Impact of improving postprandial glycemic control with intensifying insulin therapy in type 2 diabetes

Abstract

Worldwide, many people with type 2 diabetes are not at recommended glycemic targets and remain at increased risk of microvascular and macrovascular complications. Reaching recommended glycemic targets requires normalizing both fasting and postprandial glucose (PPG). For some patients, this will require addition of a prandial insulin delivered by injection to control PPG excursions. Evidence from epidemiological studies suggests an association between postprandial hyperglycemia and cardiovascular disease, and thus, expert guidelines recommend that treatment for elevated PPG not be delayed. Indeed, studies have demonstrated that PPG makes the greatest contribution to HbA in patients who are approaching, but have not yet reached HbA <7.0%. Appropriately timed exposure of the liver to insulin is critical in suppressing hepatic glucose output (and therefore PPG levels) after a meal. Rapid-acting insulin analogs, with their faster onset and shorter duration of action, offer advantages over regular human insulin. Unfortunately, even with improved pharmacokinetic/pharmacodynamic characteristics, rapid-acting insulin analogs are still unable to fully reproduce the rapid release of insulin into the portal circulation and suppression of hepatic glucose output that occurs in the individual without diabetes after starting a meal. The next generation of rapid-acting insulin analogs will have an even more favorable pharmacokinetic profile that should allow patients to further improve glycemic control. Continuous subcutaneous insulin infusion (CSII) represents another option for intensifying therapy and improving postprandial control in some patients, and studies have shown that the benefits are sustainable long-term. However, it is currently unclear which patients stand to benefit the most from the extra expense and complexity of a CSII regimen, and further studies are needed.

Effect of V-Go Versus Multiple Daily Injections on Glycemic Control, Insulin Use, and Diabetes Medication Costs Among Individuals with Type 2 Diabetes Mellitus

“…treated aggressively by intensification of basal insulin. 2,35,36 An estimated 82% also need intensification that incorporates mealtime bolus within 3 years of insulin initiation. 37 Such intensification and other treatment complications have been linked to poor adherence and negative patient perceptions regarding insulin therapy.…”

A Randomized, Placebo-Controlled Crossover Study to Evaluate Postprandial Glucometabolic Effects of Mulberry Leaf Extract, Vitamin D, Chromium, and Fiber in People with Type 2 Diabetes

“…This is particularly important in prediabetes and early stages of T2D, where the relative contribution of PP glucose, as compared with fasting glucose, to HbA1c is more prominent [2]. While there are several pharmaceutical approaches to manage PP glucose, e.g., with fast-acting insulins [4], glinides [5], a-glucosidase inhibitors [6], there are no particular nutritional interventions favored by major scientific societies (e.g., ADA/ EASD) [7]; however, most therapeutic lifestyle interventions that reduce caloric intake and attempt to reduce overall carbohydrate intake, in particular, monosaccharides [8], would result in this.…”

Efficacy and safety of linagliptin to improve glucose control in older people with type 2 diabetes on stable insulin therapy: A randomized trial

“…In a meta‐analysis, less than 50% of individuals treated with basal insulin achieved an HbA1c target of <7.0% . Furthermore, achieving glycaemic targets with basal insulin will eventually require introduction of prandial insulin, with the consequent increase in regimen complexity and number of daily injections, as well as the risk of hypoglycaemia, which is particularly undesirable in older individuals for the reasons discussed above.…”