Better Score to Predict Diabetes Remission After Bariatric Surgery

Nancy A. Melville

December 17, 2018

An expanded version of the DiaRem scoring system for predicting the chances of diabetes remission following weight loss surgery allows for longer-term prediction up to 5 years after the operation, new research finds.

"The previous DiaRem model was limited to projecting outcomes for only 1 year after only one type of procedure," said co-author Rachel Golan, PhD, MPH, a lecturer at the Ben-Gurion University of the Negev, Beersheba, Israel, in a press statement from her institution.

"Our 'Advanced-DiaRem' was able to predict the longer-term probability of achieving remission from diabetes out to 5 years following three different surgical procedures," she noted.

Type 2 diabetes commonly occurs with obesity, and bariatric surgery has been shown to induce diabetes remission in 50% to 60% of cases.

To better predict which patients are likely to achieve diabetes remission, both the ABCD (age, body mass index [BMI], C-peptide, and duration of disease) and DiaRem clinical scores have been used.

However, DiaRem is seen as a simpler score because it only requires basic clinical parameters such as the patient's age, BMI, HbA1c, and insulin or other oral antidiabetic agent use, and not the more complex measure of C-peptide included in the ABCD score.

Shortcomings of DiaRem include the fact that the tool does not factor in newer classes of diabetes drugs and little has been known about prediction of remission with bariatric procedures other than Roux-en-Y gastric bypass (RYGB) or beyond a year post-surgery.

Improving Upon the DiaRem Score

Now lead author Dror Dicker, MD, Sackler School of Medicine, Tel Aviv University, Israel, and colleagues, propose expanding the DiaRem score to include a redefined "penalty score," by adding new classes of antidiabetic drugs and diabetes duration to generate an "Advanced" DiaRem (Ad-DiaRem) score, as described in their article published online in Obesity Surgery.

To test this, the authors evaluated 1459 patients who had undergone bariatric surgery using RYBG, sleeve gastrectomy, or gastric banding, and who had 5-year post-operative diabetes data available.

Consistent with reported rates, 53.6% of patients had diabetes remission during the 5-year follow-up.

For those who had RYGB, the Ad-DiaRem score showed a mild improvement over standard DiaRem in predicting the 5-year risk of remission, with area under the receiver operating characteristic [AUROC] curve of 0.85 for the advanced score, compared with 0.78 for the original one.

Ad-DiaRem also had a higher positive predictive value (PPV) of 78.2% in detecting more than 80% of those achieving diabetes remission, compared with 73.2% with DiaRem.

After sleeve gastrectomy, the two scoring systems (DiaRem and Ad-DiaRem) each had the same AUROC of 0.82 for predicting remission; however, Ad-DiaRem again had a higher PPV for predicting over 80% of those with 5-year postoperative diabetes remission compared with DiaRem (76.2% vs 71.0%).

For predicting remission 5 years after gastric banding, both the Ad-DiaRem and DiaRem scores were lower but similar (AUROC, 0.73 for both; PPV, 66.3% and 64.3%, respectively).

The results show "the Ad-DiaRem provides reasonable predictive capacity, which is most suitable for RYBG and similarly for sleeve gastrectomy, but may be lower for gastric bypass," the authors conclude.

"If confirmed by other independent cohorts, Ad-DiaRem may contribute to better precision care for obese persons with diabetes who are candidates for bariatric surgery."

Better Predictive Tool for Diabetes Remission Will Aid Decisions

Golan added that a more effective predictive tool for diabetes remission could have broader implications for the public health system.

"We know weight-loss surgery has the potential to put diabetes in remission," she said. "The ability to predict an individual's reaction to weight loss surgery gives both doctors and patients the clarity they need to make informed medical decisions."

"More importantly, it will enable healthcare officials to address a public health crisis that is one of the major contributors to the spiraling cost of healthcare, and direct resources where they can be most effective."

The study was supported by from grants from the Ministry of Science, Technology & Space (Israeli-French collaboration) and Ministry of Higher Education and Research, France (Franco-Israeli project).

Obes Surg. Published online November 22, 2018. Abstract

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