TORONTO - Treating Type 2 diabetes early and aggressively with insulin
therapy can push the disease into remission, suggests a new study that
challenges the current paradigm of diabetes treatment.
The study, by Chinese scientists, showed that after a few days of intensive
insulin treatment, a substantial number of people with newly diagnosed diabetes
went into remission, which in some cases lasted at least a year.
"I think this is so provocative it would have to be confirmed with additional
studies. But it's hard to dispute the findings of the study," said Dr. Daniel
Drucker, a researcher with the University of Toronto's Banting and Best Diabetes
Centre who was not involved in the work.
The premise behind the therapy is that by giving the failing beta cells of the
pancreas a chance to rest, one might interrupt a cycle of decline and allow for
some recovery. The beta cells produce the insulin the body needs to keep blood
sugar levels in check; it is the inability of those cells to meet the body's
insulin needs that triggers Type 2 diabetes.
The notion of early intervention has been explored before, but previous reports
in the scientific literature have been based on small studies.
In this work, which will be published in Saturday's issue of the Lancet, Chinese
scientists from nine centres randomly assigned 382 patients with newly diagnosed
diabetes to receive either continuous insulin infusion (137 patients), multiple
daily injections of insulin (124 patients) or oral diabetes drugs (121
patients).
Treatment was stopped after regular blood glucose levels were restored for a
period of two weeks. Patients were then asked only to follow standard diabetes
lifestyle interventions - eating an appropriate diet, maintaining weight control
and exercising.
Those who received insulin were more likely to hit their blood glucose targets
and to do it more quickly.
In fact, 97 per cent of those who received the continuous infusion had normal
glucose levels within four days and 95 per cent of those who received insulin
injections got there in 5.6 days. For those on the oral diabetes drugs, 85.3 per
cent achieved normal glucose levels within 9.3 days.
After a year, 51 per cent of those who received insulin by infusion were still
able to maintain normal blood sugar levels without drugs - in other words, were
still in remission - and 45 per cent of those who received multiple daily
injections were similarly able to control their blood sugar.
By contrast, only 27 per cent of those on the oral drugs were still in remission
a year later.
"So this type of study forces us, I think, to start evaluating in more detail:
Does it matter what kind of treatment we get initially?" said Drucker, who is
also appointed to the Samuel Lunenfeld Research Institute at Toronto's Mount
Sinai Hospital. Drucker co-authored a commentary on the study for the Lancet.
"And the suggestion obviously from this study is that it may matter how you
control diabetes."
Until relatively recently, people newly diagnosed with Type 2 diabetes were
counselled to try to lose weight if they were overweight, adapt their diets and
increase their levels of physical activity, said Dr. Hertzel Gerstein, a
diabetes expert from McMaster University in Hamilton, Ont., who also had no
involvement in this study.
If that failed to bring blood sugar levels under control - and in many cases it
did - oral drugs like metformin were prescribed. But by year 10, most Type 2
diabetics needed to take insulin injections, Gerstein said.
The treatment approach was essentially that when one option failed, another
treatment or therapy was layered onto the regime.
"It may very well be that that approach is really trying to close the barn after
the horses have run out of the barn," Gerstein said.
Within the past few years, treatment guidelines have been changed. Physicians
are now urged to add oral drug treatment for Type 2 diabetes early after the
diagnosis. But in North America at least, insulin remains a drug of last resort
in most cases, Drucker said.
"We often reserve insulin therapy for those patients who have failed the oral
therapies. And this study suggests that that might not be the correct or best
course of action and that we should move (to) insulin much earlier on in the
treatment paradigm."
Both Drucker and Gerstein said more study is needed to confirm the results and
to answer questions like how long remission might last and whether repeating the
effort to rest the beta cells once a person started to come out of remission
might again reverse the process.
"Does this paper mean that we should start doing this for everybody? I think
that this is still early data to make that type of a major change in approach,"
Gerstein said.
"I think that this type of research should certainly lead to other studies
looking at this. And I think the time is ripe to do those studies."
"We have an epidemic of diabetes in Canada. ... If we can identify therapies
that can reverse it and reverse it safely and effectively, I think that really
needs to happen."
