Type 2 diabetes, generally perceived as a progressive and incurable disease, now affects 5-10% of the population, around 3.2 million people in the United Kingdom.1 Until the moment the majority of the majority of the majority ofPatients are attended entirely in the primary care of general practice.About 10% of NHS's total expenses in the United Kingdom continue to be assigned to the treatment of diabetes, and international figures suggest that medical costs for people with diabetes are two or three times greater than the average age andSex
The application of current clinical guidelines to reduce glycosylated hemoglobin (HBA1C) and cardiovascular risks, mainly with generic lifestyle medications and advice, has improved clinical results, but many patients still develop vascular complications and the hope ofLife is up to six years shorter than in people without diabetes2.The diagnosis involves important social and financial repercussions for individuals, as well as bad health perspectives.
The remission of diabetes (who no longer has diabetes, at least for a period) is clearly attainable for some patients, possibly many, but is currently very rarely reached or registered.Greater awareness, documentation and surveillance of the referrals must improve health results and reduce health care costs.
Management Change
Weight loss is associated with the extension of life expectancy for people with diabetes
In line with trends in most medical specialties, diabetes management is beginning to focus on the reversible mechanisms of the underlying disease instead of treating symptoms and subsequent multisystemic pathological consequences34.Genetic predisposition (EPI) and aging have a function in type 2 diabetes, but rarely without weight gain.
The reduction of blood glucose concentrations or HBA1C remains the main objective of management, as reflected in the current clinical guidelines and the actions of license medicines.However, management and guidelines focus on the use of antidiabetic drugs, with little attention to diet and lifestyle advice.
The magnitude of the market of pharmacological therapies and their possible insufficiency is illustrated by the fact that 488 drugs (excluded insulins) are currently authorized worldwide to treat type 2 diabetes with 70 generic compounds.5 All of them significantly reduce theBlood glucose and HBA1C, but no trial has examined the drugs administered together with an optimal diet and lifestyle advice for weight control.
On the contrary, consistent evidence demonstrates that weight loss is associated with the extension of life expectancy for people with diabetes and that weight loss of around 15 kg often produces a total biochemical remission of type 2 diabetes type 2, restoring the function of beta cells.67
The recognition that the accumulation of ectopic fat in the liver and the pancreas affects the organ function to cause type 2 diabetes, but is reversible, the awareness that the remission is possible has increased.7
The attention of the media has encouraged a growing number of people with type 2 diabetes to lose weight and eliminate the diagnosis of diabetes 2. The remission produces a strong sense of personal achievement and empowerment;It also benefits medical systems because patients no longer require antidiabetic drugs.The United Kingdom NHS currently spends about 1,000 millionof pounds sterling (1 billion dollars) per year (22 million pounds sterling per day) in antidiabetic medications, and costs increase as diabetes rates and medications prices increase.
Criteria for the remission of diabetes
There is no consensus on the criteria for the remission of diabetes.The published criteria and, therefore, the notified remission rates vary, but all require being below the diagnostic thresholds of the Diabetes of the World Health Organization / American Association of Diabetes (ADA).The majority of recent publications, including the Grande Look Ahead of lifestyle interventions, 10 refer to a consensus group declaration of the ADA8 that defined the results of the tests below the threshold diagnosis of diabetes as “Partial remission ”and to the remission of the" pre-diabetes "as" complete remission. "
Table 1 published and proposed criteria for diabetes in remission
However, the use of the term of the partial remission denoma is completely portrayed the logic or importance of becoming non -diabetic for patients.Although the remission of prediabetes is desirable because it reduces cardiovascular risk, routine management should aim to help patients escape from the diagnostic category of diabetes, with their personal charges and the risks of microvascular disease.This requires the use of WHO diagnostic thresholds for diabetes to establish the remission and acceptance that some patients will continue to have tolerance to the deteriorated or prediabetic glucose tolerance of glucose in fasting and HBA1C .8 .8
HBA1C measurement or blood glucose is sufficient to identify remission.To avoid classification errors resulting from the measurement error or biological variation, we recommend that patients have two test results (usually HBA1C) below the diagnostic threshold, with a minimum interval of two months to confirm the remission.This reflects about four months of Normaglycemia.Referral patients should be maintained under regular review with annual tests.
