1. Definition & Terminology
This is a new topic in the guidelines. Understanding the specific definitions is crucial for the exam.
- Definition: Remission is defined as achieving healthy glucose levels without any antihyperglycemic medications for a minimum of 3 months.
Why “Remission”? The terms “Reversal” or “Cure” are discouraged because glucose improvement may be temporary, and the risk of relapse remains.
Classification:
- Remission to Prediabetes: A1C between 6.0% and 6.4% (off meds > 3 months).
- Remission to Normoglycemia: A1C < 6.0% (off meds > 3 months).
Testing Protocol:
- Primary Test: A1C is the preferred criteria.
Alternative: If A1C is unreliable, use Fasting Plasma Glucose (FPG) or OGTT.
Timing: Test at 3 months and 6 months after stopping medications or starting the intervention. If remission is achieved, monitor at least every 6 months thereafter .
2. Candidate Selection (Who is Eligible?)
Not everyone is a candidate. Remission strategies usually involve significant weight loss or surgery.
Ideal Candidates:
Duration: Early Type 2 diabetes (diagnosed < 6 years ago).
Body weight: Overweight or obesity.
Treatment: Not currently taking insulin.
Motivation: Inclination to engage in intensive weight loss behaviors.
Exclusions / Caution:
Comorbidities: People with established ASCVD, Heart Failure (HF), or Chronic Kidney Disease (CKD) who require organ-protective medications (SGLT2i, GLP-1 RA) should not stop these agents even if glucose normalizes.
Mental Health: Those with significant eating disorders or severe mental health disorders.
Pregnancy: Recommendations apply to non-pregnant adults.
3. Interventions for Remission
The guidelines reviewed Surgical, Behavioural, Pharmacological, and Digital interventions. Only Surgery and Health Behavioural interventions have graded recommendations.
A. Bariatric Surgery
Recommendation: Recommended for adults with T2D and BMI > 35 kg/m²
Efficacy: High remission rates (30–63% at 1–5 years).
Relapse: 35–50% may eventually relapse.
B. Low-Calorie Diet (The “DiRECT” Protocol)
Method:
Phase 1: Total diet replacement with low-calorie formula (800–900 kcal/day) for 3–5 months.
Phase 2: Structured food reintroduction (1–2 months).
Phase 3: Weight maintenance with increased physical activity.
Target: Aim for > 15 kg weight loss.
Eligibility for this specific intervention: BMI 27–45 kg/m², T2D duration < 6 years, not on insulin.
C. Exercise + Calorie Restriction (The “U-TURN” Protocol)
Method: High-volume structured exercise (240–420 min/week) combined with calorie restriction.
Target: Modest weight loss (5–7%).
Eligibility: BMI > 25 kg/m², T2D duration < 10 years, A1C < 9%.
D. Pharmacological & Digital
Pharmacotherapy: Currently no recommendation for using meds solely to induce remission (evidence insufficient).
Digital: No specific app/tool recommended due to lack of RCT evidence.
4. Deprescribing & Safety
Stopping medications requires a safe, individualized approach.
Cardiorenal Protection: Do not stop SGLT2i or GLP-1 RA in patients with ASCVD, HF, or CKD, even if A1C is normal. This is considered “Pharmacologically-managed diabetes,” not remission.
Hypoglycemia: Minimize risk when tapering agents (especially insulin/sulfonylureas).
Blood Pressure/Lipids: Do not automatically stop statins or ACEi/ARBs. Continue if indicated for CV protection (e.g., Age > 40, established disease) .
5. Managing Expectations & Relapse
Shared Decision Making: Use tools like the COM-B Model (Capability, Opportunity, Motivation) and 5As (Ask, Assess, Advise, Agree, Assist) to guide conversations .
Relapse Management: Remission is often temporary. If weight regain > 2 kg occurs, consider “rescue” plans (e.g., brief return to meal replacements).
Language: Avoid terms like “Failure.” Frame remission as a journey where any weight loss/A1C reduction yields health benefits.
6. Diabetes Canada 2022 Guidelines Recommendations
Key takeaways from the “Recommendations” section (Page 759).
Goal: Remission may be considered for interested individuals without eating disorders or compelling indications for specific organ-protective meds [Grade D, Consensus] .
Monitoring: Test A1C every 6 months to assess for persistence or relapse.
Surgery: Recommend bariatric surgery for T2D + BMI > 35 kg/m² [Grade A, Level 1A].
Low-Calorie Diet: Recommend 800–850 kcal/day meal replacement diet for 3–5 months (target > 15 kg loss) for BMI 27–45, duration < 6 years, non-insulin users [Grade A, Level 1A].
Exercise: Recommend intensive exercise (240–420 min/week) + diet for BMI > 25, duration < 10 years [Grade C, Level 2]