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Diabetes - Biblografia sobre glicemia em jejum e sua validade e valor preditório na progressão da doença

de volta à pg sobre diabetes

: Nonfasting plasma glucose is a better marker of diabetic control than fasting plasma glucose in type 2 diabetes.

Avignon A, Radauceanu A, Monnier L.

University Hospital of Montpellier, Department of Metabolism, Lapeyronie Hospital, France.

OBJECTIVE: To evaluate the relative value of plasma glucose (PG) at different time points in assessing glucose control of type 2 diabetic patients. RESEARCH DESIGN AND METHODS: Glycemic profiles, i.e., PG at prebreakfast (8:00 A.M.), prelunch (11:00 A.M.), postlunch (2:00 P.M.), and extended postlunch (5:00 P.M.) times over the same day, were obtained in 66 type 2 diabetic patients on an ambulatory basis. The different time points of PG were compared with a measurement of HbA1c made in a reference laboratory. RESULTS: Extended postlunch PG was lower than prebreakfast PG (104 +/- 21 vs. 133 +/- 35 mg/dl, P < 0.02) in patients demonstrating good diabetic control (HbA1c < or = 7.0%), was not different from prebreakfast PG (149 +/- 47 vs. 166 +/- 26 mg/dl, NS) in patients demonstrating fair diabetic control (7.0% < HbA1c < or = 8.5%), and was higher than prebreakfast PG (221 +/- 62 vs. 199 +/- 49 mg/dl, P < or = 0.01) in those demonstrating poor diabetic control (HbA1c < or = 8.5%). Prebreakfast, prelunch, postlunch, and extended postlunch PG values were all significantly correlated with HbA1c. Multiple linear regression analysis demonstrated that postlunch PG and extended postlunch PG correlated significantly and independently with HbA1c, but that prebreakfast PG and prelunch PG did not. Moreover, postlunch PG and extended postlunch PG demonstrated better sensitivity, specificity, and positive predictive value in predicting poor glycemic control than did prebreakfast PG or prelunch PG. CONCLUSIONS: In type 2 diabetes, postlunch PG and extended postlunch PG are better predictors of glycemic control than fasting plasma glucose (FPG). We therefore suggest that they be more widely used to supplement, or substitute for, FPG in evaluating the metabolic control of type 2 diabetic patients.

PMID: 9405900 [PubMed - indexed for MEDLINE]

: Comparing easy and accessible parameters of glycemic control in type 2 diabetes.

Lerman-Garber I, Lopez-Ponce A, Murcio Flores RA, Brito-Cordova GX, Velasco-Perez ML, Villa AR, Gomez-Perez FJ, Rull-Rodrigo JA.

Departamento de Endocrinologia y Metabolismo, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran. lerman@netservice.com.mx

BACKGROUND: HbA1c is considered the gold standard of long-term glycemic control and is recommended as a routine test for every diabetic patient. However, its common use in clinical practice has some problems related to lack of standardization and its relative cost. Recent studies have suggested, that postprandial blood glucose could be better than a fasting sample, as a marker of diabetes control. The objective of the present study was to evaluate the relative value of plasma glucose samples at different times of the day, and easy and accessible programs for home blood and urinary glucose measurements compared with HbA1c in assessing the mean glycemic control of type 2 diabetic patients. METHODS: Sixty type 2 diabetic patients were instructed to do home blood and urine glucose monitoring for two months, at the end, plasma glucose profiles were obtained. RESULTS: The mean of all the capillary BG measurements had the best correlation with the HbA1c (r = 0.84, p < 0.001), followed by the mean of the capillary BG measurements before breakfast and supper (r = 0.82, p < 0.001), and the 2 hr. postbreakfast plasma glucose (r = 0.79 p < 0.001). The fasting PG had a low correlation (r = 0.65, p < 0.001), but a good sensitivity to predict a fair or a poor metabolic control. Diabetes duration and type of treatment explained 17% and 28% of variance in HbA1c levels. CONCLUSIONS: A bimonthly fasting PG correlated well with the glycosylated hemoglobin and is the easiest and cheapest way of monitoring glycemic control in type 2 diabetic patients with some preserved insulin reserve (diabetes for less than 10 years and on treatment with only one hypoglycemic agent). A sample of capillary BG, fasting, once per week correlates better with the HbA1c than a fasting PG every 2-3 months. The 2 hr and 5 hr postbreakfast PG have a good correlation with the HbA1c, but are not a substitute for doing BG monitoring. Glycosuria may be a useful parameter to rule out a fair or poor metabolic control in some patients.

PMID: 11921524 [PubMed - indexed for MEDLINE]

: Correlation between fasting plasma glucose, post prandial glucose and glycated haemoglobin and fructosamine.

Rosediani M, Azidah AK, Mafauzy M.

