Type 2 diabetes

Consensus reached on definition of diabetes remission: 5 new criteria

People with type 2 diabetes should be considered in remission after sustaining normal blood sugar levels for three months or more, according to a new consensus statement released by international peak bodies.

The statement, developed jointly by the Endocrine Society, the European Association for the Study of Diabetes (EASD), Diabetes UK and the American Diabetes Association, claims there is a need for consistency in defining the return to normal or nearly normal glucose levels that is increasingly being attained by people with T2D either through medical or lifestyle interventions or metabolic surgery.

“Improvement of glucose levels into the normal range can occur in some people living with diabetes, either spontaneously or after medical interventions, and in some cases can persist after withdrawal of glucose-lowering pharmacotherapy,” the report from a panel of international experts noted.

However, terminology for describing this process and objective measures for defining it are not well established, and the long-term risks versus benefits of its attainment are not well understood, said the group, led by Dr Matthew Riddle of Oregon Health & Science University in Portland, representing the Endocrine Society.

“The frequency of sustained metabolic improvement in this setting, its likely duration, and its effect on subsequent medical outcomes remain unclear,” they wrote in Diabetes Care.

To facilitate clinical decisions, data collection, and research regarding outcomes, more clear terminology describing such improvement is needed. They therefore proposed a series of definitions and benchmarks:

  • The term used to describe a sustained metabolic improvement in T2D to nearly normal levels should be remission of diabetes.
  • Remission should be defined as a return of HbA1c to <6.5% (<48 mmol/mol) that occurs spontaneously or following an intervention and that persists for at least 3 months in the absence of usual glucose- lowering pharmacotherapy.
  • When HbA1c is determined to be an unreliable marker of chronic glycemic control, FPG <126 mg/dL (<7.0 mmol/L) or eA1C <6.5% calculated from CGM values can be used as alternate criteria.
  • Testing of HbA1c to document a remission should be performed just prior to an intervention and no sooner than 3 months after initiation of the intervention and withdrawal of any glucose lowering pharmacotherapy.
  • Subsequent testing to determine long-term maintenance of a remission should be done at least yearly thereafter, together with the testing routinely recommended for potential complications of diabetes.

The statement discussed whether remission could be diagnosed if a person was continuing with  pharmacotherapy, and concluded that it can only be made after all glucose-lowering agents have been withheld for an interval that is sufficient both to allow waning of the drug’s effects and to assess the effect of the absence of drugs on HbA1c values.

“This criterion would apply to all glucose-lowering drugs including those with other effects,” they said, referring to agents such as metformin and GLP-1 receptor agonists prescribed for weight loss or indications.

“Diabetes remission may be occurring more often due to advances in treatment,” said co-author Dr Amy Rothberg of the University of Michigan in Ann Arbor.

“More research is needed to determine the frequency, duration and effects on short- and long-term medical outcomes of remission of type 2 diabetes using available interventions,” she suggested.

The statement is co-published in Journal of Clinical Endocrinology & Metabolism, Diabetologia and Diabetic Medicine.

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