Glycemic benefits of metabolic surgery endure for at least 10 years
medwireNews: Metabolic surgery can result in type 2 diabetes remission lasting for at least 10 years, and people who relapse still achieve markedly improved glycemic control, shows follow-up from a randomized trial published in The Lancet.
Geltrude Mingrone (Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy) and colleagues followed up 57 of 60 people who participated in the original trial. At baseline, the participants were aged an average of 44 years, had an average BMI of around 44 kg/m2, diabetes duration of 6 years, and glycated hemoglobin (HbA1c) of 8.5–8.9% (69–74 mmol/mol).
By 2 years after surgery, 34 of the 40 participants in the surgical arms of the trial had achieved diabetes remission, defined as HbA1c below 6.5% (48 mmol/mol) and fasting plasma glucose below 100 mg/dL (5.6 mmol/L) without use of medications.
By 10 years, 15 (37.5%) remained in remission, comprising 10 (50%) of those randomly assigned to undergo biliopancreatic diversion and five (25%) of those who had undergone Roux-en-Y gastric bypass (RYGB).
People who relapsed were most likely to do so during the first 5 years after surgery. However, the researchers stress that these individuals maintained much better glycemic control than at baseline, with an average HbA1c of 6.7% (50 mmol/mol) at 10 years and all but one having levels below 7.0% (53 mmol/mol) despite “drastically reduced use of diabetes medications.”
The average number of medications used in the surgical groups overall fell from 2.4 at baseline to 0.7 at 10 years in the biliopancreatic diversion group and from 2.2 to 1.4 in the RYGB group. All 10 people in the biliopancreatic diversion group who were using insulin at baseline had stopped by year 10, as had eight of nine in the RYGB group.
None of the 17 participants originally assigned to best medical care were in remission at 10 years, bar one of two people who crossed over to surgery during follow-up, and their use of diabetes medications slightly increased.
Writing in a linked commentary, Alexander Miras (Imperial College London, UK) and Carel le Roux (University College Dublin, Ireland) say: “Despite the focus of many in the field on the concept of remission, the reported relapse of type 2 diabetes should be seen in the context of the severity of type 2 diabetes at baseline.
“Clinicians will be pleased that all patients had meaningful glycaemic improvements after surgery.”
The commentators highlight that no participant went into remission beyond 2 years after surgery, and suggest these people should receive intensive treatment with “modern and potent glucose-lowering therapies,” not only to control glycemia but also to help prevent micro- and macrovascular complications.
“The dichotomous definition of glycaemic remission should not discourage clinicians from being proactive with pharmacotherapy when surgery on its own is not enough,” they write.
At 10 years, people who underwent surgery had significantly lower cardiovascular risk than those who received medical therapy, had lower triglyceride levels, better kidney function, and required fewer antihypertensive medications. They also had significantly better quality of life.
Just 5% of participants from the surgical groups had a microvascular complication during follow-up, compared with 61% of those in the medical therapy group, 11% of whom also experienced a macrovascular complication.
The only persistent surgical complication was recurrent or chronic diarrhea, which was still affecting eight people, all in the biliopancreatic diversion group, in the 5–10-year follow-up period.
Miras and le Roux describe the overall 10-year data as “reassuring” and likely to change attitudes toward surgery for type 2 diabetes.
“New generations of diabetologists are now more open to the use of metabolic surgery for patients with suboptimal responses to medical treatments,” they conclude. “These methods contrast with older approaches that included endless intensification of insulin therapies and attributing the blame for poor response to inadequate patient compliance.”
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