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T2DM remission

Diabetes under control without insulin seven years after surgery

Compared to SG, RYGB was associated with a greater reduction in BMI (12.2±5.7 vs. 7.8±4.7, p<0.001) and number of diabetes medications (1.1±1.2 vs. 0.6±1.1, p=0.01)

Seven years after bariatric surgery, 44 percent of patients with severe obesity had their diabetes under control and were able to stop taking insulin, and 15 percent achieved diabetes remission, according to researchers from the Cleveland Clinic in Ohio who presented their findings at ObesityWeek 2017 - the largest international event focused on the basic science, clinical application and prevention and treatment of obesity hosted by the American Society for Metabolic and Bariatric Surgery and The Obesity Society.

Ali Aminian

“This study shows bariatric surgery can induce a significant and sustainable improvement in metabolic profile of patients with obesity and insulin-treated type 2 diabetes, typically a much more difficult group to achieve glycemic control or remission,” said Dr Ali Aminian, study co-author and associate professor of surgery at the Cleveland Clinic in Ohio. “Anytime a patient can come off insulin and still have their diabetes be under control, it’s a big deal, in terms of quality of life, decreased healthcare costs and preventing weight gain.”

In their study, ‘Long-term effects of bariatric surgery in patients with insulin-treated type 2 diabetes: 44% at glycemic target without insulin use’, the Cleveland Clinic researchers examined the long-term effect of bariatric surgery in patients who were on insulin before surgery. They reviewed the outcomes of 252 patients who had either Roux-en-Y gastric bypass (194 patients) or sleeve gastrectomy (58 patients) between January 2004 and June 2012. Prior to surgery, patients had type 2 diabetes for an average of 11 years, were taking insulin, and had an average BMI of nearly 46. The average age of the patients was 52.

The two primary outcomes were the percentage long-term diabetes remission and the percentage long-term glycemic control without insulin use. Long-term diabetes remission was characterised by glycated hemoglobin (HbA1c) <6.5%, fasting blood glucose (FBG) <126mg/dL, and off diabetes medications at five years or more after surgery. Glycemic control without insulin use was considered as HbA1c <7% without insulin use at five years or more after surgery.

Out of 252 patients, 161 (57%) patients were female. Patients had a mean age of 51.9±10.5 years, a mean baseline BMI45.9±8.3, a mean HbA1c of 8.5±1.7%, and a median duration of T2DM of 11 (interquartile range, 7-15) years. At a median postoperative follow up of seven years (range, 5-12), a mean BMI reduction of 11.2±5.8 was associated with a significant mean reduction in HbA1c (1.5±1.9%,  <0.001), FBG (52.5±76.5 mg/dL, p<0.001), and diabetes medication requirement (1±1.2, p<0.001).

The proportion of patients met the American Diabetes Association glycemic target (HbA1c <7%) at baseline and last follow-up were 18% vs. 59%, respectively (p<0.001). Long-term glycemic control without insulin use and long-term diabetes remission were achieved in 44% and 15%, respectively.

Preoperative duration of T2DM was an independent predictor of both primary outcomes of study (p<0.001 for both analyses). Compared to SG, RYGB was associated with a greater reduction in BMI (12.2±5.7 vs. 7.8±4.7, p<0.001) and number of diabetes medications (1.1±1.2 vs. 0.6±1.1, p=0.01). A significant improvement in blood pressure and lipid profile was observed.

“The findings of this study, which is the largest series with the longest follow-up time to date, indicate that bariatric surgery can induce a significant and sustainable improvement in the metabolic profile and glycemic status in patients with insulin-treated T2DM,” the authors concluded.

“Certainly, we’d like to see patients sooner, but this study demonstrates bariatric and metabolic surgery can still have a significant impact, even after a person has had diabetes for years and years,” said Dr Samer Mattar, president-elect, ASMBS and a bariatric surgeon at Swedish Weight Loss Services in Seattle Washington, who was not involved in the study.

The study co-authors were Drs Zubaidah Nor Hanipah, Suriya Punchai, Jennifer Mackey, Stacy Brethauer and Phillip R Schauer.

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