Int'l consensus statement on definition of T2D "remission"

[Eddy Edson]

International experts outline diabetes remission diagnosis criteria – Diabetologia

diabetologia-journal.org

Summary: Defines "remission" as HbA1c < 48 mmol/mol persisting for at least 3 months in the absence of meds.

Given that this is the consensus of of the ADA, DUK, the EASD and the ES, I guess it is now the "official" definition.



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 from the Endocrine Society, the European Association for the Study of Diabetes (EASD), Diabetes UK and the American Diabetes Association, and co-published in Journal of Clinical Endocrinology & Metabolism, Diabetologia, Diabetic Medicine and Diabetes Care.

About 10% of the U.S. population has diabetes, and these numbers continue to rise. People with type 2 diabetes can achieve “remission” by sustaining normal blood sugar levels for at least three months without taking diabetes medication. There is still a lot of uncertainty around how long remission will last and what factors are associated with a relapse. A person may require ongoing support to prevent a relapse or a hyperglycemic episode, and the long-term effects of remission on mortality, heart health and quality of life are not well understood.

“Our international group of experts suggest an HbA1c (average blood sugar) level of less than 6.5% [ie 48 mmol/mol] at least three months after stopping diabetes medication as the usual diagnostic criterion for diabetes remission,” said statement author and Endocrine Society member Matthew Riddle of Oregon Health & Science University in Portland, Ore. Riddle is chair of the Diabetes Remission Consensus writing group that developed the statement. “We also made suggestions for clinicians observing patients experiencing remission and discussed further questions and unmet needs regarding predictors and outcomes.”

The authors developed the following criteria to help clinicians and researchers evaluate and study diabetes remission using more consistent terminology and methods:

1. Remission should be defined as a return of HbA1c to less than 6.5% [48 mmol/mol] that occurs spontaneously or following an intervention and that persists for at least three months in the absence of usual glucose-lowering pharmacotherapy.
2. When HbA1c is determined to be an unreliable marker of long-term glycemic control, fasting plasma glucose of less than 126 mg/dL (<7.0 mmol/L) or estimated HbA1c less than 6.5% calculated from CGM values can be used as alternate criteria.
3. Testing of HbA1c to document a remission should be performed just prior to an intervention and no sooner than three months after initiation of the intervention or withdrawal of any glucose-lowering pharmacotherapy.
4. Subsequent testing to determine long-term maintenance of a remission should be done at least yearly, together with the testing routinely recommended for potential complications of diabetes.

“Diabetes remission may be occurring more often due to advances in treatment,” said Amy Rothberg of the University of Michigan in Ann Arbor, Mich. Rothberg represents the Endocrine Society as a member of the Diabetes Remission Consensus writing group. “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.”

 

[Gwynn]

Yahoo, I'm in remission!

But we knew that already.

Good to get a concensus though.

 

[Kreator]

Well, that's me too then! - Although from what I knew before it was 6 months which to be honest is more realistic - 3 months is not long enough in my opinion - T2 Remission should be regarded as a long term goal not a 3 month quick fix!

I'll stick with my 6 months and beyond thanks!

 

[Leadinglights]

I had always thought it would be below 42mmol/mol not 48 as above that would still be prediabetic, that will encourage people to take their eye of the ball too soon and end up back where they were.
I have read of cases of that on here.

 

[mikeyB]

I agree,@Leadinglights, 42 is a far better level for the reasons you give. Then if you lapse to a degree, you will become prediabetic rather than diabetic.

 

[Kreator]

I had always thought it would be below 42mmol/mol not 48 as above that would still be prediabetic, that will encourage people to take their eye of the ball too soon and end up back where they were.
I have read of cases of that on here.

That's a good point too - since being diagnosed, I always had in my mind to be below 42...forever! - I'd suggest this decision is based so that they can say look how many diabetics we have put into remission, only for a few months later for them all to be back in diabetic range!

 

[Bruce Stephens]

I'd suggest this decision is based so that they can say look how many diabetics we have put into remission, only for a few months later for them all to be back in diabetic range!

Or they can see that actually, getting under 48 for three months is a good predictor for being under 48 for much longer, so is about as useful as using 42?

