Antihypertensive medication needs and blood pressure control with weight loss in the Diabetes Remission Clinical Trial (DiRECT) – published online 31/05/2021

Wilma S. Leslie, Eman Ali, Leanne Harris, C. Martina Messow, Naomi T. Brosnahan, George Thom, E. Louise McCombie, Alison C. Barnes, Naveed Sattar, Roy Taylor, Michael E. J. Lean

A diagnosis of type 2 diabetes carries a life-expectancy reduction ranking alongside major cancers, with several weight-related cardiometabolic factors (the metabolic syndrome) contributing to this. For example, over half of individuals with type 2 diabetes are also hypertensive. In this issue, Leslie et al (https://doi.org/10.1007/s00125-021-05471-x) present a secondary analysis of the Diabetes Remission Clinical Trial (DiRECT), in which they aimed to evaluate the safety and efficacy of the planned therapeutic withdrawal of all antihypertensive and diuretic medications, upon commencement of a formula low-energy diet replacement, targeting remission of type 2 diabetes.  The authors report that the DiRECT protocol led to remission of diabetes (i.e. HbA_1c values that were not in the diabetic range, without glucose-lowering medications) after 2 years for about one-third of all participants who commenced a dietary weight management programme. Over 80% of those who lost over 15 kg of weight achieved remission.  To avoid postural hypotension, the trial protocol included a therapeutic trial of withdrawing antihypertensive medications upon starting 12–20 weeks of a 3470 kJ/day (830 kcal/day) formula diet; no rebound hypertension was observed.  Overall, blood pressures fell, with 28% needing to resume antihypertensives before 20 weeks. The weight-loss maintenance protocol maintained normal blood pressure at 24 months, without medication, for 28% of those who stopped antihypertensives at baseline, and for 44% of those who sustained remission of diabetes (mean weight loss: 11.4 kg). The authors conclude that weight loss is a safe and effective antihypertensive treatment.

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