Re: Complacency



abroadus wrote:
Hi-

I just wanted to let you know that currently the treatment guidelines
for patients with Type II Diabetes who are on oral medications is to
test their blood glucose once daily. The reason for this is that when
you are on oral medication, unlike insulin, your blood glucose will
remain at similar fasting glucose levels through out the day. The
reason why you test once daily is to ensure that the medication is
helping to reach your goal fasting blood glucose and are not
hypoglycemic. You can always test more but when you are on oral
medication it will not truly serve a purpose. When patients are on
insulin, their blood glucose levels fluctuate throughout the day and
they must check their blood glucose multiple times in order to
determine how many units of their rapid-acting insulin is needed to
meet their blood glucose.

I do not even know where to begin with this!

"If you are on oral medication your blood glucose will remain at similar fasting glucose levels through out the day"????

Can you point to ANYTHING in ANY literature that confirms this statement?

As for only needing to test once a day... there are numerous studies that indicate post prandial numbers are the most indicative of future complications. So knowing your post prandial numbers (which do not remail constant throughout the day) is the best way to attain tight control.

Below I list just a few.

Alex... this appears to be one of the first posts I've ever seen from you. You are a pharmacy student? Just curious, why are you reading this newsgroup? Are you also a diabetic? Or are you reading all the health related newsgroups?

I'm glad you have a couple more years of study left. And I hope that your statements are not what you've been taught in the classroom.

Jennifer

Post-Meal Glucose Levels Better Predictors of Premature Mortality
than Fasting Glucose or HbA1c

MEXICO CITY, MEXICO -- November 7, 2000 - A new study indicates that two-hour blood glucose (2h-BG) levels are better predictors for all-cause mortality than either fasting plasma glucose (FPG) or hemoglobin A1c (HbA1c). The study, which was presented here at the 17th International Diabetes Federation Congress, provides further validation of 2h-BG as an independent risk factor for death from heart disease.

The data underscore the significance of mealtime glucose "spikes" which result from the body's inability to produce an early insulin response after a meal. The acute toxicity of glucose spikes, as measured by 2h-BG levels, is an independent risk factor for cardiovascular disease and mortality and a better predictor than FPG, as seen in the published research from the European DECODE study group. Cardiovascular disease is a serious complication, causing a large proportion of deaths in people with type 2 diabetes.

"These data further support the DECODE findings, but also demonstrate that two-hour blood glucose is a better predictor of mortality than HbA1c. This is true not just for cardiovascular mortality, but for death from all causes," observed Jaakko Tuomilehto, M.D., Professor of Public Health at the University of Helsinki and at the Diabetes and Genetic Epidemiology Unit of the National Public Health Institute in Helsinki, Finland. "Because of this correlation, it will be important for the control of mealtime glucose spikes to be a goal in diabetes management."

In healthy adults, the pancreas produces an early burst of insulin to metabolise the extra glucose following a meal. This early insulin response is the body's first defense against mealtime glucose spikes and post-meal hyperglycaemia. In contrast, in people with type 2 diabetes, a primary defect is the loss of early insulin secretion, ultimately resulting in mealtime glucose spikes. Because these spikes are not felt by the patient, they are a hidden threat already in the early stages of type 2 diabetes.

In the study presented here, Prof. Tuomilehto and colleagues from Finland and the Netherlands conducted multivariate analyses of data from 1,412 men and 1,276 women enrolled in three different diabetes clinical trials. The analyses assessed the relative value of three glucose variables - HbA1c, FPG and 2h-BG, measured alone and in combination - as predictors for all-cause mortality.

A total of 256 deaths were observed in men and 98 deaths occurred among women, and all three variables were associated with increased mortality when assessed individually.

Whereas neither FPG nor HbA1c added statistically significant information to the 2hr-BG regression model, the addition of 2h-BG to the models for either of the other variables (FPG and HbA1c) significantly improved the ability of the models to predict risk of death.

