Faster-acting insulins, new noninsulin drug classes, more flexible insulin-delivery systems, and improved continuous glucose monitoring devices offer unprecedented opportunities to improve postprandial glucose (PPG) management and overall care for adults with insulin-treated diabetes. These developments led the Endocrine Society to convene a working panel of diabetes experts in December 2018 to assess the current state of PPG management, identify innovative ways to improve self-management and quality of life, and align best practices to current and emerging treatment and monitoring options. Drawing on current research and collective clinical experience, we considered the following issues for the ∼200 million adults worldwide with type 1 and insulin-requiring type 2 diabetes: (i) the role of PPG management in reducing the risk of diabetes complications; (ii) barriers preventing effective PPG management; (iii) strategies to reduce PPG excursions and improve patient quality of life; and (iv) education and clinical tools to support endocrinologists in improving PPG management. We concluded that managing PPG to minimize or prevent diabetes-related complications will require elucidating fundamental questions about optimal ways to quantify and clinically assess the metabolic dysregulation and consequences of the abnormal postprandial state in diabetes and recommend research strategies to address these questions. We also identified practical strategies and tools that are already available to reduce barriers to effective PPG management, optimize use of new and emerging clinical tools, and improve patient self-management and quality of life.
Figure 4. Glucagon-like peptide 1 (GLP-1) actions in patients with type 2 diabetes. Reprinted from Nauck MA, Kleine N, Orskov C, et al. Normalization of fasting hyperglycaemia by exogenous glucagon-like peptide 1 (7-36 amide) in type 2 (non-insulin-dependent) diabetic patients. Diabetologica. 1993;36:741-744. With kind permission of Springer Science and Business Media.
A Patient With Type 2 Diabetes T he following case presentation illustrates how long-acting glucagon-like peptide 1 (GLP-1) agonists, such as exenatide, or dipeptidyl peptidase 4 (DPP-4) enzyme inhibitor incretin enhancers, such as sitagliptin or, in the future, vildagliptin, may play a role in the treatment of patients with type 2 diabetes, a disorder of β-cell dysfunction.The patient is a 48-year-old man with a 4-year history of type 2 diabetes who presents for a follow-up evaluation. Initially, he has no complaints, but he later admits to shortness of breath. He claims that he follows his diet and exercises sporadically. He does not routinely perform self-monitoring of blood glucose (SMBG). At the time of his original diagnosis 4 years earlier, his fasting plasma glucose ranged from 114 mg/dL (6.3 mmol/L) to 141 mg/dL (7.8 mmol/L), his A1C level was 7.2%, and he was participating in both diabetes education and nutrition counseling. Although he initially lost weight, he claims he has gained 10 lb in the past year. He is a social drinker with a 30-pack-year smoking history and a strong family history of diabetes. His father died of myocardial infarction at the age of 55 years. The patient's past medical history includes hypertension, dyslipidemia, diabetes, and osteoarthritis. His medications are metformin, 500 mg twice a day, as well as daily doses of hydrochlorothiazide 12.5 mg, atorvastatin 10 mg, and ibuprofen. On physical examination, his major abnormality is blood pressure of 140/90 mm Hg, which is above the goal for a patient with diabetes. The patient's body mass index (BMI) is currently 34.5 kg/m 2 . His A1C level is 7.7%, and his fasting plasma glucose level is 138 mg/dL (7.6 mmol/L). He has elevated low-density lipoprotein (LDL) cholesterol and triglycerides and low high-density lipoprotein (HDL) cholesterol. Remaining laboratory study results are within normal limits.Lawrence Blonde, MD, FACP, FACE
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