Analysis

Waking up from the DREAM of preventing diabetes with drugs

BMJ 2007; 334 doi: http://dx.doi.org/10.1136/bmj.39169.447488.94 (Published 26 April 2007) Cite this as: BMJ 2007;334:882
  1. Victor M Montori, associate professor1,
  2. William L Isley, associate professor2,
  3. Gordon H Guyatt, professor3
  1. 1Knowledge and Encounter Research Unit, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
  2. 2Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic College of Medicine
  3. 3CLARITY Research Group, Department of Biostatistics and Clinical Epidemiology and Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
  1. Correspondence to: V M Montori, Mayo E17-96, 200 First Street SW, Rochester, MN 55905, USA kerunit{at}mayo.edu
  • Accepted 12 March 2007

The current epidemic of diabetes makes a drug to prevent it attractive. But despite promotion of recent research evidence, Victor Montori, William Isley, and Gordon Guyatt argue that we are not there yet

Diabetes affects about 4% of the world population1 2 and is associated with important costs, both in financial and human terms.3 The high prevalence, increasing incidence, and associated costs makes preventing diabetes a public health priority. The diabetes reduction assessment with ramipril and rosiglitazone medication (DREAM) trial recently showed that rosiglitazone reduced the risk of diabetes in people at risk.4 The results have prompted aggressive marketing of rosiglitazone as a preventive therapy; some clinicians are already responding to this initiative. We argue that the strategy will bring harms and additional costs while the benefits for patients remain questionable.

Preventing diabetes

Several randomised trials have shown that modest weight loss and physical activity can greatly reduce the risk of diabetes.5 6 7 The Diabetes Prevention Program documented a 58% relative risk reduction (confidence interval 48% to 66%) in high risk individuals5; other trials have shown similar results.6 7

Nevertheless, the possibility of preventing diabetes with drugs has caught the imagination of the drug industry. The medicalisation of pre-disease states and risk factors has become increasingly common, including targets of precursors of hypertension, osteopenia, and obesity. The prospect of marketing existing drugs to otherwise healthy people greatly expands the market for these drugs while increasing costs for society, increasing use of health care, and potentially reducing quality of life by converting healthy people into patients.8 9

Effectiveness of drugs

Several trials have assessed the ability of drugs to prevent diabetes (box).10 Overall, except for metformin, the evidence is inconsistent and comes from trials of limited methodological quality. Two trials included drug discontinuation phases …

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