In the present scenario lot of people are misguided by the term "Reversal of Diabetes".This article will further help physicians to understand the terminology in a better way and how to help their patients in achieving and maintaining remission wherever possible.

"Remission" and "Reversal" of diabetes

Remission and reversal are two different terminologies that need to be communicated to the patient. Remission of diabetes in the real world is possible as suggested by a few studies. As per the latest international consensus, the term used to describe a sustained metabolic improvement in T2D to nearly normal levels should be remission of diabetes.

Remissions of diabetes have always attracted the patients as it gives them freedom from pill burden and insulin injections. Complete cure of the disease without relapse is defined as reversal, whereas remission implies that the disease would be in a dormant state until the patient adheres to certain conditions to avoid relapse. In today's times, there is a lot of confusion regarding the two terms and some people use them interchangeably. There is no data today which supports the reversal of diabetes.

Definition

American diabetes association has previously proposed the terms:

1. Partial remission: Return of Glycaemia below the diagnostic threshold for T2DM for at least one year.
2. Complete remission: Where Glucose tolerance is normal for at least one year.
3. Prolonged remission: remission for at least 5 years duration.

These thresholds must be achieved without any glucose-lowering pharmacotherapy. An operative position statement on remission was published by the joint Association of British Clinical Diabetologists (ABCD) and the Primary Care Diabetes Society (PCDS) defining remission as both FPG concentration < 7 mmol/l and HbA1c < 48 mmol/mol on two occasions separated by at least 6 months.

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.

Intervention to achieve remission

Weight loss through physical activity, a low-calorie diet or bariatric surgery remains the most successful method to achieve remission to date. Modest restriction of energy intake and physical activity is the key to remission.

The therapeutic successes of bariatric surgery and effective weight loss therapies as illustrated by the DiRECT trial have made achieving remission of diabetes practical. The rate of remission is around 70-80% following bariatric surgery where the patient may lose up to 40kg 1-2 years after surgery.

Weight loss of > 15% showed remission in up to 85% of type 2 Diabetes patients in the DiRECT trial. A meta-analysis by Buchwald and colleagues reported that 78% of patients with type 2 diabetes undergoing bariatric surgery had complete remission of type 2 diabetes, defined as normoglycemia without medication, and 86% had either improvement of resolution of diabetes. The diRECT trial showed that T2DM of up to 6 years duration can be reversed by weight loss of up to 15kg with help of an evidence-based structured weight management program delivered in a community setting, by routine primary care staff.

Conclusion

Although achieving remission in type 2 diabetic patients is possible through a healthy lifestyle and bariatric surgery, maintaining the same is an uphill task for the patients as remission from diabetes may not be permanent. About 35% of patients who initially realise remission may relapse within 5 years with a median duration of remission of approximately 8.3 years.

Post-bariatric surgery about one-third experience a relapse within 5 years of initial remission. Maintaining a healthy lifestyle is an important part of the ongoing management of patients in remission from type 2 diabetes. Weight gain, stress from illness, and continuing decline of β-cell function can all lead to the recurrence of the disease. Patients should always be guided to achieve realistic remission goals.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Hitesh Saraogi practising physician at a hospital in Delhi