Postprandial glucose regulation: new data and new implications.
BACKGROUND
Type 2 diabetes is characterized by a gradual decline in insulin secretion in response to nutrient loads; hence, it is primarily a disorder of postprandial glucose (PPG) regulation. However, physicians continue to rely on fasting plasma glucose (FPG) and glycosylated hemoglobin (HbA1c) to guide management.


OBJECTIVE
The objectives of this article are to review current data on postprandial hyperglycemia and to assess whether, and how, management of type 2 diabetes should change to reflect new clinical findings.


METHODS
Articles were selected from MEDLINE searches (key words: postprandial glucose, postprandial hyperglycemia, and cardiovascular disease) and from our personal reference files, with emphasis on the contribution of postprandial hyperglycemia to overall glycemic load or cardiovascular (CV) risk.


RESULTS
About 33% of people diagnosed as having type 2 diabetes based on postprandial hyperglycemia have normal FPG. PPG contributes > or =70% to the total glycemic load in patients who are fairly well controlled (HbA1c <7.3%). Furthermore, there is a linear relationship between the risk of CV death and the 2-hour oral glucose tolerance test (OGTT). Increased mortality is evident at OGTT levels of approximately 90 mg/dL (5 mmol/L), which is well below current definitions of type 2 diabetes. Biphasic insulin aspart was shown to be more effective at reducing HbA1c below currently recommended levels than basal insulin glargine (66% vs 40%; P < 0.001), and it reduced endothelial dysfunction more effectively than regular insulin (P < 0.01). Repaglinide achieved regression of carotid atherosclerosis (intima-media thickness) in 52% of patients versus 18% for glyburide (P < 0.01) over 1 year, although levels of HbA1c and CV risk factors were similar for both treatment groups. Finally, acarbose reduced the relative risk of CV events by 49% over 3.3 years versus placebo in patients with impaired glucose tolerance (2.2% vs 4.7%; P = 0.03) and by 35% over > or =1 year in patients with type 2 diabetes (9.4% vs 6.1%; P = 0.006).


CONCLUSIONS
All components of the glucose triad (ie, FPG, HbA1c, and PPG) should be considered in the management of type 2 diabetes. Therapy targeted at PPG has been shown to improve glucose control and to reduce the progression of atherosclerosis and CV events; therefore, physicians should consider monitoring and targeting PPG, as well as HbA1c and FPG, in patients with type 2 diabetes.
Leiter
Lawrence A
LA
St. Michael's Hospital, University of Toronto, Toronto, Canada. leiter@smh.toronto.on.ca
Ceriello
Antonio
A
Davidson
Jaime A
JA
Hanefeld
Markolf
M
Monnier
Louis
L
Owens
David R
DR
Tajima
Naoko
N
Tuomilehto
Jaakko
J
D050197:Atherosclerosis / Q000097:blood / Q000378:metabolism; D015415:Biomarkers; D001786:Blood Glucose / Q000378:metabolism*; D002318:Cardiovascular Diseases / Q000209:etiology; D002986:Clinical Trials as Topic; D003924:Diabetes Mellitus, Type 2 / Q000188:drug therapy / Q000378:metabolism*; D003925:Diabetic Angiopathies / Q000150:complications; D006442:Glycated Hemoglobin / Q000378:metabolism; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D019518:Postprandial Period / Q000502:physiology*
D015415:Biomarkers; D001786:Blood Glucose; D006442:Glycated Hemoglobin; D007004:Hypoglycemic Agents