Compared with evidence for a benefit in microvas- cular disease, there is less evidence for a benefit of intensive glucose control on macrovascular end points such as stroke. No macrovascular benefit was demonstrated in the main publications from DCCT, the UKPDS, or 3 other more recent trials designed to test intensive control for prevention of macrovascular disease.239 241 However, a ben- efit of intensive control emerged during long-term follow-up of the DCCT242 and the UKPDS. Two meta-analysis of 5 trials that included the UKPDS reported a benefit of intensive control for some cardiovascular outcomes but not for stroke.243,244 No trials or meta-analyses have reported the effect of intensive control on patients with a his- tory of stroke. Many experts conclude that the benefit of intensive control on macrovascular dis- ease is likely restricted to younger patients with recent-onset diabetes and without established vascular disease. In this regard, however, some professional organizations recommend targeting reduce the risk for hypoglycemia in elderly indi- viduals with limited life expectancy or significant 7. Although lifestyle change is the safest and most efficacious method to prevent progression from prediabetes to diabetes, several drugs have dem- onstrated benefit. In the Diabetes Prevention Program trial, patients with impaired glucose tolerance were randomized to standard lifestyle recommendations plus metformin 850 mg twice a day, standard lifestyle recommendation plus placebo, or intensive lifestyle counseling. The primary outcome, progression to diabetes, was observed in 11.0%, 7.8%, and 4.8% of patients in the placebo, metformin, and intensive coun- seling groups. The rate of progression was 58% lower (95% CI, 48 66) with intensive counseling and 31% (95% CI, 17 43) lower with metfor- min compared with standard lifestyle counsel- ing. Metformin is well tolerated and inexpensive. 