The superiority of 2h-BG as a predictor of mortality was also demonstrated in a model assessing the relative risk for all three variables simultaneously.

"This study firmly establishes two-hour blood glucose as a predictor for mortality in type 2 diabetes," Dr. Tuomilehto concluded. "While HbA1c is a good indicator of a long-term glycemia, it fails to mark the mealtime glucose excursions that have many acute effects deleterious to the cardiovascular system. The data highlight the importance of monitoring post-meal glucose levels, as well as the need for treatment regimens that specifically target mealtime hyperglycaemia and restore an early insulin response."


http://www.medscape.com/medscape/endocrinology/AskExperts/2001/06/ENDO-ae34.html

Of interest, in patients with diabetes, the prandial glucose level is more strongly correlated with HbA1c than is the fasting glucose level.[2] Population studies provide strong evidence
that the 2-hour postchallenge glucose level is more strongly related to mortality than the
fasting level.[3] The risk of microvascular end points also increases with postload glycemia levels.[4] The potential adverse effects of postprandial hyperglycemia include increased glomerular filtration rate and renal plasma flow, increased retinal blood flow, impaired endothelial vasodilation, increased procoagulative processes, and increased oxidative stress.

Thus, although HbA1c is currently the principal tool for assessing glycemic
status, one must continue to measure fasting and, particularly, postprandial glucose levels, in the determination of individual glycemic risk.

2.Avignon A, Radauceanu A, Monnier L. Nonfasting plasma glucose is a better
marker of diabetic control than fasting plasma glucose in type 2 diabetes. Diabetes Care. 1997;20:1822-1826.

3.The DECODE Study Group. Glucose tolerance and mortality: comparison of WHO
and American Diabetes Association diagnostic criteria. The DECODE study group. European Diabetes Epidemiology Group. Diabetes Epidemiology: Collaborative analysis
Of Diagnostic criteria in Europe. Lancet. 1999;354:617-621.

4.Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study. Diabetes Res Clin Pract. 1995;28:103-117.

=========================

http://www.medscape.com/medscape/endocrinology/AskExperts/2001/04/ENDO-ae30.html

What is the significance of the 2-hour glucose level?

An important concern would be whether one can predict an increase in adverse
outcome among individuals based on the degree of hyperglycemia.

The DECODE study analyzed mortality at 10-year follow-up.[3] To look specifically at the individual in question, the risk of adverse outcomes among patients in this study with fasting glucose between 110 and 125 mg/dL was strongly associated with 2-hour glucose level.

Their mortality increased from 15, to 19, to 24 deaths per 1000 person-years with 2-hour glucose values of < 140, 140-200, and > 200 mg/dL (Table 2).

Indeed, within each fasting glucose level, mortality increased with 2-hour glucose value, whereas only for those with normal 2-hour glucose levels was an increase in mortality directly correlated to increasing fasting glucose.

Multivariate analysis revealed that adjusting the fasting glucose for the 2-hour glucose eliminated the ability of the former to independently predict mortality, whereas adjusting the 2-hour glucose for the fasting glucose level did not eliminate the direct relationship between the 2-hour glucose level and mortality.

The data suggest that reduction of 2-hour glucose by about 35 mg/dL would decrease deaths by 28.8% in those with 2-hour glucose levels > 200 mg/dL, and by 20.5% in those with 2-hour levels > 140 mg/dL. Similar analyses have been reported from Pacific Island population studies with isolated postchallenge hyperglycemia predicting mortality almost as well as known diabetes.[4]


3.DECODE Study Group on behalf of the European Diabetes Epidemiology Group.
Diabetes Epidemiology: Collaborative analysis of diagnostic criteria in Europe.
Glucose tolerance and mortality: comparison of WHO and American Diabetes Association diagnostic criteria. Lancet. 1999;354:617-621.

4.Shaw JE, Hodge AM, de Courten M, Chitson P, Zimmet PZ. Isolated post-challenge hyperglycaemia confirmed as a risk factor for mortality. Diabetologia. 1999;42:1050-1054.

