Patients with diabetes can be considered to be in remission if they have an HbA1c level below 6.5% at least three months after glucose-lowering drugs are stopped, according to a new consensus report.
The American Diabetes Association convened an international expert group to propose nomenclature and principles for the improvement of glucose levels into the normal range in patients with diabetes, either spontaneously or after medical interventions. The group included representatives from the American Diabetes Association, the European Association for the Study of Diabetes, Diabetes UK, the Endocrine Society, and the Diabetes Surgery Summit, as well as an oncologist. The goal of the report, which was jointly published Aug. 30 by Diabetologia and Diabetes Care, was to lay a framework to help inform future clinical guidance. It did not aim to establish treatment guidelines or to favor specific interventions, the group noted.
The expert panel proposed “remission” as the most appropriate term to describe sustained improved glucose levels and said that an HbA1c level below 6.5% measured at least three months after withdrawal of glucose-lowering drugs could be used as a diagnostic criterion. If HbA1c is determined to be an unreliable marker of chronic glycemic control in a specific patient, the panel proposed alternative criteria of a fasting plasma glucose level below 126 mg/dL (<7.0 mmol/L) or an estimated HbA1c level of less than 6.5% calculated from continuous glucose monitoring values. Response to metabolic surgery can be evaluated at least three months after the procedure and three months after any pharmacotherapy is withdrawn, while response to lifestyle interventions can be evaluated at least six months after the interventions begin and three months after any pharmacotherapy is withdrawn, the panel said.
The group also noted that patients in remission should be monitored for recurrence and suggested that HbA1c or other testing be done at least yearly. “Ongoing attention to maintenance of a healthful lifestyle is needed, and pharmacotherapy for other conditions with agents known to promote hyperglycemia, especially glucocorticoids and certain antipsychotic agents, should be avoided,” the report said. The expert panel called for additional research to validate an HbA1c level below 6.5% as the criterion for remission, as well as the timing of glycemic measurements. More research is also needed on the effects of metformin and other drugs once remission is established, evaluation of nonglycemic measures during remission, remission duration, documentation of long-term outcomes, and development of educational materials for patients and clinicians, the panel said.