Post Prandial Hyperglycemia Indian Scenario

Targets for glycemic control

To achieve a normal or near normal HbA1c, both FPG and PPG levels must be normal or near normal. Thus both FPG and PPG must be targets for therapy Nevertheless, might there be situations in which it is preferable to treat one or the other first ???

Postprandial Hyperglycemia

Post-meal hyperglycaemia begins prior 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 metabolic abnormalities are first evident as elevations in post-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

Post-meal hyperglycaemia begins prior to type 2 diabetesNatural history of type 2 diabetes

Is PPG important? Why PPG is important?

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.

As Patients Get Closer to A1C Goal, the Need to Successfully Manage PPG Significantly Increases
Increasing Contribution of PPG as A1C Improves
100% % Contribution 80% 60% 40% 20% 0% < 10.2 10.2 to 9.3 9.2 to 8.5 8.4 to 7.3 A1C Range (%)
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.

30% 70% 60% 55% 50%

70% 30% 40% 45% 50%

FPG PPG

< 7.3

Relative Changes in FPG and 2-h PG as HbA1c Increases

Van Haeften T et al Metabolism 2000

PPG Levels better indicator

PPG levels contribute to a large portion of the HbA1C value, and there are differences in the degree to which PPG affects the HbA1C value for specific meals. A number of studies suggest that PPG may be a better indicator of glycemic control than fasting/premeal blood glucose levels

Postmeal hyperglycaemia is common in diabetes

In a cross-sectional study of 443 individuals with type 2 diabetes, 71% of those studied had a mean two hour postmeal plasma glucose of >14 mmol/l (252mg/dl). A study looking at daily plasma glucose profiles from 3,284 people with type 2 diabetes compiled over a one-week period, demonstrated

PPG value > 8.9 mmol (160 mg/dl) was recorded at least once 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. Clinical Nutrition (2004) 23, 631640

Many patients have high PPG at FPG 126mg/dl

97

100

% of patients PPG >200mg/dl

90 80 70 60 50 40 30 20 10 0
52

126 mg/dl

<126 mg/dl

FPG
South Med J.2001;94(8)

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

2007

2011

Page 16

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

2011 Guideline for Management of Postmeal Glucos

PPHG: Indian Scenario

More than half of the global diabetes burden now resides in China and India which has outpaced the developed economies from North America and Europe. This is clearly linked to food and activity patterns which have undergone a sudden transformation in these geographic regions. Traditional Asian Indian and Chinese diets are carbohydrate-rich sometimes even as high as 80 percent of the macronutrient composition coming from this proximate principle.

JAPI November 2010 VO L. 58

PPHG: Indian Scenario

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

greater

prandial glycemic excursion, glucosidase and incretin activity in the gut and

increased 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 lipemic peaks and has links to cardiovascular disease.

epidemiological

JAPI November 2010 VO L. 58

PPG guidelines

Aghg

jhjhj

Role of -Glucosidase Inhibitors is emphasized

1. IDF T2DM Treatment Algorhithm 2011; Available at http://www.idf.org

Which therapies are effective in controlling post meal glucose?

Therapies

Diet Oral Agents

AGIs Glinides DPP-4 inhibitor

Low GI/GL

Acarbose Repaglinide Sitagliptin

Voglibose Nateglinide Vildagliptin

Miglitol

Saxagliptin

Injectables
Insulin GLP-1 Analogue Amylin Analogue Short/Rapid Exenatide Pramlintide Biphasic Liraglutide Inhaled

Alpha-glucosidase inhibitors (AGIs)

The

alpha-glucosidase inhibitors are effective in lowering PPG because they delay carbohydrate absorption alpha-glucosidase inhibitors have the added advantage of being weight neutral;

The

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

Where can AGIs be used to target PPG

At diagnosis when PPG is high Patients uncontrolled on monotherapy with high PPG Start with AGI alternative to Metformin

Add AGI if PPG is high on monotherapy

Patients uncontrolled on monotherapy with high PPG

Add AGI if PPG is high on dual therapy

However, gastrointestinal side effects often limit patient acceptance..

Voglibose has better GI side effect profile

Voglibose: May avoid secondary failure of SUs

Voglibose has been shown to improve insulin sensitivity This may reduce the requirement of insulin secretion from the beta cells reduce overwork of beta cells This mechanism helps when used with SUs With SUs there may be secondary failure because of most probably exhaustion of beta cells Therefore it is assumed that concomitant use of voglibose and sulfonylureas, may avoid this secondary failure

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

Voglibose : Reduce Glycemic Excursion s

Compared to SU

Voglibose

SU

Also reduce post-meal insulin secretion

Voglibose

SU

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

Thanks