Earlier surgery may be better for early-onset Type 2 diabetes

By Eleanor McDermid

Research suggests that prompt surgical intervention may maximise the chances of patients with early-onset Type 2 diabetes achieving remission.

The study, published just over a week after the endorsement of metabolic surgery by multiple diabetes societies, shows significantly greater weight loss and higher rates of Type 2 diabetes remission in patients diagnosed when younger than 40 years than in those who were older at diagnosis.

And there was a strong association between shorter duration of diabetes and likelihood of remission, particularly among patients with early-onset diabetes, report Wei-Jei Lee (Min-Sheng General Hospital, Taoyuan City, Taiwan) and colleagues.

This was despite the two groups overall having a similar duration of diabetes, at 3.7 years in the 339 patients with early-onset diabetes and 3.8 years in the 219 patients with late-onset diabetes. Early-onset patients had significantly poorer glycaemic control at baseline, yet remission rates (glycated haemoglobin <6.0%) were 56.9% versus 50.2% after 1 year, and 65.3% versus 54.2% after 5 years.

However, this indicates a substantial proportion of patients with recurrent diabetes, which commentators David Harris and Ali Tavakkoli, from Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, USA, describe as "an Achilles heel of bariatric surgery".

"Thus, identifying markers of long-term [Type 2 diabetes] remission is, and will continue to be, an area of heavy interest in the field", they write in JAMA Surgery.

At 1 year after surgery, average body mass index had decreased by 11.6 kg/m² in the early-onset group and 9.1 kg/m² in the late-onset group, which was a significant difference. The improvements were retained in the 72 and 48 patients from the early- and late-onset groups, respectively, who had 5-year follow-up data.

Harris and Tavakkoli note that 5 years of follow-up is rare after bariatric surgery, making the data "valuable to the field", despite the proportion of patients lost to follow-up.

Duration of diabetes was strongly related to the proportion of weight lost at both 1 and 5 years after surgery in the early-onset group, and to diabetes remission rates at both timepoints in early-onset patients, but only at 1 year after surgery in the late-onset group.

The highest remission rate was observed among early-onset patients whose diabetes had been diagnosed less than a year before surgery, at 91.3% after 1 year, falling to 79.4% at 5 years. The corresponding rates among those with diabetes of more than 10 years' duration were 25.0% and 12.5%.

The commentators conclude that there "appears to be an amassing body of data" to support early surgery for obese patients with Type 2 diabetes. "This not only has the potential to reduce their long-term need for multiple medications but also has the potential to significantly mitigate their risks of health complications compounded over their lifetime", they say.

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