How careful should healthcare workers and patients be in describing a total remission of diabetes as a “cure?” That’s a question that has taken on increasing urgency in the wake of reports about dramatic reversals of type 2 symptoms after gastric bypass surgery and the cessation of symptoms in people with type 1 diabetes after pancreatic islet replacement. To answer it, a group of endocrinologists met earlier this year to come up with descriptions and definitions that accurately describe what happens when people with diabetes experience a reversal of symptoms.
Their answer, recently published in Diabetes Care, is that caregivers should use the term “remission” rather than “cure” as the preferred word. Their reasoning was based on the difference between what they call “dichotomous” diseases, like cancer, and diseases that exist on a continuum, like diabetes. In other words, with a disease like cancer, you either have it or you don’t. With diabetes, which is defined by the level of hyperglycemia, the symptoms can be well controlled day by day even as the underlying cause of the disease remains uncured. At most, then, the disease can be said to be in remission if the hyperglycemia is successfully controlled over a prolonged period.
The endocrinologists agreed on certain definitions for describing remission in type 1 and type 2 patients:
* “Partial remission” is when hyperglycemia remains below the diagnostic thresholds for diabetes for at least one year without the assistance of drugs or ongoing medical procedures.
* “Complete remission” is when a patient consistently achieves normal non-diabetic glycemic levels for at least one year without the assistance of drugs or ongoing medical procedures.
* “Prolonged remission” is a complete remission that lasts at least five years.
Although the endocrinologists reported that prolonged remission could be considered “essentially equivalent to a cure,” for now “prolonged remission” is the closest they want to come to using “cure” to describing dramatic, enduring changes in diabetes symptoms. They reasoned that “remission” is more accurate than “cure” because therapies for type 1 and type 2 will probably always leave patients at risk for relapse.
For type 1 diabetes, the endocrinologists described remission as a consequence of immune system modulation or islet replacement that doesn’t require continuing immune suppression via drugs. They also said that in people with type 1 who have undergone transplants and require continuing doses of immunosuppressive drugs, the term “remission” should not apply.
Remission in type 2 patients, they said, could follow bariatric/metabolic surgery or changes in diet, exercise and weight that produce a reversal of hyperglycemia. However, in the case of devices such as gastric banding, remission cannot be said to have occurred until the patient no longer requires adjustments to the device and has been living with it problem-free for some time.
The endocrinologists noted that even if treatments given to type 2s result in A1c levels of 6.5 percent or below-levels that some might consider to indicate an absence of diabetes-those levels continue to be a sign of impaired ability to properly produce or use glucose. Thus, the best they can do in describing such lower A1c levels is “partial remission.”
* * *