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Can Weight Surgery Cause Remission of Type 2 Diabetes?

Apr 13, 2019
 
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Ghazal Blair, Pharm.D. Candidate 2019, LECOM School of Pharmacy

Gastric bypass surgery is not only for treating obesity.

Bariatric surgery is an operation that helps patients with obesity to lose weight by making changes to the digestive system. There are many different types of bariatric surgeries, including: laparoscopic adjustable gastric band, vertical sleeve gastrectomy, and gastric bypass. Though bariatric surgeries were originally designed to promote weight loss in patients with obesity, it has been found that they also can be used to treat type 2 diabetes. These observations brought up the idea to consider these types of surgeries as “metabolic surgery,” used for treatment of diabetes in patients with type 2 diabetes who are somewhat obese or overweight.  

The results from several randomized trials which were conducted to compare the efficacy and safety of surgical intervention vs non-surgical interventions for diabetes, suggest that surgical intervention significantly improved all glycemic variables, as well as other metabolic endpoints in comparison to non-surgical intervention. Therefore, the 2nd Diabetes Surgery Summit (DSS-II), an international consensus conference, recommended to include bariatric/metabolic surgeries in the global guidelines as a treatment option for selected patients with type 2 diabetes and obesity.

A recent study, published in February of 2019, was conducted to investigate the effect of Roux-en-Y (RYGB) gastric bypass surgery on diabetes remission, relapse and micro- and macrovascular complications in individuals with type 2 diabetes and obesity (BMI >35 kg/m2). This study was designed as a population-based cohort study. Data included in this study was pooled from the Civil Registration System linked to the Danish National Patients Registry, the Danish National Health Service Prescription Database (DNHPD), and national data on laboratory and clinical testing. Investigators compared the data for a total 1,111 patients with type 2 diabetes who underwent RYGB  between 2006 to 2015, with 1,074 matched individuals with type 2 diabetes who did not have surgical intervention.

For this study, diabetes remission was defined as HbA1c <6.5% without administration of antidiabetic medications, or HbA1c <6.0% with administration of metformin as monotherapy. Upon data analysis, it was noted that the average age of patients was 46.8 years; over half (63.5%) of included patents were females. Lastly, average duration of diabetes was 3.6 years at the index date.

The results from this study showed that within six months 65% of patients who underwent RYGB surgery went into remission. A total of 74% of patients who had RYGB were in diabetes remission at 1 year of follow-up. In contrast, 27% of cohort experienced relapsed after 5 years. Patients who were on insulin therapy prior to surgery had a 43% lower rate of remission. Additionally, results suggested that younger patients (<50 years of age) who were diabetic for less than 5 years had a better chance of achieving remission. HbA1C>7% at baseline along with administration of antidiabetic medications (other than metformin) was associated with no remission.

Using Cox regression models, researchers compared the risk of macro and microvascular complications in non-operated patients and the cohort treated by RYGB. The results showed that patients who had RYGB experienced 47% lower risk of microvascular complications (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.38-0.73). they also had 24% lower risk of macrovascular complications (HR, 0.76; 95% CI, 0.49-1.18). The risk for developing retinopathy and kidney disease appeared to be lower in patients who underwent RYGB (48% and 46% respectively). Moreover, 7.5 % patients were hospitalized due to complications associated with RYGB within 1 month of surgery.

The researchers concluded that remission was seen after 1 year in three out of four individuals with type 2 diabetes and obesity who were treated with RYGB surgery. However, 27% of these individuals relapsed at 5 years of follow-up. In addition, RYGB surgery led to a significantly lower risk of microvascular complications. Although RYGB surgery is associated with surgery related complications, using this intervention shortly after a type 2 diabetes diagnosis may assist in the prevention of many diabetes-related health complications. However, ongoing monitoring and continued lifestyle modifications are warranted after surgery. Furthermore, it was recommended that healthcare providers discuss as well as present this option to achieve diabetes remission with patients.

Practice Pearls:

  • In routine clinical care, 75% of individuals with type 2 diabetes and obesity treated by RYGB experienced diabetes remission after 1 year.
  • Predictors of non-remission were age >50 years, diabetes duration >5 years, use of glucose-lowering drugs other than metformin, and baseline HbA1c>53 mmol/mol (>7.0%).
  • Patients who underwent RYGB had 47% lower risk of microvascular complications.

 

Citation:

Rubino, Francesco, et al. “Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations.” Diabetes Care, American Diabetes Association, 1 June 2016, care.diabetesjournals.org/content/39/6/861.long.

Madsen, Lene R., et al. “Effect of Roux-En-Y Gastric Bypass Surgery on Diabetes Remission and Complications in Individuals with Type 2 Diabetes: a Danish Population-Based Matched Cohort Study.” SpringerLink, Springer, 6 Feb. 2019, link.springer.com/article/10.1007/s00125-019-4816-2.

 

Ghazal Blair, Pharm.D. Candidate 2019, LECOM School of Pharmacy