Achieving Better Glycemic Control
Through Management of Mealtime Glucose



At a symposium held in conjunction with the American Association of Clinical Endocrinologists annual meeting, two leaders in endocrinology presented the latest research on postprandial glycemic control in the management of type 2 diabetes. Topics included the role of postprandial glucose in the onset of diabetes and its complications as well as the assessment of treatment options in targeting postprandial hyperglycemia.

This program was supported by an unrestricted educational grant from Novartis Pharmaceuticals Corporation.

The Importance of Postprandial Hyperglycemia

Although data from prospective randomized clinical trials are still awaited, current evidence suggests that postprandial plasma glucose (PPG) levels may be an earlier indicator of the development of type 2 diabetes than glycosylated hemoglobin (HbA1c) or fasting plasma glucose (FPG) levels. “By the time HbA1c is 6% to 7% and fasting plasma glucose is greater than 126 mg/dL, nearly 75% of patients have a 2-hour postchallenge glucose level of over 200 mg/dL,” said Daniel Einhorn, MD, FACP, FACE, Medical Director, Scripps Whittier Diabetes Institute, La Jolla, Associate Clinical Professor of Medicine, University of California, San Diego, and Diabetes and Endocrine Associates. Dr. Einhorn provided an overview of the role of first-phase insulin secretion dysfunction, the association between increased PPG and microvascular and macrovascular complications, and the need to target postprandial hyperglycemia in the management of type 2 diabetes.

Postprandial Glucose and Early-Phase Insulin Secretion
Existing data indicate that PPG levels have a significant impact on HbA1c values. In addition, PPG-related hyperglycemia precedes FPG hyperglycemia as a marker of glucose intolerance. According to Dr. Einhorn, while many factors contribute to poor PPG control in type 2 diabetes, early-phase insulin release dysfunction is an area of particular significance. Normal insulin secretion includes an early-phase insulin release in anticipation of a meal as well as a second-phase insulin release with a meal. First-phase release of insulin acts, in part, to shut down hepatic glucose output. In persons with type 2 diabetes, both phases of insulin release are impaired. Dysfunction of first-phase insulin contributes to the need for a greater amount of insulin in the second phase, to drive glucose into the muscle. This may occur, said Dr. Einhorn, even when FPG or HbA1c levels still appear normal. A study by Barrett-Connor and Ferrara shows that postprandial hyperglycemia may be especially important in elderly patients.

Postprandial Glucose and Complications
Type 2 diabetes is a serious condition that is associated with a number of life-threatening complications, including coronary disease. In addition to being a marker for the onset of type 2 diabetes, PPG appears to be associated with the development of both the macrovascular and microvascular complications of diabetes, independently of HbA1c and FPG levels. In the Honolulu Heart Study, for example, fatal coronary events as well as overall coronary events were associated with increased postchallenge glucose quintiles. Similarly, after 11 years of followup in the Diabetes Intervention Study, patients showed an association between mortality and PPG levels, independent of FPG levels. In the retrospective DECODE analysis, more than 25,000 persons were studied for approximately 10 years. Results demonstrated that PPG levels were associated with mortality, independent of FPG levels; FPG levels were not significantly related to mortality after adjustment for PPG levels. In terms of microvascular complications, the Kumamoto Study showed that 2-hour postmeal glucose levels above 180 mg/dL were associated with an increased risk for nephropathy and retinopathy. Indeed, in the mid-200 mg/dL range, the risk for nephrophathy was increased by a factor of 10, the risk for retinopathy by six.


In addition, Ceriello showed a relationship between PPG spikes and diabetic microvascular and macrovascular complications (Table 1). “While it is well known that high HbA1c values demonstrate chronic hyperglycemia that contributes to diabetic complications, it appears that similar complications may result from acute toxicity due to postprandial glucose spiking,” Dr. Einhorn explained.