Department of Family Medicine, School of Medical Sciences, Health Campus, Universiti Sains Malaysia, 16150 Kubang Kerian, Kota Bharu, Kelantan, Malaysia.

This study was done to determine the correlation between glucose monitoring by fasting blood glucose or 2 hours postprandial blood glucose with HbA1c and fructosamine in type 2 diabetic patients. A total of 82 patients from the Primary Care Clinic were enrolled in the study. Fasting blood was drawn for fasting plasma glucose (FPG), glycated haemoglobin (HbA1c) and fructosamine. Two hours after a standard breakfast, blood was again drawn for prandial plasma glucose (PPG). Both PPG and FPG significantly correlated with both HbA1c and fructosamine but PPG showed better correlation to HbA1c than FPG (r= 0.604 vs.0.575) whereas that of FPG and PPG were equally correlated to fructosamine (r= 0.566 vs. 0.551). In predicting good glycaemic control (HbA1c < 7.0%), the sensitivity, specificity and positive predictive value of PPG were 75.0%, 80.6% and 82.5% whereas FPG were 81.8%, 58.3% and 70.6% respectively. These results show that PPG correlated better than FPG to HbA1c and both equally correlated to fructosamine levels. Thus, PPG predicted overall glycaemic control better than FPG. Compared to HbA1c, fructosamine correlated least well with mean glucose profiles. Hence, using HbAlc in monitoring overall glycaemic control is better than fructosamine.

PMID: 16708736 [PubMed - indexed for MEDLINE]

4: Diabetes Care. 1999 Jun;22(6):904-7.

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Comment in:

Diabetes Care. 1999 Nov;22(11):1918-9.

How valid is fasting plasma glucose as a parameter of glycemic control in non-insulin-using patients with type 2 diabetes?

Bouma M, Dekker JH, de Sonnaville JJ, van der Does FE, de Vries H, Kriegsman DM, Kostense PJ, Heine RJ, van Eijk JT.

Institute for Research in Extramural Medicine, Amsterdam, The Netherlands.

OBJECTIVE: To assess the value of fasting blood glucose as a parameter for glycemic control in type 2 diabetic patients not using insulin. RESEARCH DESIGN AND METHODS: In 1,020 type 2 diabetic patients treated with diet or oral hypoglycemic agents (OHAs), measurements of fasting plasma glucose (FPG) and HbA1c were taken. In 617 patients, the measurement could be repeated after 3 months. Cross-sectional correlation coefficients were calculated for the association between HbA1c and FPG. Receiver-operating characteristic (ROC)-curve analyses were applied to examine the performance of FPG as a diagnostic test for HbA1c. Longitudinally, the change in FPG was compared with the change in HbA1c, with both correlation measures and ROC curve analyses. RESULTS: Correlation coefficients between HbA1c and FPG and between FPG change and HbA1c change were 0.77 and 0.65, respectively. ROC curve analysis showed that HbA1c is difficult to predict from FPG values: 66% of the patients with good HbA1c (< 7.0%) were identified as such by FPG values < 7.8 mmol/l. As a test for HbA1c change, FPG change performed moderately: the highest combined values of sensitivity and specificity (87.7 and 57%, respectively) were reached at a cutoff point of zero in the range of FPG change values. CONCLUSIONS: FPG and HbA1c values that do not correspond are not rare in type 2 diabetic patients on diet or OHA treatment. HbA1c is difficult to predict from FPG values, and even more difficult is the prediction of HbA1c changes from FPG changes.

PMID: 10372239 [PubMed - indexed for MEDLINE]

5: Diabetes Care. 1998 Aug;21(8):1221-5.

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Comment in:

Diabetes Care. 1998 Aug;21(8):1215-6.

Combined use of a fasting plasma glucose concentration and HbA1c or fructosamine predicts the likelihood of having diabetes in high-risk subjects.

Ko GT, Chan JC, Yeung VT, Chow CC, Tsang LW, Li JK, So WY, Wai HP, Cockram CS.

Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Tai Po, Hong Kong, China.

