Should postprandial glucose be routinely measured and treated to a particular target? No!

Glycaemic control for painful diabetic peripheral neuropathy is more than fasting plasma glucose and glycated haemoglobin

BACKGROUND

The relationship between postprandial hyperglycaemia and diabetic peripheral neuropathy (DPN), whether painful or painless, has yet to be determined. Thus, the aim of this study was to investigate the relationship in patients with type 2 diabetes (T2D).

METHODS

This cross-sectional study was conducted in adults with T2D between January and October 2013. Blood samples were collected after overnight fasting every 3 months prior to enrolment. For this study, increased postprandial glycaemic exposure was defined as high glycated haemoglobin (HbA_1c) and near-normal mean fasting plasma glucose (FPG) levels. Both painless and painful DPN were evaluated using two validated tools, the Michigan Neuropathy Screening Instrument (MNSI) and Douleur Neuropathique 4 (DN4) questionnaire.

RESULTS

This study included 1040 participants with mean FPG levels<140mg/dL, 535 of which were<126mg/dL. Of these patients, 200/1040 (19.2%) and 105/535 (19.6%) had DPN. Multivariate analysis demonstrated that higher HbA_1c levels (≥7%) did not increase risk of painless DPN, but did significantly increase risk of painful DPN in T2D patients with FPG<140mg/dL and<126mg/dL, with corresponding odds ratios of 2.49 and 3.77 (95% confidence intervals: 1.09-5.71 and 1.20-11.79), respectively, after adjusting for demographic factors, diabetes-related variables and comorbidities.

CONCLUSION

This study is the first to reveal that increased postprandial glycaemic exposure, as assessed by high HbA1c and near-normal FPG levels, is associated with an increased risk of painful DPN in adults with T2D.

Targeting postprandial blood sugar over fasting blood sugar: A clinic based comparative study

INTRODUCTION

Recent studies indicate that modulation of post prandial blood sugar (PPBS) plays an important role in the long term glycemic control. Measurement of PPBS is more convenient for patients attending outpatient clinics than fasting blood sugar (FBS) as the former needs only two hours of fasting from the last meal.

OBJECTIVE

To assess the value of PPBS monitoring in optimization of long term glycemic control among diabetic patients attending an outpatient clinic.

METHODS

A total of 240 patients with type 2 diabetes (T2DM) attending an out-patient medical clinic were randomized to either PPBS or FBS monitoring. Those who selected to PPBS-group underwent blood sugar measurement 2-h after last meal on the day of their clinic visits and those in the FBS group underwent blood sugar measurement after fasting overnight (8-10h) in the morning of their clinic visits. Treating team was asked to optimize the anti-diabetic medications based on the available PPBS or FBS results. All patients were followed up monthly for six months. Glycemic control was assessed with glycosylated hemoglobin (HbA1c) at baseline and six months later.

RESULTS

Baseline characteristics of the two arms including age, gender, and duration of T2DM were not significantly different. Mean HbA1c (SD) of FBS and PPBS arms at baseline were 7.20 (0.45), and 7.33 (0.43) and were not significantly different (P=0.115). During the study period, HbA1c dropped by 0.20 in FBS arm compared to 0.25 drop in PPBS arm (p=0.59). Incidence of hypoglycemia was similar in FBS (2.42%) and PPBS arms (2.70%).

CONCLUSION

Monitoring of PPBS is a safe and effective alternative to FBS to optimize glycemic control in managing patients with T2DM attending outpatient clinics.

Shadow of diabetes over cardiovascular disease: comparative quantification of population-attributable all-cause and cardiovascular mortality

BACKGROUND

We contrasted impacts on all-cause and cardiovascular disease (CVD) mortality of diabetes vs. CVD.

METHODS

Among participants the Tehran lipid and glucose study aged ≥ 30 years (n = 9752), we selected those who participated in the follow-up study until 20 March 2009 (n = 8795). Complete data on covariate were available for 8, 469 participants, contributing to a 67935 person-year follow up. In the analysis of outcomes (all-cause and CVD mortality), diabetes and CVD were assessed using Cox proportional hazard regression model adjusting for established CVD risk factors. We used population attributable hazard fraction (PAHF) and rate advancement period (RAP) that expresses how much sooner a given mortality rate is reached among exposed than among unexposed individuals.

