational hypertension or preeclampsia, and primary cesarean section." As expected, a diagnosis of gestational diabetes was more common in participants who underwent one-step screening (16.5%) compared to the two-step approach (8.5%). However, intention-to-treat analyses found no statistically significant differences in any perinatal or maternal complications. Although the trial was not designed to measure potential long-term benefits of post-pregnancy risk-reduction strategies to prevent type 2 diabetes, the results suggest that the two-step approach produces equivalent benefits, and fewer harms, than the one-step approach.

The USPSTF is also updating its recommendation on screening for prediabetes and type 2 diabetes in nonpregnant adults. Compared to its 2015 statement, which recommends screening overweight or obese adults between the ages of 40 and 70, the updated draft statement lowers the age range to include persons aged 35 to 39 years. Although the focus of the Task Force's old and new diabetes screening guidelines is identifying persons with prediabetes in order to prevent them from developing diabetes and its complications, the utility of the term "prediabetes" is controversial, as Dr. Jennifer Middleton discussed in a previous AFP Community Blog post. In older adults, prediabetes is extremely common. In a prospective cohort study of community-dwelling adults aged 71 to 90 years, 73 percent met one or both of the diagnostic criteria for prediabetes (hemoglobin A1c level of 5.7% to 6.4%, impaired fasting glucose of 100-125 mg/dL). After 6.5 years of follow-up, persons with prediabetes at baseline were substantially more likely to revert to normoglycemia or to die than to progress to diabetes. Based on these findings, stopping diabetes screening after age 70 will avoid overdiagnosis and unnecessary treatment.