What intervention is most likely to result in remission of diabetes in a 49-year-old obese diabetic patient with hypertension on Mycardis (beta blocker) and Chlorthalidone (thiazide-like diuretic)?

From the Guidelines

Bariatric surgery is the intervention most likely to result in remission of diabetes in a 49-year-old obese diabetic patient with hypertension. The Diabetes Remission Clinical Trial (DiRECT) 1 has shown that almost one-half of the participants achieved remission to a non-diabetic state and were off glucose-lowering drugs at 12 months, with sustained remissions at 24 months for over one-third of people with T2DM. This study highlights the effectiveness of weight loss interventions in achieving diabetes remission.

Key Considerations

• The patient's current medications, Mycardis and Chlorthalidone, would need to be adjusted post-surgery as blood pressure typically improves following significant weight loss 1.
• Bariatric surgery causes long-term weight loss, reduces DM and risk factor elevations, with effects that are superior to lifestyle and intensive medical management alone 1.
• While intensive lifestyle modifications including caloric restriction and increased physical activity can lead to remission in some cases, the durability and magnitude of effect is substantially greater with surgical intervention, particularly in patients with longer-standing diabetes and higher BMI values 1.

Recommendations

• Refer the patient to a bariatric surgery center for evaluation, where they would undergo pre-surgical counseling, nutritional assessment, and psychological evaluation.
• Post-surgery, closely monitor blood glucose levels as medication requirements often decrease rapidly, sometimes within days of surgery.
• Adjust antihypertensive medications as needed to account for improvements in blood pressure following significant weight loss.

The most recent and highest quality study, the 2019 ESC guidelines on diabetes, pre-diabetes, and cardiovascular diseases 1, supports the use of bariatric surgery as an effective intervention for achieving diabetes remission in obese patients.

From the FDA Drug Label

Table 3: Clinically Significant Drug Interactions with Metformin Hydrochloride Tablets Drugs Affecting Glycemic Control Clinical Impact:Certain drugs tend to produce hyperglycemia and may lead to loss of glycemic control Intervention:When such drugs are administered to a patient receiving metformin hydrochloride tablets, observe the patient closely for loss of blood glucose control. When such drugs are withdrawn from a patient receiving metformin hydrochloride tablets, observe the patient closely for hypoglycemia Examples:Thiazides and other diuretics, corticosteroids, phenothiazines, thyroid products, estrogens, oral contraceptives, phenytoin, nicotinic acid, sympathomimetics, calcium channel blockers, and isoniazid.

The most likely intervention to result in remission of diabetes in a 49-year-old obese diabetic patient with hypertension is weight loss and potentially discontinuation or modification of medications that can worsen glycemic control, such as Chlorthalidone (a thiazide-like diuretic). However, the provided drug label does not directly answer the question regarding the most effective intervention for remission of diabetes in this specific patient population.

• Lifestyle modifications, including diet and exercise, are typically recommended for patients with diabetes, but the label does not provide information on these interventions.
• Medication adjustments, such as adding metformin or other anti-diabetic medications, may be considered, but the label does not provide direct guidance on the most effective intervention for remission of diabetes 2.

From the Research

Intervention Options for Remission of Diabetes

To achieve remission of diabetes in a 49-year-old obese diabetic patient with hypertension, several intervention options can be considered. The patient is currently on Mycardis (beta blocker) and Chlorthalidone (thiazide-like diuretic).

Lifestyle Interventions

• Weight loss is a key predictor of remission, and lifestyle interventions such as dietary changes and increased physical activity can be effective in achieving weight loss and improving diabetes control 3, 4.
• A low-energy diet or a low-carbohydrate diet may be used to support the achievement of euglycaemia and potentially remission 5.
• Tailored lifestyle self-management interventions can help patients reduce fat intake and increase lifestyle physical activity levels, leading to weight maintenance and reduction in waist circumference 4.

Medical Interventions

• Bariatric surgery may be necessary to achieve greater magnitudes of weight loss and improve diabetes control, potentially leading to remission 3.
• Total diet replacement (TDR) studies have shown that remission of type 2 diabetes is possible with significant weight loss 5.

Dietary Approaches

• A range of dietary approaches, including low-energy diets and low-carbohydrate diets, can be used to support the achievement of euglycaemia and potentially remission 5.
• Emphasizing whole, plant-based foods with minimal consumption of meat and other animal products may be an effective dietary approach for achieving remission 6.

Considerations for Remission

• Remission of type 2 diabetes should be defined as HbA1c <6.5% for at least 3 months with no surgery, devices, or active pharmacologic therapy for the specific purpose of lowering blood glucose 6.
• Predictors of remission include 10% weight loss, higher BMI, lower A1C, and shorter type 2 diabetes duration at enrollment 7.