 

[Kreator]

Or they can see that actually, getting under 48 for three months is a good predictor for being under 48 for much longer, so is about as useful as using 42?

I guess that's a fair point - I for example for 3 years was controlled with Metformin being between 52-45, but it didn't really do me any favours really until I came off Metformin, went on a Low Calorie Diet, changed my whole thinking around food etc. etc. - my latest level was 42 a couple of months ago (No Meds) - next HbA1c in 2 weeks time - if it's not in the mid 30's by then, I have more work to do - but I still even then need to keep it up as I'm still suseptable to going back up again if I'm not mindful...

My point really is that making it 3 months and bingo you're in remission doesn't quite send the right message...

 

[Bruce Stephens]

My point really is that making it 3 months and bingo you're in remission doesn't quite send the right message...

I agree, but maybe they have evidence that it's fine really? Or maybe they're OK with having remission often being just temporary.

 

[AndBreathe]

Personally, I feel the fairest way to judge remission is on sustainability. I'm not necessarily suggesting 10yrs of HbA1c <42, but perhaps 12 or 24 months. I fear a single <48 HbA1c might lead to yo-yo diagnosis, just like yo-yo dieting.

 

[everydayupsanddowns]

I was reading this Diabetes UK position statement on how the consensus was put together a couple of days ago.

There’s a more person-with-diabetes-friendly version which explains things here too 🙂

Type 2 diabetes remission

Type 2 diabetes remission is when your blood sugar levels return to a safe, non-diabetes level long-term, without the need for glucose-lowering medication. It stops diabetes in its tracks and boosts your chances of a healthy future. When you are in remission, you reduce the risk of diabetes...

www.diabetes.org.uk

 

[Eddy Edson]

I was reading this Diabetes UK position statement on how the consensus was put together a couple of days ago.

There’s a more person-with-diabetes-friendly version which explains things here too 🙂

Type 2 diabetes remission

Type 2 diabetes remission is when your blood sugar levels return to a safe, non-diabetes level long-term, without the need for glucose-lowering medication. It stops diabetes in its tracks and boosts your chances of a healthy future. When you are in remission, you reduce the risk of diabetes...

www.diabetes.org.uk

The DUK position statement is well worth reading.

 

[Eddy Edson]

It's a bit interesting that the position statements don't say anything about weight loss meds.

Recent large semaglutide trials show "remission"-type HbA1c outcomes in T2D, driven just by weight loss, with far greater proportions of people hitting and maintaining 15%+ weight loss targets than you find in lifestyle programs.

Would achieving normoglycemia via semaglutide-induced weight loss count as "remission" and if not, is there actually a useful reason why not? I suppose the expert groups are considering this kind of question.

 

[Kreator]

From my own personal standpoint being diagnosed with T2 over 3 years ago knowing at that point I could aim for remission, found that until I was invited onto the NHS 5000 Pilot Low Calorie Diet Program my GP/DN aims were for good control with meds - fine, but that advise was only going to lead one way...down...more meds, eventually insulin etc...

I had good control and was doing well - but in my mind wanted better and better results - to the point of asking my DN to come off the Metformin only to be told late last year that they don't like to do that...! - I asked 'how can I achieve remission then?' - No answer...

...Until the NHS Pilot came along...

Meds stopped a month before starting the pilot and no meds since including statins...in 15 weeks lost 15Kg, totally changed my thinking and behabiour around food, and bacame much more active....

I know from daily Glucose testing (Fasting/Post Prandial/after exercise) it's working - I am finally becoming normal if you like - But....I also know that after 30 years of abuse my body can't recover that quickly - my Liver perhaps, but my Pancreas has still a way to go, so I don't intend relaxing any time soon...

So the point of <48 with no meds for remission is a start and a line has to be drawn somewhere, but T2 remission is much much more than this...and from my experience <48 with meds was not remission, and I doubt 47 without meds would be much different in terms of day to day glucose levels - although I can see it might offer a glimmer of hope for people going forward so long as it's emphasised that it's a long term strategy and not a quick fix...

 

[Gwynn]

Just read the diabetes Uk position statement and agree with it completely.

I have acheived remission from T2 with a HbA1c now of 34.

I fitted the bill. Obese, terrible diet, no exercise. Diagnosed. Shoved on meds. Turned all that around, came off meds and got into remission nine months down the line.