Considerations for Treatment
Although there is currently no single ideal treatment for type 2 diabetes, there are many effective options available. For most patients with type 2 diabetes, combination therapy is necessary to control both FPG and PPG levels to achieve optimal HbA1c levels and overall glycemic control. According to Dr. Einhorn, among the characteristics to consider when choosing an agent to control PPG include efficacy, safety, patient comfort and convenience, and cost. When making treatment decisions with patients, clinicians need to consider the advantages and disadvantages of each available agent, as well as patient preferences.

Conclusion
Traditionally, the diagnosis and progression of type 2 diabetes have been determined by HbA1c and FPG values. In terms of diagnosis and monitoring, PPG is the earliest indicator of type 2 diabetes. With regard to treatment, clinicians should remember that even short periods of postprandial hyperglycemia can lead to complications, including cardiovascular morbidity and mortality. Dr. Einhorn urged the use of continuous glucose monitoring to identify the real glucose patterns, noting that a majority of patients with postprandial hyperglycemic spiking may be overlooked using traditional monitoring methods. “Growing evidence indicates that the effective management of type 2 diabetes requires the targeting of postprandial glycemic excursions, as well as fasting glucose and HbA1c levels,” he concluded.




Table 1. Possible Effects of Postprandial Acute Hyperglycemia*

Nephropathy
• increased glomerular filtration rate in diabetic patients
• more severe in patients with nephropathy

Retinopathy
• increased retinal perfusion

Neuropathy
• lower pain threshold
• may contribute to neuropathic pain & affect mood

Hypertension
• reduced acetylcholine-induced vasodilation

Myocardial infarction/stroke
• worsened prognosis
• aggravation of neuronal damage after stroke
• increased risk of thrombosis & atherogenesis

*Source: Ceriello A. Diabet Med. 1998; 15:188-193.

Treatment of Postprandial Hyperglycemia in Type 2 Diabetes

While there is no one ideal therapy for the management of type 2 diabetes, there are now many treatment options, each with its own advantages and disadvantages to consider (Table 1). “Many patients with type 2 diabetes can achieve a glycosylated hemoglobin value of 7% by monitoring fasting plasma glucose and using an effective combination therapy. However, achieving glycosylated hemoglobin levels below 7% requires the monitoring and targeting of postprandial plasma glucose as well,” said John B. Buse, MD, PhD, CDE, FACE, Director, Diabetes Program and Endocrinology Clinic, and Associate Professor, Division of Endocrinology, University of North Carolina School of Medicine, Chapel Hill. Dr. Buse noted that, with effective monitoring and control of postprandial plasma glucose (PPG), patients can both observe the effect of their diet and exercise on glucose levels and achieve glycosylated hemoglobin (HbA1c) levels near 6%.


Treatment Goalsand Considerations
According to Dr. Buse, treatment goals for patients with type 2 diabetes include: a premeal plasma glucose level of 90 to 130 mg/dL; a PPG level of 110 to 170 mg/dL; and a HbA1c level of below 7%.


“In assessing the treatment options for the management of type 2 diabetes, it is important to consider not only the efficacy and safety of the agents, but also the preference of the patient,” Dr. Buse explained. For example, some patients may prioritize such issues as cost, ease of administration, titrability of dosing, or potential weight gain. For the vast majority of patients, achieving effective glycemic control will require targeting insulin sensitivity and insulin secretory defects as well as preprandial and postprandial glucose levels, requiring a combination of therapies (Table 2). Although some monotherapies, such as high-dose insulin therapy, may result in nearly normal HbA1c levels in many patients, they may also cause side effects such as hypoglycemia and significant weight gain.

The Role of Postprandial Glucose
Prospective clinical evidence on the role of PPG in determining outcomes in persons with type 2 diabetes is still lacking. However, available data suggest that postprandial hyperglycemia serves as an early marker for type 2 diabetes; influences HbA1c levels; is associated with macrovascular and microvascular complications, including coronary disease; and may be overlooked using traditional monitoring methods. For these reasons, Dr. Buse recommended that clinicians consider the use of PPG monitoring, in addition to fasting plasma glucose (FPG) monitoring, in the management of type 2 diabetes.


