This Sunday, we bring to you an old article from our archives section. In an exclusive series for M3 India, Dr. Sanjay Kalra discusses the chances of remission in type 2 diabetes and the approach and changes that can be made to a diabetes patient's lifestyle, plus the treatment options available.

The last few years have witnessed heightened interest in the concept of diabetes reversal. The scientifically correct term, “remission in type 2 diabetes,” is often replaced by the words reversal or cure, without specifying the type of diabetes. The public often assumes that everyone can achieve remission, irrespective of the characteristic of the patient. This leads to confusion in the minds of patients, which is aggravated by non-qualified practitioners who offer freedom from diabetes through dubious means. It is important to speak the same language with all our patients, and the community at large.

The following schemata shares a pragmatic approach which can be used in most conversations. Changes may be made, based upon the needs and concerns of the individual involved. Note the emphasis on ongoing evolution of knowledge, on optimistic attitude towards outcomes. Also note the repeated reference to healthy lifestyle, while avoiding malnutrition and overexertion. Optimism should be tempered by reality, but enthusiasm for self-care should not be discouraged by pessimism.

Current understanding

Our understanding of diabetes is evolving: modern research is helping us improve the quality of diabetes care. We now have newer methods of diabetes management which protect our organs and prevent complications. The main aim of diabetes care is to maintain good health and avoid complications due to poor control. Good glucose control is a means to this aim; it is not an end in itself.

Limitations

• High glucose is just one of the many contributors to the development of complications. All factors have to be considered while managing diabetes
• It must be understood that the concept is relevant only to type 2 diabetes, and not to other types of diabetes.
• It may be possible to achieve remission in some persons with diabetes, but this does not mean that they can discontinue lifestyle modification
• Remission of diabetes does not obviate the need to screen, manage and monitor for other components of metabolic syndrome, or complications of diabetes
• At times, glucose-lowering drugs may be used for non-diabetic indications such as weight loss, prevention of heart failure, and preservation of kidney function. It is not clear whether continued use of these drugs qualifies for remission

Caveats and contraindications

1. At times, glucose levels may fall because of complications like renal impairment, medical disease like hepatic impairment, and endocrine conditions such as hypopituitarism, hypothyroidism and Addison’s disease. This should not be an aim of therapy.
2. At times, very low carbohydrate diets can lead to normalisation of glucose levels, but at the cost of malnutrition and starvation ketosis. Apart from this, such diets are difficult to sustain in the long run.
3. At times, stress hyperglycemia or drug-induced hyperglycemia misdiagnosed as type 2 diabetes. Resolution of the offending cause will lead to normoglycemia, which may be misconstrued as remission of diabetes.

The chances of remission are more in persons with lesser age, higher body mass index, high C-peptide, and shorter duration of diabetes, provided they are able to lose weight, and maintain this weight loss.

Methods and means

Certain diets, surgical procedures, and novel medications have been reported to achieve remission in selected patients. This does not mean that these interventions will lead to remission on all persons, for an infinite period of time. Medical nutrition therapy can help achieve remission, but has to be continued indefinitely.

Bariatric surgery does lead to remission in some, but not all patients. There are different types of surgical procedures: not all are effective in achieving remission. Drugs such as GLP1-RA and SGLT2i may be used in initial phases of diabetes to correct glucotoxicity, but it is doubtful if their glucose-lowering effects will be sustained after discontinuation of the drug.

Pragmatic conclusion

The aim of diabetes management should be to ensure long-term health, free of avoidable complications. Lifestyle modification and medication including insulin, should be viewed as a means to achieve this aim. We should work together to achieve and maintain good glucose control with safe and well tolerated drugs. We can deescalate regimens and down-titrate doses as and when needed

Keeping ourselves healthy and complication-free will allow us to take full advantage of remission-inducing therapies when they are developed, in the future.

To read other articles in this series, click,

Difficult diabetes- The diagnosis is important

Hyperglycemia- Think beyond glucose

Diabetes and the liver- Why this vicious circle needs immediate attention

Diabetes & dermatoses: How to diagnose & treat?

This article was originally published on January 6, 2021.

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

The author, Dr. Sanjay Kalra is a leading Endocrinologist and the current President of the Endocrine Society of India.