Diabetes duration and insulin use predicted remission in ARMMS-T2D

The study

This paper reports predictors of type 2 diabetes remission and relapse in ARMMS-T2D (Alliance of Randomized Trials of Medicine vs. Metabolic Surgery in Type 2 Diabetes). It is a 14-year, multicentre study of health outcomes. It follows 262 patients who were earlier randomised to metabolic-bariatric surgery (MBS, n = 166) or to medical-lifestyle management (n = 96). The MBS group had one of three procedures.

At baseline, 68% were women. Mean age was 49.9 years (SD 8.3), mean BMI was 36.4 kg/m2 (SD 3.5) and mean HbA1c was 8.5% (SD 1.5).

Remission was defined as HbA1c below 6.5% on no glucose-lowering medications. The authors looked for predictors of remission and of relapse. They used time-to-event analyses of prespecified candidate predictors. They also used an agnostic multivariate method (least absolute shrinkage and selection operator).

What they found

Median follow-up was 11 years, with a maximum of 14 years. Remission occurred in 58% of participants randomised to MBS and in 3% of those randomised to medical-lifestyle management.

In univariate analyses, these factors were linked with remission (all P < 0.05):

• shorter diabetes duration
• no insulin use
• fewer glucose-lowering medication classes
• greater body weight
• higher fasting C-peptide and insulin levels
• weight loss at 1 year

In multivariate analyses, three factors predicted remission (all P < 0.01): baseline diabetes duration, insulin use and weight change at 1 year.

Relapse after initial remission was assessed in the MBS group. It was predicted by longer baseline diabetes duration and by a greater number of glucose-lowering medication classes used.

How much weight to give it

The 58% versus 3% comparison comes from randomised groups. The predictor analyses are different. They look at which patient features go with remission or relapse, so they show association, not cause. The abstract does not report effect sizes, confidence intervals, the number of patients who relapsed, or funding.

The authors call these "baseline predictors". Weight change at 1 year is measured after treatment starts, so it is not a baseline measure.

The abstract does not say how the predictors differed between the three MBS procedures. It does not say whether the findings were tested in a separate group of patients. Both points matter before the findings are used to guide treatment choice. Remission here is defined by HbA1c and medication use. The abstract does not report hard clinical outcomes.

For your clinic

In this cohort, shorter diabetes duration, no insulin use and fewer glucose-lowering medication classes went with a higher chance of remission. In the MBS group, longer baseline duration and more medication classes went with relapse after remission. This may help when discussing expectations with patients who are considering surgery.

These are group-level associations. They should not be used to exclude any patient from a surgical referral. Read the full paper before using the findings in practice. Check the effect sizes, the results for each procedure, and how well the cohort matches your patients. Local guidelines should still guide decisions on surgery.