Cohort studyindependent cross-checkabstract checked★ key study I-INS-128 in-depth review
Who can stop insulin after a first episode of ketoacidosis?
Phenotype and predictors of insulin independence in adults presenting with diabetic ketoacidosis: a prospective cohort study.
Overview
Raubenheimer PJ et al.. Diabetologia 2024 · PMID 38240751 · DOI 10.1007/s00125-023-06067-3
In Cape Town, about a quarter of adults could stay off insulin for 5 years, mostly those with a type 2-like profile; people with type 1 antibodies rarely could.
Does the study support the specific claim? Partly · Methodological quality: moderate
Plain-language summary
Study explained simply
- What did the researchers want to find out?
Find predictors of insulin independence after DKA.
- How was the study done?
Prospective cohort with supervised weaning.
- How many people, animals or samples were studied?
88 adults.
- What was actually found?
46% at 1 year, 26% at 5 years off insulin; antibodies predict dependence.
- How large was the observed effect?
OR 11.5 (acanthosis); 0.10 (antibodies).
- What do the results mean in everyday life?
Stopping insulin is possible for some people with a specific type 2 profile, under medical supervision only.
- What are the study's limitations?
Small study.
- What does it say about Elawady's specific claim?
Partly qualifies 'nobody can stop insulin'; contradicts stopping it in type 1.
- Do the results apply to Germany and Europe?
Phenotype rarer in Europe.
- What can explicitly not be concluded from this study?
Cannot support stopping insulin without testing and supervision.
Scientific in-depth review
1. Full reference
- Authors
- Raubenheimer PJ et al.
- Journal
- Diabetologia
- Year
- 2024
- Identifier
- PMID 38240751 DOI 10.1007/s00125-023-06067-3
- Verification
- verified – PubMed efetch 2026-10-26; Crossref 2026-10-26
- Retracted
- no
- Corrections
- none
- Extent checked
- abstract only
- Conflicts of interest and funding
Non-US government support (record).
2. Research question
What predicts insulin independence after a first DKA episode?
3. Study design and population
- Study design
- Cohort study – Prospective cohort with systematic, supervised insulin weaning; 5-year follow-up
- Population
Adults newly diagnosed with diabetes presenting with DKA, four public hospitals
- Country
South Africa (Cape Town)
- Period
5-year follow-up
- Sample size
88
- Inclusion and exclusion criteria
First DKA, >=18 years
4. Methods and endpoints
- Exposure / intervention
Clinical phenotype (antibodies, C-peptide, acanthosis)
- Comparator
Within cohort
- Endpoints
Insulin independence at 12 and 60 months
- Statistical methods
Logistic regression
5. Actual results
- Results
46% insulin independent at 12 months and 26% at 5 years; in antibody-negative patients with C-peptide >0.3 nmol/l: 68% and 37%. Acanthosis nigricans predicted independence (OR 11.5 at 5 years); antibody positivity lowered the likelihood (OR 0.10). Insulin was weaned only under medical supervision when normoglycaemia was achieved.
- Absolute risks
not reported
- Authors' conclusion
Ketosis-prone type 2 diabetes predominated; such individuals could potentially be weaned off insulin; classic T1D was less common.
6. Strengths
- Prospective
- Antibody and C-peptide phenotyping
- 5-year follow-up
7. Weaknesses
- Small
- Single region
8. Risk of bias
- Orienting tool
- ROBINS-E
- Type of assessment
- simplified assessment (abstract only)
- Full formal assessment
- no
- Overall risk of bias
- some concerns
- Rationale
Small cohort.
9. Assessment of the statistical interpretation
Wide CIs for ORs (e.g. 2.5-53.2).
10. Relevance to the specific claim
Honest nuance: some adults who present with DKA (ketosis-prone T2D, antibody-negative, preserved C-peptide) can stop insulin under supervision; antibody-positive (type 1) patients rarely can. This is phenotype-based medical weaning, not a diet.
11. Independent contrary findings
12. Transferability to Germany and Europe
Ketosis-prone T2D is more common in people of African descent; relevant also to Egypt/Africa.
13. Overall methodological judgement
Supports careful supervised deprescribing in selected phenotypes; refutes stopping insulin in T1D.
| Multidimensional assessment | |
|---|---|
| Authenticity of the source | verified |
| Methodological quality | moderate |
| Risk of bias | some concerns |
| Precision of results | low |
| Directness | direct |
| Reproducibility | partly replicated |
| Consistency with the overall evidence | consistent |
| Regional transferability | moderate |
| Adequacy of the interpretation (by the archive) | not applicable |
14. Open questions
15. Linked fact checks
- People with diabetes can stop insulin and diabetes medication by following the Tayebat system ('zero medicine'), as shown by followers who stopped insulin and are 'perfectly fine'. – Studies with mixed or unclear results
- Diabetes can be cured by following the Tayebat system without medication, illustrated by a patient who stopped insulin after 30 years of insulin use. – Studies with mixed or unclear results