OBJECTIVE: To assess the validity of using fasting plasma glucose (FPG) concentrations in conjunction with HbA1c or fructosamine for the screening of diabetes in high-risk individuals. RESEARCH DESIGN AND METHODS: In this study 2,877 Hong Kong Chinese (565 [19.6%] men; 2,312 [80.4%] women) with various risk factors for glucose intolerance underwent a 75-g oral glucose tolerance test (OGTT) for screening of diabetes. The risk factors included a family history positive for diabetes, a history of gestational diabetes or impaired glucose tolerance, and obesity. RESULTS: Using World Health Organization (WHO) criteria, 1,593 (55.4%) had normal glucose tolerance, 657 (22.8%) had impaired glucose tolerance, and 627 (21.8%) had diabetes. When the 1997 American Diabetes Association (ADA) criteria were applied, 394 (13.7%) had diabetes with an FPG > or = 7.0 mmol/l. Using multiple receiver operating characteristic curve analysis, the paired values of an FPG of 5.6 mmol/l and a HbA1c of 5.5% gave an optimal sensitivity of 83.8% and specificity of 83.6% to predict a 2-h plasma glucose (PG) > or = 11.1 mmol/l. Likewise, the paired values of an FPG of 5.4 mmol/l and a fructosamine level of 235 mumol/l (n = 2,408) gave an optimal sensitivity of 81.5% and specificity of 83.2%. An FPG > or = 5.6 mmol/l and an HbA1c > or = 5.5% was 5.4-fold more likely to occur in diabetic subjects (based on the WHO criteria) compared with nondiabetic subjects. For paired parameters less than these values, the likelihood ratio of this occurring in diabetic subjects was only 0.11. Similarly, an FPG > or = 5.4 mmol/l and a fructosamine > or = 235 mumol/l was fivefold more likely to occur in diabetic subjects than in nondiabetic subjects, with both parameters less than these values having a likelihood ratio of 0.04. Using these paired values as initial screening tests, only subjects who had an FPG > or = 5.6 mmol/l and < 7.8 mmol/l and an HbA1c > or = 5.5% (n = 642) required an OGTT to confirm diabetes, thereby saving 77.7% [(2,877-642)/2,877] of the OGTTs performed. Similarly, only subjects who had an FPG > or = 5.4 mmol/l and < 7.8 mmol/l and a fructosamine > or = 235 mumol/l (n = 526) required OGTT to confirm diabetes, meaning that 78.2% [(2,408-526)/2,408] of the OGTTs could have been saved. Based on the 1997 ADA criterion of an FPG cutoff value of 7.0 mmol/l, the corresponding numbers of OGTTs to be saved were 82.6% and 85.5%, respectively. CONCLUSIONS: The paired values of FPG and HbA1c or FPG and fructosamine helped to identify potentially diabetic subjects, the diagnosis of which could be further confirmed by the 75-g OGTT. Using this approach approximately 80% of OGTTs could have been saved, depending on the diagnostic cutoff value of FPG.

PMID: 9702423 [PubMed - indexed for MEDLINE]

: Contributions of fasting and postprandial plasma glucose increments to the overall diurnal hyperglycemia of type 2 diabetic patients: variations with increasing levels of HbA(1c).

Monnier L, Lapinski H, Colette C.

Department of Metabolism, Lapeyronie Hospital, Montpellier, France. l-monnier@chu-montpellier.fr

OBJECTIVE: The exact contributions of postprandial and fasting glucose increments to overall hyperglycemia remain controversial. The discrepancies between the data published previously might be caused by the interference of several factors. To test the effect of overall glycemic control itself, we analyzed the diurnal glycemic profiles of type 2 diabetic patients investigated at different levels of HbA(1c). RESEARCH DESIGN AND METHODS: In 290 non-insulin- and non-acarbose-using patients with type 2 diabetes, plasma glucose (PG) concentrations were determined at fasting (8:00 A.M.) and during postprandial and postabsorptive periods (at 11:00 A.M., 2:00 P.M., and 5:00 P.M.). The areas under the curve above fasting PG concentrations (AUC(1)) and >6.1 mmol/l (AUC(2)) were calculated for further evaluation of the relative contributions of postprandial (AUC(1)/AUC(2), %) and fasting [(AUC(2) - AUC(1))/AUC(2), %] PG increments to the overall diurnal hyperglycemia. The data were compared over quintiles of HbA(1c). RESULTS: The relative contribution of postprandial glucose decreased progressively from the lowest (69.7%) to the highest quintile of HbA(1c) (30.5%, P < 0.001), whereas the relative contribution of fasting glucose increased gradually with increasing levels of HbA(1c): 30.3% in the lowest vs. 69.5% in the highest quintile (P < 0.001). CONCLUSIONS: The relative contribution of postprandial glucose excursions is predominant in fairly controlled patients, whereas the contribution of fasting hyperglycemia increases gradually with diabetes worsening. These results could therefore provide a unifying explanation for the discrepancies as observed in previous studies.

PMID: 12610053 [PubMed - indexed for MEDLINE]

: What is the relative contribution of blood glucose levels at different time points of the day to HbA1c in Type 1 diabetes?

Hillman N, Herranz L, Grande C, Vaquero PM, Pallardo LF.