RESULTS

Ten percent of the participants self-reported to have pervious CVD, and diabetes was ascertained in 17% of participants at baseline examination. During a median follow-up of 9 years 386 participants died of which 184 were due to CVD. All-cause and CVD mortality rate (95% CIs) were 5.5 (5.0-6.1) and 2.6 (2.3-3.0) per 1000 person-year, respectively. The PAHF of all-cause mortality for diabetes 9.2 (7.3-11.1) was greater than the one for CVD 3.5 (1.1-5.5). RAP estimates for all-cause mortality associated with diabetes ranged from 7.4 to 8.6 years whereas the RAP estimates for all-cause mortality associated with CVD ranged from 3.1 to 4.3 years. The PAHF of CVD mortality for diabetes 9.4 (6.8-12.0) was greater than the one for CVD 4.5 (1.8-7.0). RAP estimates for CVD mortality associated with diabetes ranged from 8.2 to 9.8 years whereas the RAP estimates for CVD mortality associated with CVD ranged from 4.7 to 6.7 years.

CONCLUSIONS

We demonstrated that diabetes, which was shown to be keeping pace with prevalent CVD in terms of conferring excess risk of incident CVD, is currently causing more deaths in the population than does CVD.

Postprandial and basal glucose in type 2 diabetes: assessment and respective impacts

The independent contribution of postprandial glucose (PPG) excursions to the overall glucose exposure and its role in the development of both micro- and macrovascular complications of diabetes remain subject to continuing debate in type 2 diabetes. Discussion continues on whether postprandial hyperglycemia is the main contributor to the overall hyperglycemia in fairly well-controlled individuals, whereas basal hyperglycemia becomes the preponderant contributor in poorly controlled patients. The concern about the role of PPG as a risk factor for diabetes complications is related to the controversial data obtained in individuals with impaired glucose tolerance. It remains, however, that the total glucose exposure as reflected by hemoglobin A1c (HbA1c) levels is an undoubted major vascular risk factor. Excluding the contribution of PPG is nonsensical. In support of this position is the fact that the absolute impact of PPG on HbA1c, expressed as percentage levels of HbA1c, remains constant at 1% across the HbA1c continuum in non-insulin-treated type 2 diabetes patients. This key feature clearly depicts the absolute contribution of PPG in contrast to its relative contribution and better explains why PPG contributes to the excess of glycation with the basal hyperglycemia.

A Head-to-Head Comparison of the Postprandial Effects of 3 Meal Replacement Beverages Among People With Type 2 Diabetes

Purpose

The purpose of this study was to compare the effects of 3 meal replacement beverages on glycemic response among people with type 2 diabetes.

Methods

The study examined Glucerna® Weight Loss Shake, Slim-Fast® Shake, and Ensure® with Fiber Shake, using a prospective, 3-way, cross-over design. Eighteen subjects with type 2 diabetes drank the beverages in random order on different weeks. The volume of each beverage was adjusted to include 50 grams of carbohydrates. Glucose was measured 0 to 180 minutes postprandial. Analyses included 2-factor analysis of variance (ANOVA) for repeated measures on both factors, calculation of area under the curve (AUC), and 1-way repeated measures ANOVA of AUC.

Results

The postprandial glucose profiles of the shakes differed. Glucerna® had the best profile as indicated by the graph of mean postprandial glucose levels and its lower incremental AUC. Despite the superiority of Glucerna®, 2-hour postprandial blood glucose values exceeded the ADA’s recommended upper limit for 22% of the subjects.

Conclusions

Meal replacement beverages are a popular and potentially effective option for people trying to lose or maintain weight; however, it is unknown to what degrees they affect postprandial blood glucose in people with type 2 diabetes. Because postprandial glycemic excursion is linked to cardiovascular disease, identifying a meal replacement beverage with the lowest glycemic response may mitigate some of the risks in patients with diabetes. Of the meal replacements observed in this study, Glucerna® had the smallest effect on postprandial glucose. Glycemic response to meal replacements should be monitored given product and individual variability.

