Current strategies for controlling postprandial hyperglycaemia.

Abstract

In patients with diabetes mellitus glycosylated haemoglobin (HbA1c), which reflects mean glycaemic values in the previous 3 months, is typically used as a clinical measure of blood glucose control. However, it does not always correlate satisfactorily with postprandial blood glucose excursions, which may occur only for a few hours and be insufficient to alter HbA1c formation. Thus, postprandial glucose peaks may have a significant impact on diabetic complications but not be monitored sufficiently from HbA1c measurements. Epidemiological studies have shown stronger correlations for incidence of cardiovascular events with postprandial glucose levels than with preprandial levels. Results from the UKPDS suggest that HbA1c had to be reduced below 7 per cent to ameliorate macrovascular outcomes. In patients with type 2 diabetes there is a loss of the first phase insulin response so a logical treatment strategy is to use a rapid-acting insulin analogue. Rapid-acting insulin analogues have a greater effect on postprandial glucose levels than regular human insulin. This is due to the faster absorption and higher insulin peak in blood, but also due to the increased ability of rapid-acting analogues to suppress hepatic glucose release. In clinical practice, preprandial injection of rapid-acting insulin reveals significant advantages including treatment flexibility, lack of weight gain, stable insulin doses and reduction of hypoglycaemic episodes. These effects are more pronounced if this type of therapy is used early in the course of the disease. Thus rapid-acting insulin analogues are being increasingly used as first-line therapy with multiple daily injection in patients with type 2 diabetes.