Is Lasting Remission of Type 2 Diabetes Feasible in the Real-World Setting?

[Northerner]

The prospect of remission of type 2 diabetes (T2D) has captured the hearts and minds of many patients with T2D and healthcare professionals, including myself.

Kevin Fernando, MBChB, MSc
I have changed my narrative when supporting my patients with T2D. I used to say that T2D is a progressive condition, but considering seminal recent evidence like the DiRECT trial, I now say that T2D can be a progressive condition. Through significant weight loss, patients can reverse it and achieve remission of T2D. This has given my patients hope that their T2D is no longer an inexorable condition. And hope, of course, is a powerful enabler of change.

However, the million-dollar question is whether remission of T2D can be maintained in the long term in the real-world setting of primary care, which is chiefly where T2D is managed.


I therefore relished the opportunity to attend a debate on this topic at the 59th EASD Annual Meeting in Hamburg, Germany, between Roy Taylor, MD, principal investigator for the DiRECT study and professor of medicine and metabolism at the University of Newcastle, United Kingdom, and Kamlesh Khunti, MD, PhD, professor of primary care diabetes at the University of Leicester, United Kingdom.

Is Lasting Remission of T2D Feasible in the Real World?

Tantalizing data suggest that remission is achievable, but how long can it be maintained?

www.medscape.com

 

[Burylancs]

The prospect of remission of type 2 diabetes (T2D) has captured the hearts and minds of many patients with T2D and healthcare professionals, including myself.

Kevin Fernando, MBChB, MSc
I have changed my narrative when supporting my patients with T2D. I used to say that T2D is a progressive condition, but considering seminal recent evidence like the DiRECT trial, I now say that T2D can be a progressive condition. Through significant weight loss, patients can reverse it and achieve remission of T2D. This has given my patients hope that their T2D is no longer an inexorable condition. And hope, of course, is a powerful enabler of change.

However, the million-dollar question is whether remission of T2D can be maintained in the long term in the real-world setting of primary care, which is chiefly where T2D is managed.


I therefore relished the opportunity to attend a debate on this topic at the 59th EASD Annual Meeting in Hamburg, Germany, between Roy Taylor, MD, principal investigator for the DiRECT study and professor of medicine and metabolism at the University of Newcastle, United Kingdom, and Kamlesh Khunti, MD, PhD, professor of primary care diabetes at the University of Leicester, United Kingdom.

Is Lasting Remission of T2D Feasible in the Real World?

Tantalizing data suggest that remission is achievable, but how long can it be maintained?

www.medscape.com

The conclusion of the speaker in the recent debate ...Khunti concluded by proposing new terminology for remission: remission of hyperglycemia or euglycemia, aiming for A1c < 48 mmol/mol with or without glucose-lowering therapy.'

Note the 'with ...glucose lowering therapy'. A new definition abandoning the idea that not taking medication is essential for 'remission'. Moving back towards the idea of Good Control by any means necessary. Although it's still setting a 'one size fits all target' irrespective of age, stage, duration of T2 and co-morbidities.

 

[everydayupsanddowns]

Note the 'with ...glucose lowering therapy'. A new definition abandoning the idea that not taking medication is essential for 'remission'. Moving back towards the idea of Good Control by any means necessary.

I’m not sure I think that’s much of an improvement personally. Perhaps it depends on the nature of the medication, and the person’s relationship to it?

My last A1c was 41, and I take medication. I feel my diabetes is fairly well managed (but not controlled, as there are many factors that influence my BG that I cannot control).

But my medication (and many other T2s on insulin) requires ongoing adjustment and balancing on a day to day (and occasionally minute by minute) basis. I can’t really see that it feels like ‘remission’ in any meaningful sense, and I don’t think a person with T2 on basal/bolus would either? (if the remission terminology is to remain solely applicable to T2s)

My personal feeling is that well managed diabetes is one thing, but remission somehow needs to capture something else? I think management (or control if you prefer) and remission could exist alongside each other as terms to identify slightly different things.

I’m interested to hear what others think.

 

[Eddy Edson]

https://forum.diabetes.org.uk/boards/threads/t2d-remission-direct-aus-same-as-original-uk-direct.108728/#post-1300581

 

[AndBreathe]

For me there are several things in play here.

Firstly, not everyone needs to achieve significant weight loss to achieve remission. There is still a near blinkered view that all T2s are obese and living sedentary lifestyles. Of course, there are subjects, such a Richard Doughty, one of the earlier days ND adopters who only lost a handful of pounds, but still achieved remission/reversal, or whatever you want to call it

And more widely, there need, in my view to be some categorisations, for T2s. I recently sat in on a pre-meeting to a research programme planned to work with T2s in remission, under the current definition. Of the T2s present to give feedback, a very common topic was the lack of recognition given to those who achieve great results, never mind maintain them.