Adjust to target in type 2 diabetes: comparison of a simple algorithm with carbohydrate counting for adjustment of mealtime insulin glulisine

OBJECTIVE

Carbohydrate counting is an effective approach to mealtime insulin adjustment in type 1 diabetes but has not been rigorously assessed in type 2 diabetes. We sought to compare an insulin-to-carbohydrate ratio with a simple algorithm for adjusting the dose of prandial insulin glusiline.

RESEARCH AND DESIGN METHODS

This 24-week, multicenter, randomized, controlled study compared two algorithms for adjusting mealtime (glulisine) insulin along with a standard algorithm for adjusting background (glargine) insulin in 273 intent-to-treat patients with type 2 diabetes. Glulisine and glargine were adjusted weekly in both groups based on self-monitored blood glucose (SMBG) results from the previous week. The simple algorithm group was provided set doses of glulisine to take before each meal. The carbohydrate counting (carb count) group was provided an insulin-to-carbohydrate ratio to use for each meal and adjusted their glulisine dose based on the amount of carbohydrate consumed.

RESULTS

A1C levels at week 24 were 6.70% (simple algorithm) and 6.54% (carb count). The respective mean A1C changes from baseline to 24 weeks were -1.46 and -1.59% (P = 0.24). A1C <7.0% was achieved by 73.2% (simple algorithm) and 69.2% (carb count) (P = 0.70) of subjects; respective values for A1C <6.5% were 44.3 and 49.5% (P = 0.28). The total daily dose of insulin was lower, and there was a trend toward less weight gain in carb count group patients. Severe hypoglycemia rates were low and equal in the two groups.

CONCLUSIONS

Weekly basal-bolus insulin adjustments based on premeal and bedtime glucose patterns resulted in significant reductions in A1C. Having two effective approaches to delivering and adjusting rapid-acting mealtime insulin may increase physicians' and patients' willingness to advance therapy to a basal-bolus insulin regimen.

Which basal insulin should be used in patients with type 2 diabetes mellitus?

The initiation of insulin therapy is a significant event for patients with diabetes and the physicians who care for them. Reluctance to begin insulin is multifactorial, with major stumbling blocks being the perceived complexity of insulin and fear of hypoglycemia. Recent guidelines supporting earlier introduction of insulin to achieve glycemic goals in patients with type 2 diabetes mellitus will require that traditional approaches to insulin therapy be altered and a new paradigm be introduced into clinical practice. In particular, an understanding of the role of basal insulin in the regulation of glucose and the development of strategies to implement basal insulin therapy can provide a transition that is rational and highly effective in most patients. The strategy also offers a unique approach to diabetes education that permits a focused and patient-specific correction to glucose abnormalities.

Effects of S21403 (mitiglinide) on postprandial generation of oxidative stress and inflammation in type 2 diabetic patients

AIM/HYPOTHESIS

Evidence suggests that postprandial hyperglycaemia may be a cardiovascular risk factor in diabetes. Oxidative stress and inflammation are involved in the pathogenesis of diabetic complications and previous studies have shown increased oxidative stress and inflammation in the postprandial phase in diabetic patients. The aim of the present study was to evaluate whether controlling postprandial hyperglycaemia with S21403 (mitiglinide) is accompanied by a reduced generation of oxidative stress and inflammation.

SUBJECTS AND METHODS

Forty type 2 diabetic patients participated in the study. Two different breakfast-tests were performed in each patient, with placebo or S21403. Plasma nitrotyrosine, plasma malondialdehyde (MDA), oxidised LDL (oxLDL), plasma total radical-trapping antioxidant parameter (TRAP), IL-6, IL-18, TNF-alpha, plasma glucose and insulin were measured.

