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Can a Protocol for Glycaemic Control Improve Type 2 Diabetes Outcomes After Gastric Bypass?

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Abstract

Background

Roux-en-Y gastric bypass surgery (RYGB) is an effective treatment for patients with type 2 diabetes (T2DM). Tight glycaemic control immediately after RYGB for T2DM may improve long-term glycaemic outcomes, but is also associated with a higher risk of hypoglycaemia. We designed a treatment algorithm to achieve optimal glycaemic control in patients with insulin-treated T2DM after RYGB and evaluated its feasibility, safety and efficacy.

Methods

Fifty patients following protocol-driven diabetes management were discharged on a fixed amount of metformin and glargine, with the insulin dose adjusted according to a standardised insulin sliding scale aiming for a fasting capillary glucose (FCG) of 5.5–6.9 mmol/L. Glycaemic outcome and remission of diabetes (defined as HbA1c < 6% and FCG levels < 5.6 mmol/L for at least 1 year without hypoglycaemic medication) were compared between patients who received protocol-driven treatment and a similar cohort of 49 patients following standard glycaemic management.

Results

At 1 year follow-up, the protocol-driven group showed a greater improvement in glycaemic control than the non-protocol-driven group (HbA1c −3.0 ± 0.2% vs. −1.2 ± 0.1%, P < 0.001; FCG levels −3.4 ± 0.2 vs. −2.0 ± 0.2 mmol/L, P = 0.02) and a higher remission rate from T2DM (50.0% vs. 6.1%, P < 0.001). No symptomatic hypoglycaemia was reported in either group.

Conclusions

The protocol-driven management proved to be feasible, safe and effective in achieving targeted glycaemic control in T2DM after RYGB. The next step will be to scrutinise the efficacy of protocol-driven management in a randomised controlled clinical trial.

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References

  1. Buchwald H, Estok R, Fahrbach K, et al. Weight and type 2 diabetes after bariatric surgery: systematic review and meta-analysis. Am J Med. 2009;122(3):248–56. e5.

    Article  PubMed  Google Scholar 

  2. Ramos AC, Galvao Neto MP, de Souza YM, et al. Laparoscopic duodenal–jejunal exclusion in the treatment of type 2 diabetes mellitus in patients with BMI < 30 kg/m2 (LBMI). Obes Surg. 2009;19(3):307–12.

    Article  PubMed  Google Scholar 

  3. Reed MA, Pories WJ, Chapman W, et al. Roux-en-Y gastric bypass corrects hyperinsulinemia implications for the remission of type 2 diabetes. J Clin Endocr Metab. 2011;96(8):2525–31.

    Article  PubMed  CAS  Google Scholar 

  4. Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. N Engl J Med. 2004;351(26):2683–93.

    Article  PubMed  Google Scholar 

  5. Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–37.

    Article  PubMed  CAS  Google Scholar 

  6. Arora S, Ashrafian H, Smock ED, et al. Total laparoscopic repair of sigmoid foreign body perforation. J Laparoendosc Adv S. 2009;19(3):401–3.

    Article  Google Scholar 

  7. Pournaras DJ, Osborne A, Hawkins SC, et al. Remission of type 2 diabetes after gastric bypass and banding: mechanisms and 2 year outcomes. Ann Surg. 2010;252(6):966–71.

    Article  PubMed  Google Scholar 

  8. Hall TC, Pellen MG, Sedman PC, et al. Preoperative factors predicting remission of type 2 diabetes mellitus after Roux-en-Y gastric bypass surgery for obesity. Obes Surg. 2010;20(9):1245–50.

    Article  PubMed  Google Scholar 

  9. Pories WJ, Swanson MS, MacDonald KG, et al. Who would have thought it? An operation proves to be the most effective therapy for adult-onset diabetes mellitus. Ann Surg. 1995;222(3):339–50. discussion 50–2.

    Article  PubMed  CAS  Google Scholar 

  10. Gerstein HC, Miller ME, Byington RP, et al. Effects of intensive glucose lowering in type 2 diabetes. N Engl J Med. 2008;358(24):2545–59.

    Article  PubMed  CAS  Google Scholar 

  11. Duckworth W, Abraira C, Moritz T, et al. Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med. 2009;360(2):129–39.

    Article  PubMed  CAS  Google Scholar 

  12. Scopinaro N, Adami GF, Papadia FS, et al. Effects of biliopanceratic diversion on type 2 diabetes in patients with BMI 25 to 35. Ann Surg. 2011;253(4):699–703.