In one study of gestational diabetes by De Veciana and colleagues, women who were 28 weeks’ pregnant and receiving NPH/regular insulin were randomized to either preprandial or postprandial glucose monitoring. Both groups achieved their goals in terms of glucose levels. However, those undergoing PPG monitoring also experienced a reduction in HbA1c levels of 3%, compared with less than 1% in those in the preprandial monitoring group. The PPG monitoring group also had a 70% reduction in the risk of complications in mothers and infants; 70% reduction in large for gestational age babies; 70% reduction in the rate of cesarean sections; and 70% reduction in the risk for neonatal hypoglycemia.


In a study by Bastyr and colleagues, persons with type 2 diabetes for whom sulfonylurea therapy had failed continued with sulfonylurea and also received either 1) insulin lispro before meals, 2) metformin, or 3) NPH insulin at bedtime. Strikingly, the results showed that those receiving insulin lispro had better PPG control and the lowest HbA1c levels (near 7%), despite FPG levels of 185 mg/dL.


Targeting Postprandial Hyperglycemia: Treatment Options
Especially as FPG and HbA1c levels become lower, therapy to target elevated PPG levels is needed to achieve an HbA1c below 7% and potentially reduce the risk for complications (Figure 1). Among the effective therapies available are alpha-glucosidase inhibitors; newer insulin secretagogues, such as repaglinide and nateglinide; and insulin.

Alpha-glucosidase inhibitors
These agents shift the absorption of carbohydrates distally in the intestine, prolonging carbohydrate absorption. The result is a second-phase insulin secretion that can better manage the elevated PPG levels, reducing PPG levels with minimal change in FPG. However, first-phase insulin secretion remains impaired with alpha-glucosidase inhibitor therapy.

Newer insulin secretagogues
As glucose enters the body, beta cells metabolize the routine mechanisms that occur in most cells (using the enzyme glucokinase), resulting in an increase in ATP, a decrease in ADP, and closure of the potassium channel. Insulin secretagogues act to restore early-phase insulin secretion and control mealtime glucose spiking by interacting with the sulfonylurea receptors of the beta cells. Part of the effect of individual secretagogues —such as glyburide, repaglinide, and nateglinide—may be determined by the duration of time spent on the sulfonylurea receptor. Nateglinide has the shortest residence time on the sulfonylurea receptor.


Although the newer orally administered insulin secretagogues, repaglinide and nateglinide, are both non-sulfonylurea sulfonylurea receptor agonists, they are structurally very different. Repaglinide is derived from the structure of meglitinide, while nateglinide is a D-phenylalanine derivative. The pharmacokinetics of nateglinide and repaglinide are, however, similar. Nateglinide is absorbed rapidly (Cmax enhanced by meals; Tmax about 1 hour); has a short elimination half-life (about 1.5 hour, no drug accumulation); and has similar pharmacokinetics in different patient populations, including patients with mild hepatic impairment and those on dialysis due to renal impairment. The agent is taken orally 1 to 30 minutes before a meal, and no titration is needed.


In vitro studies show that after pancreas perfusion (100 mg/dL glucose) with repaglinide or nateglinide, insulin secretion is stimulated within 10 minutes. This effect continues for approximately 80 minutes after removal of repaglinide. However, in identical studies, nateglinide reveals an even faster pattern of onset of action and its effect is discontinued almost immediately upon its removal, demonstrating a unique onset of action that is fast on and fast off.