I am glad that the NHS are waking up to better acheivable possibilities for T2s and to the hope advice and support on remission can give.

I got zero advice and zero support but at least they didn't try to stop me trying. But, and its a big but, I had to learn for myself how to do it. Of course this forum pointed me in all the right directions.

 

[AndBreathe]

@everydayupsanddowns (I only tag you as I understand you are a member of Diabetes UK staff - apologies if this isn't the case) - Whilst most of those diagnosed with T2 will be carrying some additional weight, that doesn't cover everyone. My concern with the Diabetes UK statement on remission is its focus on weight loss:

"....

How can you put diabetes into remission?​

The strongest evidence we have suggests that diabetes is mainly put into remission by weight loss. ...."

Surely T2 is put into remission by reducing the blood glucose scores? Dietary changes, resulting in weight loss may be a mechanism for doing that, but the fact there are slim and even skinny T2s suggests there's more to diabetes than love handles.

Yes, the statement states mainly, but it could be taken, by those don't understand T2 well, to be discouraged, simply because they don't carry much, if any, excess weight.

 

[Eddy Edson]

@everydayupsanddowns (I only tag you as I understand you are a member of Diabetes UK staff - apologies if this isn't the case) - Whilst most of those diagnosed with T2 will be carrying some additional weight, that doesn't cover everyone. My concern with the Diabetes UK statement on remission is its focus on weight loss:

"....

How can you put diabetes into remission?​

The strongest evidence we have suggests that diabetes is mainly put into remission by weight loss. ...."

Surely T2 is put into remission by reducing the blood glucose scores? Dietary changes, resulting in weight loss may be a mechanism for doing that, but the fact there are slim and even skinny T2s suggests there's more to diabetes than love handles.

Yes, the statement states mainly, but it could be taken, by those don't understand T2 well, to be discouraged, simply because they don't carry much, if any, excess weight.

Just because you have a "normal" BMI doesn't mean you won't get to T2D remission by losing weight. Eg: I had a BMI of 25 point something at DX and zapped my T2D by losing 10kg. There are plenty of other anecdotes along the same lines, and the delayed ReTUNE study of weight-loss remission amongst slimmer T2D's hopefully reports soon.

The model doesn't depend on how much fat you're carrying, rather on where that fat is stored and how your individual make-up responds to it. Pack too much visceral fat for your "personal fat threshhold" and you may develop T2D, regardless of your BMI. https://www.ncl.ac.uk/media/wwwncla...onancecentre/files/fat-threshholds-slides.pdf



Of course there are people for whom a weight-loss approach won't work. But I'd say that the "weight loss but only if you need to lose weight" kind of messaging you see may well be more problematic, because it might lead somebody with a "healthy-ish" BMI to conclude that the weight-loss approach wouldn't work for them, when it most likely would.

 

[everydayupsanddowns]

Yes I spotted that too @AndBreathe

I wasn’t involved in the position statement, but I would imagine that much of the research data that underpins the statement comes from the ongoing and pivotal DIRECT trial, which has made important discoveries about some of the weight-related drivers behind T2 diabetes (or at least the majority of T2 cases), and how these can be put in remission by significant weight loss.

If you are interested I can ask the Information Team for details?

 

[Burylancs]

I agree,@Leadinglights, 42 is a far better level for the reasons you give. Then if you lapse to a degree, you will become prediabetic rather than diabetic.

No you won't, you will still be diabetic. A diagnosis of T2 is for life. What's this fad for 'remission' all about, what was wrong with 'good control'? It seems to be feeding denial and implying that T2s shouldn't be taking meds. Both highly irresponsible.

 

[AndBreathe]

Yes I spotted that too @AndBreathe

I wasn’t involved in the position statement, but I would imagine that much of the research data that underpins the statement comes from the ongoing and pivotal DIRECT trial, which has made important discoveries about some of the weight-related drivers behind T2 diabetes (or at least the majority of T2 cases), and how these can be put in remission by significant weight loss.

If you are interested I can ask the Information Team for details?

Yes, I'd be interested please. I'd be very disappointed if the stance was created purely based on the DiRECT trial, or indeed solely on trials funded by Diabetes UK.