Disclosures: Riddle reports receiving research grant support through Oregon Health & Science University from Eli Lilly & Co., Novo Nordisk, and AstraZeneca and honoraria for consulting from Adocia, Intercept and Theracos. Please see the study for all other authors’ relevant financial disclosures.
August 30, 2021
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‘Remission’ best term to define return of normal glucose levels in type 2 diabetes

Disclosures: Riddle reports receiving research grant support through Oregon Health & Science University from Eli Lilly & Co., Novo Nordisk, and AstraZeneca and honoraria for consulting from Adocia, Intercept and Theracos. Please see the study for all other authors’ relevant financial disclosures.
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The term “remission” should be used to describe a person with type 2 diabetes who has achieved a disease-free status, according to a consensus report.

Representatives from the American Diabetes Association, the European Association for the Study of Diabetes, Diabetes UK, the Endocrine Society and the Diabetes Surgery Summit wrote that is the best term to use for people with type 2 diabetes who have a sustained metabolic improvement to near normal levels. They said remission is a better term than resolution, reversal or cure since it “strikes an appropriate balance” between the diabetes not being active and progressive, but also recognizing improvement may not be permanent. In addition, the researchers detailed a methodology for determining diabetes remissionThe report was jointly published in The Journal of Clinical Endocrinology & Metabolism, Diabetologia, Diabetic Medicine and Diabetes Care

Researchers outlined important steps providers should follow when determining diabetes remission. Infographic content were derived from Riddle MC, et al. Diabetologia. 2021;doi:10.1007/s00125-021-05542-z.

“This report proposes a single definition for remissions and a single preferred means of confirming it — a return of HbA1c to less than 6.5%, either spontaneously or following an intervention, that persists at least 3 months after cessation of any glucose-lowering pharmacotherapy,” Matthew C. Riddle, MD, emeritus professor of medicine in the division of endocrinology, diabetes and clinical nutrition at Oregon Health and Science University, and editor-in-chief of Diabetes Care, told Healio.

Matthew C. Riddle

The researchers favored using HbA1c over fasting plasma glucose, 2-hour plasma glucose and mean daily glucose levels as measured by continuous glucose monitoring. However, 24-hour mean glucose concentrations provided through CGM can be used as an alternative way to measure glucose for some people with diabetes.

“A number of factors can affect HbA1c measurements, including a variant hemoglobin, differing rates of glycation or alterations of erythrocyte survival that can occur in a variety of disease states. ... Thus, in some people a normal HbA1c value may be present when glucose is actually elevated, or HbA1c may be high when mean glucose is normal,” the researchers wrote.

The researchers defined diabetes remission as an HbA1c of less than 6.5% sustained at least 3 months. When HbA1c cannot be used, a fasting plasma glucose of less than 7 mmol/L as calculated from CGM values can be an alternate criterion for remission.

Prior to an intervention, providers should document HbA1c in a person with diabetes to evaluate their response. Diabetes remission should not be determined until at least 3 months after glucose-lowering medication is stopped in any intervention. For surgery, providers should wait until at least 3 months after the procedure whereas for lifestyle interventions, diabetes remission should not be determined until at least 6 months after the intervention begins.

After diabetes remission, patients should have periodic HbA1c testing to monitor glucose levels, according to the researchers. HbA1c or other glycemic testing should be performed at least once per year. People with diabetes remission should also have regular retinal screening, tests of renal function, foot evaluation and measurement of blood pressure and weight performed regularly.

“At present, there is no long-term evidence indicating that any of the usually recommended assessments for complications can safely be discontinued,” the researchers wrote. “Individuals who are in remission should be advised to remain under active medical observation, including regular check-ups.”

The researchers wrote that studies are needed to determine medical outcomes of remission of type 2 diabetes based on their suggestions. They noted several areas for future research:

  • Validation of an HbA1c of less than 6.5% as a defining measurement for remission;
  • Validation of the timing of glycemic measurements;
  • Evaluating the effects of metformin and other drugs after remission;
  • Evaluating nonglycemic measures during remission;
  • Research on duration of remission;
  • Documenting long-term outcomes of remission; and
  • Developing education materials for providers and patients

“We need prospectively planned data collection for both medical outcomes and any risks or costs after a remission associated with various interventions, including lifestyle alterations, drug therapies and metabolic surgery,” Riddle said.

For more information:

Matthew C. Riddle, MD, can be reached at riddlem@ohsu.edu.