In addition, a placebo-controlled clinical trial by Walter and colleagues involved the treatment of patients with type 2 diabetes with nateglinide 120 mg three times daily. After each meal, nateglinide-treated patients showed an acute rise in insulin secretion and reduced PPG levels after meals, but a smaller rise in insulin after snacks. “These results show that nateglinide is sensitive to glucose levels, reducing postprandial glucose levels but avoiding hypoglycemia after smaller meals and snacks,” Dr. Buse explained, noting that this agent may prove particularly useful in combination with insulin-sensitizing agents in patients with advanced disease. Indeed, a study by Horton and colleagues demonstrates the complementary action of nateglinide and metformin. The combination achieves lower HbA1c levels than either monotherapy. Nateglinide is associated with minimal weight gain and a low incidence of hypoglycemia.

Insulin
Insulin and rapid-acting insulin analogues, such as insulin lispro and insulin aspart, are also highly effective in controlling PPG levels. Patient concerns about taking insulin remain, however. Such concerns include fear of injections, hypoglycemia, and weight gain. This is despite the fact that administration methods have been improved, incidence of hypoglycemia is low with type 2 diabetes, and weight gain is manageable. While there is also question about an increased atheroslerotic risk, clinical trials thus far show a decrease in this risk with insulin.

Future Directions
Dr. Buse pointed to the growing use of multiple daily oral or injection therapy to manage type 2 diabetes, using an oral rapid-acting agent or rapid-acting insulin to control PPG levels and either oral agents or insulin to control FPG levels. This approach will become more widely used, he projected, once inhaled insulins become available. In closing, Dr. Buse emphasized the need for early diagnosis of type 2 diabetes and the need to achieve HbA1c levels below 7%, as recommended by the American Diabetes Association Consensus Panel. “If clinicians are not achieving this HbA1c goal, they need to consider monitoring and targeting postprandial glucose levels,” he concluded.



Table 2. General Therapeutic Approaches to Achieve Day-Long Glycemic and HbA1c Goals

Fasting and Preprandial Approaches
• Decreasing hepatic glucose output (metformin)
• Increasing insulin action, decreasing insulin resistance (thiazolidinediones)
• Increasing insulin availability, basal and meal related (long-acting insulins, sulfonylureas)


Postprandial Approaches
• Decreasing carbohydrate absorption rate (alpha-glucosidase inhibitors)
• Decreasing carbohydrate intake (diet modification)
• Increasing acute insulin availability (rapid-acting insulins, “glinides”)


May/June 2001 - Volume 134, Number 3



Therapeutics
Targeting postprandial blood glucose levels reduced hemoglobin A1c levels in type 2 diabetes mellitus
ACP Journal Club. 2001 May-June;134:88.
Bastyr EJ 3d, Stuart CA, Brodows RG, et al., for the IOEZ Study Group. Therapy focused on lowering postprandial glucose, not fasting glucose, may be superior for lowering HbA1c. Diabetes Care. 2000 Sep;23:1236-41. [PubMed ID: 10977012]

Question

What is the comparative efficacy and safety of treatment strategies that target either fasting, premeal, or postprandial glucose levels in patients with type 2 diabetes mellitus that was not adequately controlled with sulfonylurea agents alone?

Design

Randomized {allocation concealed*}†, unblinded,* controlled trial with 3-month follow-up.

Setting

22 centers in the United States.

Patients

135 patients (mean age 57 y, 60% men) with type 2 diabetes who had secondary sulfonylurea failure defined as initial stabilization of glucose control for 6 months and a subsequent lack of glucose control using maximal sulfonylurea doses. 114 patients (84%) had complete follow-up.

Intervention

Patients were allocated to 1 of 3 groups for 3 months: insulin lispro plus glyburide (L plus G group, n = 41), which targeted postprandial blood glucose levels; metformin plus glyburide (M plus G group, n = 40), which targeted premeal glucose levels; or NPH insulin plus glyburide (NPH plus G group, n = 50), which targeted fasting glucose levels. For all 3 groups, glyburide was given as 10 mg by mouth twice daily. Insulin lispro was given subcutaneously in divided doses before meals starting at 0.25 U/kg per day. Metformin was given starting at 500 mg by mouth twice daily. NPH insulin was given subcutaneously at bedtime starting at 0.2 U/kg. Dose adjustments were made as necessary.