potential metabolic value of the remission
The clinical results for people with type 2 diabetes are worse at higher concentrations of glucose or HBA1C.10 No study has reported results for people who achieve remission, but good glycemic control through pharmacological treatment improves microvascular results (Retinopathy, neuropathy, nephropathy) Type 1 diabetes and type 2 diabetes. Reduced cardiac events have also been observed in patients with type 2 diabetes after bariatric surgery. 12
In contrast, some clinical trials have indicated greater mortality when HBA1C approaches normal levels, probably through hypoglycemia that cause arrhythmias.
Ahead, an essay on lifestyle intervention in patients with an average duration of five -year diabetes, reported 11.5% remission at 12 months with 8.6% weight loss, but that proportion was reducedin 30% annual.10 The results on the health of the participants have not yet been informed, but the limited evidence and the first principles suggest that the remission of diabetes (without antidiabetic drugs) improves the prognosis, becoming a primary objectiveof the administration as soon as possible after diagnosis.10
Coding in health records
The remission of type 2 diabetes can be deduced from the routine records of diabetic patients who haveNon -diabetic biochemical results (generally HBA1C & LT; 48 mmol / mol), when there is no record that antidiabetic drugs are prescribed.14 In the United Kingdom, reading codes have been used to record the findings and procedures of patients since 198515, but now they are becoming the International Snomed system.The basic coding frame will remain, however.
The reading dictionary includes codes 21263 or 212h for "resolved diabetes" and C10P for "diabetes in remission".Solved diabetes is used for patients diagnosed with diabetes or in which diabetes was secondary to a factor that has been eliminated, such as: the elimination of steroid treatment.Such patients do not require annual reviews or surveillance.
The C10P code should be used for patients who have reached the remission of type 2 diabetes, usually by substantial loss of weight.These patients can be considered non -diabetic for issues such as insurance, driving or employment, but since the code is diagnosed, it will be programmed for annual reviews and retinal damage detection programs.
Achieve the remission
In the few countries with data, it is rarely recorded that patients have diabetes in remission.Karter and his colleagues found remissions in only 0.14% of 120,000 patients in the United States followed for seven years.14 The Scottish Care Information Diabetes database, which includes all patients in Scotland, shows that less than 0, 1% of patients with type 2 diabetes were encoded as in remission in March 2017.
Table 2 number of people in Scotland with different coding categories recorded in the Sci Diabetes database (March 2017)
The lack of agreed criteria and a guide on recoding may have given a doubt in the coding of the remission, but the main reason for the low number of patients in this category is probably that few patients are trying to achieve remission.Patients and doctors may not be aware that type 2 diabetes can be reversed, despite recent advertising.Despite structured approaches publications that use an initial diet replacement formula to achieve rapid weight loss and the possibility of maintaining a loss of 12-15 kg at 12 months and more.
The 2010 Intercollegiate Guidelines Network Scottish Guide recommends sustained weight loss of 10% of body weight or 15 kg for people with severe and complicated obesity, including type 2.18 diabetes this is difficult to achieve even with bariatric surgeryand only 75 -80% of patients who succeed are rewarded with the remission of diabetes.
Physical and social factors, emotional states and self-regulation skills are important factors that affect health.It is unknown if the degree of weight loss necessary to achieve remission will be the same for the people of Asia, who commonly develop type 2 diabetes with a body mass index lower than that of people of European origin, but probably with similar content of similar contentBody fat.
Doctors can be understandably reluctant to redefine a patient as "in remission" if they are concerned that the remission, depending on maintaining weight loss, cannot persist, and that the routine withdrawal of annual controls could be abandoned.However, by virtue of the coding of the remission, the annual reviews and will continue.
Another specific factor of the United Kingdom may have been fear of losing incentive payments for diabetes management under the quality framework and results (QOF).Once again, theCoding "Diabetes in remission" retains the diagnostic state so the payment of the practice would continue.
