Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations

Rubino, Francesco; Nathan, David M.; Eckel, Robert H.; Schauer, Philip R.; Alberti, K. G. M. M.; Zimmet, Paul; Prato, Stefano Del; Ji, Linong; Sadikot, S.M.; Herman, William H.; Amiel, Stephanie A.; Kaplan, Lee M.; Taroncher-Oldenburg, Gaspar; Cummings, David E.; Albache, Nizar; Batterham, Rachel L.; Bhatt, Deepak L.; Boza, Camilo; Cefalu, William T.; Cohen, Ricardo; Courcoulas, Anita P.; Dinneen, Seán F.; Dixon, John; Ferrannini, Ele; Fioretto, Paola; Frühbeck, Gema; Gautier, Michel; Grant, Richard W.; Ikramuddin, Sayeed; Johnston, Desmond G.; Kashyap, Sangeeta R.; Kelly, Terence A.; Klupa, Tomasz; Körner, Judith; Laferrère, Blandine; Lebovitz, Harold E.; Lee, Wei-Jei; Roux, Carel W. le; Mechanick, Jeffrey I.; Mingrone, Geltrude; Morton, John M.; Pories, Walter J.; Ratner, Robert E.; Rayman, Gerry; Sugerman, Harvey J.; Gaal, Luc Van; Vidal, J; Weng, Jianping; Wolfe, Bruce M.

doi:10.2337/dc16-0236

Cited by 789 publications

(567 citation statements)

References 107 publications

(198 reference statements)

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“…The new guidelines advise that such procedures (metabolic surgery) be considered specifically for the treatment of diabetes in people who have not adequately controlled their blood-sugar levels through other means, and whose BMI is greater than 30 (or 27.5 for people of Asian descent). Perhaps more significantly, they also state that the gastrointestinal tract is an appropriate biological target for interventions designed to treat diabetes 1 . These recommendations arguably signify the most radical departure from mainstream approaches to the management of diabetes since the introduction of insulin in the 1920s.…”

Section: Clinical Shiftmentioning

confidence: 99%

“…Non-randomized studies, involving people receiving surgery and matched subjects treated with standard interventions, suggest that surgery may also reduce heart attacks, stroke and diabetes-related mortality 1 . And several economic analyses suggest that the costs of surgery (roughly US$20,000-25,000 per procedure in the United States) may be recouped within 2 years through reduced spending on medication and care 5 .…”

Section: Clinical Shiftmentioning

confidence: 99%

“…The summit inspired the randomized clinical trials that now provide the evidence supporting a role of surgery in diabetes. In September 2015, the introduction of surgery into standard care for type 2 diabetes was formally recommended by the participants of the second Diabetes Surgery Summit 1 . F.R.…”

Section: Clinical Shiftmentioning

confidence: 99%

“…These recommendations arguably signify the most radical departure from mainstream approaches to the management of diabetes since the introduction of insulin in the 1920s. They are based on findings from a large body of work, including 11 randomized clinical trials conducted over the past decade 1 . In these studies, most surgically treated people (up to 80% in a recent 5-year follow-up 4 of a randomized trial) fall into one of two categories.…”

Section: Clinical Shiftmentioning

confidence: 99%

“…Appearing in Diabetes Care, a journal of the American Diabetes Association, and endorsed by 45 professional societies around the world, the guidelines propose that surgery involving the manipulation of the stomach or intestine be considered as a standard treatment option for appropriate candidates. This development follows multiple clinical trials showing that gastrointestinal surgery can improve blood-sugar levels more effectively than any lifestyle or pharmaceutical intervention, and even lead to long-term remission of the disease 1 …”

mentioning

confidence: 99%

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Medical research: Time to think differently about diabetes

Rubino

2016

Nature

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Section: Clinical Shiftmentioning

confidence: 99%

Section: Clinical Shiftmentioning

confidence: 99%

Section: Clinical Shiftmentioning

confidence: 99%

Section: Clinical Shiftmentioning

confidence: 99%

mentioning

confidence: 99%

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Medical research: Time to think differently about diabetes