Main outcome measures

Blood glucose levels, hemoglobin (Hb) A1c levels, rate of hypoglycemic episodes, and patient satisfaction with treatment.

Main results

The mean HbA1c level was lower for the L plus G group (7.7%) than for the NPH plus G group (8.5%, P = 0.003) or the M plus G group (8.3%, P = 0.025). The mean fasting blood glucose level was lower for the NPH plus G group (8.5 mmol/L) than for the L plus G group (10.6 mmol/L, P < 0.001) or the M plus G group (9.7 mmol/L, P = 0.03). The mean 2-hour postprandial glucose level after a test meal was lower for the L plus G group (10.9 mmol/L) than for the NPH plus G group (12.2 mmol/L, P = 0.05) or the M plus G group (12.7 mmol/L, P = 0.009). The groups did not differ for rates of hypoglycemic episodes or patient satisfaction with treatment.

Conclusion

A combination regimen with insulin lispro plus glyburide that targeted postprandial blood glucose levels was well tolerated and lowered hemoglobin A1c levels more than did regimens that targeted fasting blood glucose levels in patients with type 2 diabetes that was not adequately controlled with sulfonylurea treatment alone.



Source of funding: No external funding.

For correspondence: Dr. E.J. Bastyr III, Lilly Research Laboratories, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, IN 46285, USA. FAX 317-277-1234.

*See Glossary.

†Information provided by author.



Commentary

Clinical trials consistently support tight glycemic control to reduce or delay diabetes-related microvascular complications. Strategies to achieve this control are limited by adherence to complex treatment regimens, adverse effects, and the burdens of living with chronic disease.

Clinical practice traditionally targets fasting glycemic control. This practice has been motivated, in part, by glucose-lowering medications with convenient dosing intervals that reduce fasting and premeal glucose levels, have acceptable side effects, and promote adherence. The results of the trial by Bastyr and colleagues suggest that the focus should shift to postprandial hyperglycemia.

This short-term study supports the hypothesis that postprandial glycemic control contributes to improvements in HbA1c level and suggests that this contribution is larger than that of fasting glycemic control. The study is limited by the lack of blinding and the number of patients who discontinued (17 of 135), although only 4 of 135 were excluded from the final analysis because of not meeting inclusion criteria. However, the results of this trial are concordant with other physiologic, clinical, and epidemiologic research.

Achieving fasting and postprandial glycemic control may lower the risk for microvascular complications (1). The contributions of postprandial glycemic control in lowering this risk are unknown. Available regimens targeting postprandial glucose levels require patient effort, such as the use of multiple administrations of insulin or oral agents, which is difficult to sustain. High-quality trials and simpler regimens may help to convince patients and clinicians that focusing on postprandial glycemic control is worth the effort.
Victor Montori, MD
Mayo Clinic
Rochester, Minnesota, USA



Reference

1. Ohkubo Y, Kishikawa H, Araki E, et al. Intensive insulin therapy prevents the progression of diabetic microvascular complications in Japanese patients with non-insulin-dependent diabetes mellitus: a randomized prospective 6-year study. Diabetes. 1995;28:103-17.

Copyright ©2002 American College of Physicians – American Society of Internal Medicine. The information contained herein should never be used as a substitute for good clinical judgment.






It is always important to take diabetes seriously. Truly, educating
patients about the potential long term outcomes that result from
uncontrolled diabetes is a serious hurdle as many patients don't feel
"sick" but testing your blood glucose often is not the key to a
successful type II diabetes program in most cases. Taking your
medication regularly, keeping a log book of your readings and
discussing them with healthcare professionals, eating well and
attempting to lose weight if needed, and exercising regularly are the
most effective ways to control your type II diabetes and live a long,
healthy life!

Alex
PharmD candidate, class of 2008

.