Remission of Type 2 Diabetes New Clinical Practice Guidelines
At the most recent Diabetes Canada Conference in November 2022, a new Clinical Practice Guideline chapter on diabetes remission was released. Diabetes Canada also published a “Remission of Type 2 Diabetes: Users Guide” in their Practice Guidelines.
Type 2 diabetes remission is defined as “no anti-hyperglycemia medication for at least 3 consecutive months and achieving an A1C of < 6.0% for diabetes”. The term “remission” was chosen versus “cure” as often this state is temporary and therefore screening for relapse should be done every 6 months.
The Guideline recommends three options that may potentially induce diabetes remission:
1) Bariatric surgery,
2) A low calorie diet (of 800 to 850 cals/day) with meal replacement products for 3 to 5 months followed by a structured food re-introduction program and increase in physical activity, or
3) Exercise training/physical activity (240 to 420 minutes/week) WITH a caloric restricted diet.
The Primary Care Nurse should consider remission of Diabetes as an option for their clients with:
· Early type 2 diabetes (of 6 years or less) not on insulin.
· Are overweight or
obese (losing at least 15kg or 33lbs gives the best chance of achieving remission),
· Do NOT have significant eating or mental health disorders and our Are able/inclined/motivated to lose weight
· Do NOT have cardiovascular disease, heart failure or chronic kidney disease,
Once identified using the above criteria, the primary care nurse should assess the health history of the client and then ask permission to discuss diabetes remission with them. The nurse is cautioned to discuss remission as a “journey, not a destination” and to be conscious of not using success/failure language.
During the discussion, the client should be made aware:
· To be considered in remission, they would need to stop taking all diabetes specific medications.
· That blood pressure lowering and cholesterol medications should be continued in Type 2 diabetes with or without remission. (Remission is often temporary and relapse rates are high).
· That any improvement in their blood sugars and\or weight loss, regardless of reaching remission are still achieving important health improvements and this in itself is something to celebrate!
· Screening for diabetes complications should be continued. Regular eye exams, foot checks, assessing kidney health through urine and blood checks and monitoring A1C should be performed.
· The long term benefits of remission are currently unknown. Careful consideration of benefit versus overall risk and an individualized plan must be taken before starting a patient on a journey towards remission. For example, we know that SGLT2 inhibitors can both treat and prevent heart failure in people with Type 2 diabetes, and that heart failure often goes undiagnosed in people with type 2 diabetes. The primary care nurse should consider if stopping an SGLT2 inhibitor for people with diabetes who have a high cardiovascular risk but no known cardiovascular disease would be an overall benefit to the patient. (The loss of the prevention/protection for heart failure versus diabetes remission).
· Meeting regularly with a nurse with experience managing Type 2 diabetes for follow up and support is extremely important for success.