Response

We thank Drs Yang and Hu1Yang H. Hu B. Duodenal mucosal resurfacing before its clinical practice.Gastrointest Endosc. 2022; 95: 875Abstract Full Text Full Text PDF Scopus (1) Google Scholar for their questions. It is correct that the exact mechanism underlying duodenal mucosal resurfacing (DMR) remains unclear, as mentioned in our discussion.2van Baar A.C.G. Meiring S. Smeele P. et al.Duodenal mucosal resurfacing combined with glucagon-like peptide-1 receptor agonism to discontinue insulin in type 2 diabetes: a feasibility study.Gastrointest Endosc. 2021; 94: 111-120Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar We are conducting additional mechanistic research, and we recently published 2 articles in which we report the results from our first mechanistic assessments: 1 report about the role of bile acids3Meiring S. Meessen E.C.E. van Baar A.C.G. et al.Duodenal mucosal resurfacing with a GLP-1 receptor agonist increases postprandial unconjugated bile acids in patients with insulin-dependent type 2 diabetes.Am J Physiol Endocrinol Metab. 2022; 322: E132-E140Crossref PubMed Scopus (9) Google Scholar and a second report about changes in the microbiome.4Meiring S. van Baar A.C.G. Sørensen N. et al.A changed gut microbiota diversity is associated with metabolic improvements after duodenal mucosal resurfacing with glucagon-like-peptide-1 receptor agonist in type 2 diabetes in a pilot study.Front Clin Diabetes Healthc. 2022; 3: 856661Crossref Google Scholar The changes we found are interesting and noteworthy, but the exact mechanism has still to be elucidated. In the upcoming months we will publish a third article to report our study of changes in the duodenal mucosa itself after DMR. We agree with Drs Yang and Hu1Yang H. Hu B. Duodenal mucosal resurfacing before its clinical practice.Gastrointest Endosc. 2022; 95: 875Abstract Full Text Full Text PDF Scopus (1) Google Scholar that our study patients were followed up more regularly and closely with more education on health and diet. The main goal of our feasibility study was to evaluate whether it was possible to discontinue insulin treatment in patients with type 2 diabetes by replacing it with DMR and GLP-1RA and to get an idea of the effect size of such a combined intervention. Because our small study was successful, it has been followed by an adequately powered, multicenter, sham controlled trial (Revitalize-1) to control for the addressed confounding factors. This mimics our prior approach, where we first conducted the uncontrolled Revita-1 study (DMR for patients with type 2 diabetes using oral glucose-lowering medication) and performed the sham controlled randomized Revita-2 trial thereafter. We are also designing our next study in which we will evaluate the length of DMR. Dr Bergman received research support from and was a consultant for Fractyl. The other author disclosed no financial relationships.