Rubino

2016

Nature

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Clinical Practice Guidelines

Greenfield

2017

JAMA

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Mastery of the rapidly expanding "evidence" base for the practice of medicine, coupled with the skills needed to synthesize that information for the treatment of individual patients, represents a nearly unachievable challenge for most practicing physicians. Clinical practice guidelines were originally developed to support clinical decision making in conjunction with physician knowledge and experience. However, clinical practice guidelines are now being used for broader purposes: as institutional policy, to inform insurance coverage, for deriving quality of care criteria, and for medicolegal liability standards. The broadening uses of clinical practice guidelines and the recent proliferation of both systematic reviews 1 and clinical practice guidelines produced by specialty societies raise 2 concerns: (1) Is the process of development of these "guidelines" adequate to support the expanded uses? and (2) Once developed, how should clinical practice guidelines be evaluated and certified as trustworthy for the expanded purposes?The guideline by Rubino et al 2 and the synopsis of that guideline by Brito et al 3 in this issue of JAMA illustrate the tension between clinical practice guidelines developed for the purpose of decision support at the individual physician level and those developed for wider uses. This guideline is a pioneering effort to incorporate 2 perspectives, those of endocrinologists and surgeons, into a "treatment algorithm" or clinical practice guideline for metabolic surgery for patients with type 2 diabetes. However, based on the inadequate documentation of the evidence summary, the guideline might not meet minimum standards even for the purpose of decision support. 4 For example, how would a practicing physician treating a class 1 (body mass index of 30-35) obese patient with type 2 diabetes interpret "inadequately controlled" hyperglycemia and "despite optimal medical treatment" to determine eligibility for metabolic surgery? These terms lack specificity, which may reduce the utility of guidelines. 5 The practical and scientific limitations of this guideline, even for the purpose of decision support, raise concern regarding the more expanded uses of this guideline (eg, for institutional policy, insurance coverage, or quality of care) and highlight fundamental flaws in the current guideline development process. The Institute of Medicine report Clinical Practical Guidelines We Can Trust set out criteria that, if widely adopted and rigorously applied, would substantially

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Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes

Brito

Montori

Davis

2017

JAMA

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Type 2 diabetes affects 12% to 14% of persons in the United States, with prevalence rates exceeding 20% in non-Hispanic black, Asian, and Hispanic populations. 1 Pharmaceutical and behavioral approaches to restore glucose homeostasis and to avoid longterm complications of diabetes may be effective, but sustaining adherence is often difficult. 2 Gastrointestinal operations (Roux-en-Y gastric bypass, vertical sleeve gastrectomy, laparoscopic adjustable gastric banding, and biliopancreatic diversion) provide substantial weight loss and often improve function and reduce obesity-related complications. 3 Some consider bariatric interventions as metabolic surgeries when the goal is to improve metabolic health rather than weight alone, and these procedures can lead to changes in the gut microbiome and hormones, bile acid metabolism, and other factors that affect glucose homeostasis independent of weight loss. 4 Recent studies and an emerging consensus suggest metabolic surgery to treat T2D in some patients. However, a firm link between controlling diabetes through metabolic surgery and preventing diabetes complications has yet to be established. Characteristics of the Guideline SourceThis guideline was published by delegates of the Second Diabetes Surgery Summit (DSS-II), an international consensus conference organized in collaboration with major diabetes organizations (Table ). 4 The DSS-II organizing committee tasked 48 academic experts (75% nonsurgeons) with unclear relevant financial relationships to write a guideline for the surgical treatment of T2D. Prior to meeting, delegates received an evidence summary and the proposed recommendations. They used an interactive feedback process to reach agreement (Ն67%). Consensus recommendations were presented Clinical Review & Education JAMA Clinical Guidelines Synopsis

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Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes: A Joint Statement by International Diabetes Organizations

Cited by 789 publications

References 107 publications

Medical research: Time to think differently about diabetes

Medical research: Time to think differently about diabetes

Clinical Practice Guidelines

Metabolic Surgery in the Treatment Algorithm for Type 2 Diabetes

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