For me, the concept of remission with medication makes a nonsense of it. You could say, with my own story I would say that, but where is the incentive (aside from personal pride and a desire to be healthier) to get to a drug-free status, then do the hard yards and maintain that.

Whilst the Americans can have some funny ideas, they do have a tiered system of expressing remission, with a category of something like Operational Cure, at 5years+ in remission.

 

[Drummer]

I sometimes sigh over the many decades I was telling HCPs that carbs made me feel unwell, that I could not control my weight even at very low levels of calories - a decade before diagnosis a blood test showed that my blood glucose was high - nothing was done other than continued pressure to eat brown starchy foods.
As soon as I went back to low carb I felt better and things turned around - in a few weeks I was no longer diabetic, but HCPs had nothing to do with my progress or improvement.
If only the push to eat starch could be cut off at source - if only HCPs could believe what a patient is telling them, if only they would not be nasty, insulting, and belittling when they are told that their advice is ruining someone's life...

 

[Burylancs]

I’m not sure I think that’s much of an improvement personally. Perhaps it depends on the nature of the medication, and the person’s relationship to it?

My last A1c was 41, and I take medication. I feel my diabetes is fairly well managed (but not controlled, as there are many factors that influence my BG that I cannot control).

But my medication (and many other T2s on insulin) requires ongoing adjustment and balancing on a day to day (and occasionally minute by minute) basis. I can’t really see that it feels like ‘remission’ in any meaningful sense, and I don’t think a person with T2 on basal/bolus would either? (if the remission terminology is to remain solely applicable to T2s)

My personal feeling is that well managed diabetes is one thing, but remission somehow needs to capture something else? I think management (or control if you prefer) and remission could exist alongside each other as terms to identify slightly different things.

I’m interested to hear what others think.

I still prefer 'Oumibiglou'....from a post last Feb ...

'
Well as a Type 2 of 31 years standing I've heard enough recently about Castles-in-the-Air such ' reversal' and 'remission'.

So instead I'm proposing another target for T2s ....

'Oumibiglou

Achieving an HbA1c, Lipid Panel and Blood Pressure in the ranges recommended for your age, stage and duration of Type 2 Diabetes by any means necessary.'

 

[harbottle]

When I was diagnosed by phone, I was told by a GP who clearly wanted to do something else that 'there's no cure, but lose some weight, go for a walk 5 days a week, change diet and aim to get hba1c around 48.' I did. It worked (Who knows how much the 1000mg, now 500mg, of Metformin helped). As I've got no chance of scans or 'first phase and second phase' insulin being measured, I have no idea what it going on, whether it's under control from diet... or whether it's like a George Romero movie in there with the risen dead beta cells on the rampage against glucose. As long as I don't feel as bad as I did in 2021, I'm happy! (And I don't particularly miss the 'old' lifestyle)

Given a rather high hba1c of 83, and the fact I have no idea how long I've had it, perhaps years, I suspect the glucose army entering the pancreas encounters a rather weak mass of beta cells that can't be bothered to really react to it anymore and just go 'meh' and fall back to sleep rather than give out some insulin ("You had enough of that in the past, now it's our turn to rest!"). Hopefully reversal of rotundness has fixed the insulin resistance.

 

[Burylancs]

When I was diagnosed by phone, I was told by a GP who clearly wanted to do something else that 'there's no cure, but lose some weight, go for a walk 5 days a week, change diet and aim to get hba1c around 48.' I did. It worked (Who knows how much the 1000mg, now 500mg, of Metformin helped). As I've got no chance of scans or 'first phase and second phase' insulin being measured, I have no idea what it going on, whether it's under control from diet... or whether it's like a George Romero movie in there with the risen dead beta cells on the rampage against glucose. As long as I don't feel as bad as I did in 2021, I'm happy! (And I don't particularly miss the 'old' lifestyle)

Given a rather high hba1c of 83, and the fact I have no idea how long I've had it, perhaps years, I suspect the glucose army entering the pancreas encounters a rather weak mass of beta cells that can't be bothered to really react to it anymore and just go 'meh' and fall back to sleep rather than give out some insulin ("You had enough of that in the past, now it's our turn to rest!"). Hopefully reversal of rotundness has fixed the insulin resistance.

Why would glucose enter the pancreas and encounter Beta Cells ?

 

[harbottle]

Gets a helping hand by the public transport in that region, a nationalised service called GLUT{x} transporters. Maybe privatisation stops them from working?