RESULTS

After the administration of S21403, 40 mg, a rapid stimulation of insulin secretion was observed, accompanied by a reduction of postprandial hyperglycaemia. With S21403, a significant decrease of either nitrotyrosine, MDA and oxLDL levels, and a preservation of plasma TRAP compared with placebo was found. Significant decreases of IL-6, IL-18 and TNF-alpha were also observed with S21403 compared with placebo.

CONCLUSIONS/INTERPRETATION

This study shows that controlling postprandial hyperglycaemia with S21403 significantly improves the cluster of oxidative stress and inflammation markers that are increased in the postprandial state in diabetic patients.

Phosphorylated heat shock protein 27 is involved in enhanced heart tolerance to ischemia in short-term type 1 diabetic rats

AIM

To examine the tolerance of type 1 diabetic hearts to ischemia and reperfusion injury. Myocardial contents of 27-kDa and 70-kDa heat shock proteins (hsp) as well as phosphorylated hsp27 were also determined.

METHODS

Hearts from hyperglycemic rats 3 weeks after streptozocin injection and age-matched normal rats were subjected to ischemia and reperfusion in vitro. Cardiac function and electrocardiogram were recorded throughout experiments. Myocardial heat shock proteins were detected with Western blot.

RESULTS

Despite depressed systolic function at the baseline, diabetic hearts exhibited considerable enhancement in post-ischemic heart function, manifested by an increase in the maximal rate of left ventricular pressure rise and fall (post-ischemic dp/dtmax and dp/dtmin were 560+/-117 and -313+/-68 mmHg/s in control, n=7, 1249+/-57 and -1204+/-36 mmHg/s in diabetes, n=10, P<0.01). Reperfusion ventricular fibrillation in the diabetic group were attenuated compared with controls (1.5+/-0.3 vs 7.2+/-2.1 min in control, P<0.01). The increased heart resistance to ischemia in diabetes was associated with hyperglycemia and accompanied by enhanced expression of myocardial phosphorylated hsp27 with normal aortic vessel relaxation. Cardioprotection was abrogated by metabolic correction with insulin and accompanied by phospho-hsp27 reduction.

CONCLUSION

Heart resistance to ischemia is increased in type 1 diabetes, and hyperglycemia may present a mild yet stressful stimulus leading to upregulation of endogenous stress protein, which may play a potential role in cardioprotection and compensate for detrimental effects of hyperglycemia in diabetes.

Basal insulin therapy

The initiation of insulin therapy is a significant event for patients with diabetes and the physicians who care for them. Reluctance to begin insulin is multifactorial, with a major stumbling block being the perceived complexity of insulin. However, this complexity can be easily overcome by separation of insulin administration into its two components: basal and bolus therapy. An understanding of the role of basal insulin in the regulation of glucose and the development of strategies to implement basal insulin therapy can provide a transition that is rational and highly effective in most patients. The strategy also offers a unique approach to diabetes education, which permits a focused and patient-specific correction to glucose abnormalities.

Reduction of cardiovascular morbidity and mortality in type 2 diabetes. A rational approach to hypoglycemic therapy

Type 2 diabetes mellitus is the single most important risk factor for the development of coronary artery disease. Unfortunately, the traditional therapeutic strategies for the treatment of hyperglycemia have proven to be ineffective in preventing cardiovascular complications. In recent years the number of available hypoglycemic agents has increased and considerable progress has been made regarding the comprehension of the pathophysiology of diabetes and its vascular complications. In the present article we firstly present benefits and risks of intensive vs standard hypoglycemic intervention, and the pros and cons of therapy targeted to postprandial hyperglycemia. Secondly, we discuss the cardiovascular effects of sulfonylurea agents and insulin, focusing on the role of intensive insulin treatment in the context of acute coronary syndromes. Thirdly, we review the epidemiological, clinical and experimental evidence linking insulin resistance and cardiovascular disease. Finally, we present the rationale and the role of metformin and thiazolidinedionetherapy in the prevention of cardiovascular complications. We conclude that the optimal use of the full spectrum of hypoglycemic agents has the potential to play a key role in the prevention of diabetes-related macrovascular complications.