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Measuring T2D remission

ADA criteria better defines T2D remission after surgery

No significant differences found between the criteria
Call for scientific societies to uniform inclusion criteria of complete or partial remission of T2D

According to Spanish researchers, the criteria of the American Diabetes Association (ADA) should be utilised to evaluate diabetes remission after bariatric surgery. The paper, published online by on Biomed Central states the ADA criteria “may be of a more practical and affordable clinical application, as well as realistic regarding what outcomes to expect.

The researchers from Complutense University, Madrid, Spain, undertook a retrospective analysis of patients with type 2 diabetes and morbid obesity, who underwent bariatric surgery. They then compared the two following models of remission of type 2 diabetes after bariatric surgery:

2009 consensus statement (model 1): complete remission if “normal” measures of glucose metabolism were achieved (HbA1c < 6% and FG < 100 mg/dl [< 5.6mmol/l]; partial remission if HbA1c < 6.5% and FG 100–125 mg/dl (5.6-6.9mmol/l), in both cases in the absence of pharmacologic therapy or on-going procedures, for a duration of at least one year.

“HbA1c criteria”, based on HbA1c levels used to define diabetes in current ADA guidelines (model 2): remission if HbA1c < 5.7%, improvement if HbA1c 5.7 - 6.5%, in both cases without hypoglycemic treatment and a duration of at least one year, and no remission if these criteria were not met.

The researchers collect data from 539 patients who underwent bariatric surgery with a preoperative diagnosis of diabetes and morbid obesity, and recorded the duration of diabetes, previous hypoglycaemic treatment, age, weight, height, BMI, fasting glucose (FG) and HbA1c.

Three types of bariatric surgery were performed: laparoscopic Roux-en-Y gastric bypass, biliopancreatic diversion and sleeve gastrectomy. Preoperative features were compared at 18-month follow-up.

Results

Data was gathered from 110 patients with type 2 diabetes (61.8% women). Mean ± SD preoperative characteristics were: age 53 ± 10 years, BMI 43.6 ± 5.5, FG 165.2 ± 58.5mg/dL and HbA1c 7.9 ±1.8%. Mean duration of diabetes was 7.6 ±7.5 years and 44.5% of patients were on insulin therapy prior to surgery.

At 18-months follow-up, mean ± SD BMI, FG and HbA1c were 29.0 ± 5.0, 100.2 ± 23.9mg/dL and 5.4 ± 0.7%, respectively, all being significantly different from their corresponding preoperative values (p< 0.001 in all cases).

Eighteen months after bariatric surgery, according to model 1, 50% obtained complete remission, 12.7% partial remission, and 37.3% no remission. With model 2, rates in the analogous categories were 50%, 15% and 34.5%, respectively.

There were no significant differences found whichever the criteria used (p=0.673). Age and preoperative BMI did not influence the rate of remission. Percentage of body weight loss (% WL) and percentage of excess body weight loss (% EWL) were greater in the complete remission group (p<0.05).

Mean duration of diabetes was significantly different across the three remission categories (p=0.001), and was greater in the non-remission group (p<0.05). Previous insulin treatment was more frequent in the non-remission group (p=0.000).

Conclusion

The authors conclude that using the simpler criteria based on ADA’s criteria resulted in remission rates comparable to the criteria proposed by the 2009 consensus group.

However, the write that the ADA’s criteria “were more straightforward and of easy application, as they are based on only one biochemical parameter (the HbA1c level), in the absence of hypoglycemic treatment”.

They also note that the longer the duration of diabetes and previous treatment with insulin, were found to be associated with a lower rate of remission, and may be useful to determine how much improvement can be potentially expected after a specific bariatric procedure. They found that in this study remission rates in patients previously on insulin therapy were around 30%, whilst rates increased up to 70% in those patients receiving only oral medication.

They recommend that in future studies, differences in remission rates should be specified according to previous hypoglycaemic treatments and/or diabetes duration.

In addition, the investigators call on scientific societies to published position statements that define uniform inclusion criteria of complete or partial remission of type 2 diabetes after bariatric surgery.

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