    Article  PubMed  Google Scholar 

  13. Barnett A. Dosing of insulin glargine in the treatment of type 2 diabetes. Clin Ther. 2007;29(6):987–99.

    Article  PubMed  CAS  Google Scholar 

  14. American Diabetes Association. Standards of medical care in diabetes—2010. Diabetes Care. 2010;33 Suppl 1:S11–61.

    Article  Google Scholar 

  15. Buse JB, Caprio S, Cefalu WT, et al. How do we define cure of diabetes? Diabetes Care. 2009;32(11):2133–5.

    Article  PubMed  Google Scholar 

  16. Wyles SM, Ahmed AR. Tips and tricks in bariatric surgical procedures: a review article. Minerva Chir. 2009;64(3):253–64.

    PubMed  CAS  Google Scholar 

  17. Buse JB. Can we become victims of our own success? Diabetes Care. 2009;32(11):2140–1.

    Article  PubMed  Google Scholar 

  18. Sovik TT, Irandoust B, Birkeland KI, et al. Type 2 diabetes and metabolic syndrome before and after gastric bypass. Tidsskr Norske Laege. 2010;130(13):1347–50.

    Article  Google Scholar 

  19. Schauer PR, Burguera B, Ikramuddin S, et al. Effect of laparoscopic Roux-en Y gastric bypass on type 2 diabetes mellitus. Ann Surg. 2003;238(4):467–84. discussion 84–5.

    PubMed  Google Scholar 

  20. Pories WJ, MacDonald Jr KG, Flickinger EG, et al. Is type II diabetes mellitus (NIDDM) a surgical disease? Ann Surg. 1992;215(6):633–42. discussion 43.

    Article  PubMed  CAS  Google Scholar 

  21. Pournaras DJ, Aasheim ET, Søvik TT, et al. Effect of the definition of type II diabetes remission in the evaluation of bariatric surgery for metabolic disorders. Brit J Surg. 2011. doi:10.1002/bjs.7704

  22. Holman RR, Paul SK, Bethel MA, et al. Long-term follow-up after tight control of blood pressure in type 2 diabetes. N Engl J Med. 2008;359(15):1565–76.

    Article  PubMed  CAS  Google Scholar 

  23. Nasr CE, Hoogwerf BJ, Faiman C. Effects of glucose and blood pressure control on complications of type 2 diabetes mellitus. Clev Clin J Med. 1999;66(4):247–53.

    CAS  Google Scholar 

  24. Datta S, Qaadir A, Villanueva G, et al. Once-daily insulin glargine versus 6-hour sliding scale regular insulin for control of hyperglycemia after a bariatric surgical procedure: a randomized clinical trial. Endocr Pract. 2007;13(3):225–31.

    PubMed  Google Scholar 

  25. Yki-Jarvinen H. Management of type 2 diabetes mellitus and cardiovascular risk: lessons from intervention trials. Drugs. 2000;60(5):975–83.

    Article  PubMed  CAS  Google Scholar 

  26. Riddle MC, Rosenstock J, Gerich J. The treat-to-target trial: randomized addition of glargine or human NPH insulin to oral therapy of type 2 diabetic patients. Diabetes Care. 2003;26(11):3080–6.

    Article  PubMed  CAS  Google Scholar 

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Acknowledgements

W.K.F. was supported by the German Research Society (DFG), C.W.leR. by a Department of Health clinician scientist award and A.D.M. was supported by the Medical Research Council. Imperial College London receives support from the National Institute for Health Research Biomedical Research Centre funding scheme.

Disclosures

None.

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Authors and Affiliations

  1. Department of Investigative Medicine, Imperial Weight Centre, Imperial College London, London, UK

    Wiebke K. Fenske, Dimitri J. Pournaras, Erlend T. Aasheim, Alexander D. Miras, Samantha Scholtz & Carel W. le Roux

  2. Department of Internal Medicine I, Endocrine and Diabetes Unit, University Hospital Würzburg, Würzburg, Germany

    Wiebke K. Fenske

  3. University of Genoa Medical School, Genoa, Italy

    Nicola Scopinaro

Authors
  1. Wiebke K. Fenske
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  2. Dimitri J. Pournaras
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  3. Erlend T. Aasheim
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  4. Alexander D. Miras
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  5. Nicola Scopinaro
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  6. Samantha Scholtz
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  7. Carel W. le Roux
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Corresponding author

Correspondence to Carel W. le Roux.

Additional information

This trial was registered at www.clinicaltrials.gov (NCT01213563).

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Fenske, W.K., Pournaras, D.J., Aasheim, E.T. et al. Can a Protocol for Glycaemic Control Improve Type 2 Diabetes Outcomes After Gastric Bypass?. OBES SURG 22, 90–96 (2012). https://doi.org/10.1007/s11695-011-0543-6

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  • DOI: https://doi.org/10.1007/s11695-011-0543-6

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