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Post Prandial Hyperglycemia

Indian Scenario

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Targets for glycemic control

To achieve a normal or near normal HbA1c, bothFPG and PPG levels must be normal or nearnormal.

Thus both FPG and PPG must be targets fortherapy

Nevertheless, might there be situations in which itis preferable to treat one or the other first ???

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Postprandial

Hyperglycemia

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Post-meal hyperglycaemia beginsprior to type 2 diabetes

The development of type 2 DM is characterized by a progressive decline in insulin action & deterioration of -cell function & hence insulin secretion.

Prior to clinical diabetes, these metabolicabnormalities are first evident as elevations inpost-meal plasma glucose, due to the loss of first phase insulin secretion, decreased insulin sensitivity in peripheral tissues and consequent decreased suppression of hepatic glucose

output after meals due to insulin deficiency

2007 Guideline for Management of Postmeal Glucose

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Natural history of type 2 diabetes

Post-meal hyperglycaemia begins prior to type 2diabetes

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Is PPG important?

Why PPG is important?

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Correlation of FPG & PPG to A1C

A strong correlation exists between HbA1C levels

and FPG and PPG concentrations

The contribution of FPG to A1C is greater at higher

A1C levels,

While PPG contributes more to A1C when A1C

levels are closer to goal

In patients with an A1C below 7.3%, 70% of the

A1C is attributed to PPG.

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As Patients Get Closer to A1C Goal, theNeed to Successfully Manage PPG

Significantly Increases

Increasing Contribution of PPG as A1C Improves

30%40% 45%

50%

70%

60% 55%50%

30%

70%

0%

20%

40%

60%

80%

100%

< 10.2 10.2 to 9.3 9.2 to 8.5 8.4 to 7.3 < 7.3

A1C Range (%)

%

Contribution

FPG

PPG

Adapted from Monnier L, Lapinski H, Collette C. Contributions of fasting and

postprandial plasnma glucose increments to the overall diurnal hyper glycemia

of Type 2 diabetic patients: variations with increasing levels of HBA(1c).Diabetes Care. 2003;26:881-885.

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Relative Changes in FPG and 2-h PGas HbA1c Increases

Van Haeften T et al Metabolism 2000

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PPG Levels better indicator

PPG levels contribute to a large portion of the HbA1Cvalue, and there are differences in the degree to whichPPG affects the HbA1C value for specific meals.

A number of studies suggest that PPG may be a betterindicator of glycemic control than fasting/premealblood glucose levels

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Postmeal hyperglycaemia iscommon in diabetes In a cross-sectional study of 443 individuals with

type 2 diabetes, 71% of those studied had a meantwo hour postmeal plasma glucose of >14 mmol/l(252mg/dl).

A study looking at daily plasma glucose profiles from3,284 people with type 2 diabetes compiled over aone-week period, demonstrated

PPG value > 8.9 mmol (160 mg/dl) was recorded at leastonce in 84% of those studied.

Postprandial hyperglycemia is manifest in about 60%of newly diagnosed patients with type 2 diabetes

1. Guideline for Management of Postmeal Glucose. IDF, 2007 ; 2. Ezenwaka et al. ClinicalNutrition (2004) 23, 631640

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Many patients have high PPG atFPG 126mg/dl

126 mg/dl 200mg/dl

FPG

South Med J. 2001;94(8)

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Down loaded from IDF home page: www.idf.org.

IDF Guideline for Management of Postmeal Glucose has been revised andannounced at IDF Annual Congress at Dubai in Dec-11

2007 2011

Page 16

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19/312011 Guideline for Management of Postmeal Gluco

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PPHG: Indian Scenario

More than half of the global diabetes burden now

resides in China and India which has outpaced thedeveloped economies from North America and Europe.

This is clearly linked to food and activity patternswhich have undergone a sudden transformation inthese geographic regions.

Traditional Asian Indian and Chinese diets are

carbohydrate-rich sometimes even as high as 80percent of the macronutrient composition coming fromthis proximate principle.

JAPI November 2010 VO L. 58

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PPHG: Indian Scenario

The higher glucose load in the Indo-Chinese diets lead to

greater prandial glycemic excursion,

increased glucosidase and incretin activity in the gut and

may need special therapeutic strategies to tackle these

glucose peaks.

Thus a typical Indo-Chinese post-meal glucose curve

has wider glycemic excursion as well as

greater post-prandial load which leads to higher lipemicpeaks and has

epidemiological links to cardiovascular disease.

JAPI November 2010 VO L. 58

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PPG guidelines

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Aghg

jhjhj

1. IDF T2DM Treatment Algorhithm 2011; Available at http://www.idf.orgRole of -Glucosidase Inhibitors is emphasized

http://www.idf.org/http://www.idf.org/

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Which therapies are effective incontrolling post meal glucose?

Therapies

Diet Low GI/GL

Oral Agents

AGIs Acarbose Voglibose Miglitol

Glinides Repaglinide Nateglinide

DPP-4 inhibitor Sitagliptin Vildagliptin Saxagliptin

Injectables

Insulin Short/Rapid Biphasic Inhaled

GLP-1 Analogue Exenatide Liraglutide

AmylinAnalogue

Pramlintide

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Alpha-glucosidase inhibitors(AGIs)

The alpha-glucosidase inhibitors areeffective in lowering PPG because theydelay carbohydrate absorption

The alpha-glucosidase inhibitors havethe added advantage of being weight

neutral;

J of Family Practice, May 2010 Vol. 59, No. 05 Suppl: S9-S14

Wh AGI b d t t t

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Where can AGIs be used to targetPPG

At diagnosis when PPG is high

Patients uncontrolled onmonotherapy

with high PPG

atients uncontrolled on monotherapy

with high PPG

Start with AGI alternative

to Metformin

Add AGI if PPG is high onmonotherapy

Add AGI if PPG is high on dualtherapy

However, gastrointestinal side effectsoften limit patient acceptance..

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Voglibose has better GI sideeffect profile

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Voglibose: May avoid secondaryfailure of SUs

Voglibose has been shown to improve insulin sensitivity

This may reduce the requirement of insulin secretion from thebeta cells reduce overwork of beta cells

This mechanism helps when used with SUs

With SUs there may be secondary failure because of mostprobably exhaustion of beta cells

Therefore it is assumed that concomitant use of vogliboseand sulfonylureas, may avoid this secondary failure

Diabetes care, Vol 21, No-2, Feb 1998

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Voglibose: ReduceGlycemicExcursions

Comparedto SU

Also reducepost-mealinsulin

secretion

Voglibose SU

Voglibose SU

Diabetes care, Vol 21, No-2, Feb 1998

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Thanks