Diabetes in remission has not been specifically rewarded as a management objective.Incentives have been shown to improve attention and risk factors in other areas such as asthma and cardiovascular diseases.The next reviews of the NHS England practice guides and their replacement in NHS Scotland, provide opportunities to include the remission of diabetes as an encouraged objective.
benefits of remission
The achievement of remission has patient health benefits and eliminates daily surveillance and treatment, but the correct coding of remission has multiple additional benefits.Eliminates the stigma of having diabetes and provides a sense of personal achievement and social status (box 1).
For patients
- Eliminates personal and social stigmatization as patients or "diabetics."
- Provides an objective and a reward for hard and sustained work normally necessary to achieve and maintain substantial weight loss.
- You can allow life insurance, mortgages, travel insurance, etc., without the highest premiums added for people with a diagnosis of type 2 diabetes.
- Eliminates some occupational restrictions.
For epidemiology and health systems
- Identify a valuable indicator of success in healthcare, through the national surveillance of the disease registration.
- It allows a better analysis of the risks of long -term morbidity and mortality.
- Improves the forecast of resource requirements
Diabetes is expensive, both for individuals and for health systems.Tests on health demands and survival are needed after remission, but the demands are likely to be minor.The average annual medical costs of type 2 diabetes in the USA. They were calculated at $ 6414 in 2007, increasing age at $ 9061 in over 6420 and is around 2.5 times higher than for people without diabetes21.
The costs are rising as new expensive drugs are launched, under pharmacocentric clinical guidelines.In the United Kingdom these growing costs are supported by the NHS.In other countries, costs fall on the individual.Private health insurance does not usually cover existing diabetes, which represents a barrier for optimal medical care.
Thus, significantly more American adults with diabetes, and most older than 65 years depend on public insurance such as Medicare.The American Diabetes Association offers the costs indicative of Medicare's coverage for people with diabetes.The annual premiums are around $ 1200 more (optionally) $ 166 to allow half of the costs of prescription medications to be covered.Recipe costs are not completely covered until an individual has spent more than $ 4950 on medications in one year.22
The 2009 National Health Interviews Survey found that, depending on the total home admission, people from 18 to 64 years with diabetes spend around $ 3000 a year in private or $ 2000- $ 6000 a year in health care (of worse quality) if they do not have health insurance.23
Other types of insurance are also more expensive.Life insurance premiums are usually doubled for people with diabetes, adding around £ 600 a year to an average policy.The International Online Insurance Corridor Moneyupermarket.com currently offers people with type 2 diabetes travel policies equivalent to almost double the price that for a person without medical problems,Adding £ 20- £ 30 at the cost of 14 days of coverage in the US, or more if insulin is needed.
At present, people who have diabetes in remission are included in the cheapest category (as well as people with prediabetes).Tangible savings awareness of this type could help maintain weight loss and remission of type 2 diabetes: the promise of rewards and praise for the objectives achieved are key elements in the behavior change strategy.
moving towards the future
It is of interest to all reclassify people with type 2 diabetes when they become non -diabetic.Official guidelines and international consensus are needed to register "diabetes in remission."We have proposed that two non -diabetic test results are required, with a minimum separation of two months, with annual HBA1C reviews to confirm the continuation of this category.
The appropriate interval between the tests to establish the remission is open to the debate.It must be long enough to eliminate people with temporary casualties in blood glucose, but short enough for patients to maintain motivation.
Have agreed criteria to encode diabetes in remission (C10P in the United Kingdom) in registration systems will benefit patients and health care planning.An appropriate coding will allow monitoring progress in achieving the remission of type 2 diabetes at national and international level and to improve the predictions of long -term health results for patients with a known duration of remission.
Key messages
The remission of type 2 diabetes can be achieved by substantial weight loss, but it is rarely registered and probably not notified insufficiently.
Recognizing the remission of diabetes can be a powerful motivating for patients to maintain weight loss.
The diagnostic coding of "diabetes in remission" relieves the social and financial penalties of the diagnosis for patients while continuing medical surveillance.
The correct coding provides a valuable indication of the success of health care and can inform the planning of healthcare.
BMJ 2017;358 DOI: Link (Published 13 SEPTEmber 2017)