Department of Endocrinology and Nutrition, University Hospital La Paz, P. Castellana 261, 28046 Madrid, Spain. nataliahillman@terra.es

AIMS: To evaluate the relative contribution of blood glucose levels at different time points of the day to HbA(1c) in Type 1 diabetes. METHODS: Consecutive home blood glucose records (n = 146) from 71 Type 1 diabetic patients who were on an intensive diabetes therapy programme were examined. Each home blood glucose record included six daily blood glucose profiles over 2 months. The relationship between glycaemic values at each time point and HbA(1c) measured at the end of each record period was analysed. RESULTS: Significant linear correlations were found between HbA(1c) and glycaemia at each time point of the day (ranged from 0.413 to 0.593), the strongest being with predinner glycaemia (r = 0.593; P = 0.000). Total daily glycaemia, mean preprandial and mean postprandial glycaemia were also significant and linearly correlated with HbA(1c) (r = 0.701; r = 0.686; r = 0.620, respectively; P < 0.0001). Multiple linear regression analysis showed that predinner, prebreakfast and post-breakfast glycaemia correlated significantly and independently with HbA(1c). The model accounted for 47.8% of the variance in HbA(1c). CONCLUSIONS: Our study shows that among individual time points, prebreakfast and predinner are those with more influence on HbA(1c) in Type 1 diabetes and, to a lesser extent, post breakfast. It also confirms that preprandial glycaemia better predicts overall glycaemic control in Type 1 diabetes than postprandial glycaemia.

PMID: 15089792 [PubMed - indexed for MEDLINE]

: Morning hyperglycemic excursions: a constant failure in the metabolic control of non-insulin-using patients with type 2 diabetes.

Monnier L, Colette C, Rabasa-Lhoret R, Lapinski H, Caubel C, Avignon A, Boniface H.

Department of Metabolic Diseases, Lapeyronie Hospital, Montpellier, France. mal-meta-@chu-montpellier.fr

OBJECTIVE: To determine whether, over daytime, one or several hyperglycemic excursions exist that can be general failures in the glycemic control of patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: In 200 non-insulin-using patients with type 2 diabetes, diurnal plasma glucose and insulin profiles were studied. Plasma glucose concentrations were measured after an overnight fast (at 8:00 A.M. immediately before breakfast), during the postprandial period (at 11:00 A.M. and 2:00 P.M.), and during the postabsorptive period (at 5:00 P.M., extended postlunch time). RESULTS: In the population considered as a whole, prelunch glucose concentrations (12.0 mmol/l) were found to be significantly increased (P < 0.0001) when compared with those observed at 8:00 A.M. (8.8 mmol/l), at 2:00 P.M. (10.5 mmol/l), and at 5:00 P.M. (8.6 mmol/l). Similar significant excursions (P < 0.0001) in prelunch glucose were observed within subsets of patients selected from the following criteria: 1) body weight, 2) HbA(1c), 3) categories of treatment, and 4) residual beta-cell function. From the calculation of areas under the daytime glucose curves, the relative contributions of postprandial and fasting glucose to the total glucose increment were found to be similar. CONCLUSIONS: High plasma glucose excursions over morning periods seem to be a permanent failure in non-insulin-using patients with type 2 diabetes, whatever the clinical (BMI), biological (HbA(1c)), therapeutic, and pathophysiological (residual beta-cell function) status. Midmorning glucose testing should be recommended for detecting such abnormalities and for correcting them with appropriate therapies.

PMID: 11919134 [PubMed - indexed for MEDLINE]

: Fasting and post-prandial glycemia and their correlation with glycated hemoglobin in Type 2 diabetes.

Monami M, Lamanna C, Lambertucci L, Longo R, Cocca C, Addante F, Lotti E, Masotti G, Marchionni N, Mannucci E.

Geriatric Unit, Department of Critical Care, University of Florence Medical School, 50141 Florence, Italy. mmonami@libero.it

OBJECTIVE: The relative contribution of fasting and post-prandial glucose to glycated hemoglobin (HbA1c) is controversial. In the present study, we assessed the relationship with HbA1c of fasting and post-prandial glucose measured in a more naturalistic setting, through home glucose self-monitoring or with a continuous glucose monitoring system (CGM). MATERIALS AND METHODS: A consecutive series of 300 patients with Type 2 diabetes were enrolled in the study, provided that they performed blood glucose self-monitoring. HbA1c and fasting plasma glucose (FPG) were measured at enrolment. RESULTS: Both fasting plasma and capillary glucose showed a significant correlation with HbA1c (r=0.66 and 0.61, respectively; p<0.001). When home glucose monitoring was considered, both mean fasting and post-prandial glucose showed a significant correlation with HbA1c (r=0.71 and 0.73, respectively). In patients in the lower tertile of body mass index (BMI), HbA1c showed a significant correlation at multivariate analysis with post-prandial glucose, but not with fasting glucose. In patients with HbA1c >7%, both fasting and post-prandial glucose showed a significant correlation, after adjustment for age and BMI, with HbA1c (both p<0.01); conversely, in those with HbA1c < or =7%, such a correlation could be observed for fasting (p<0.01), but not for post-prandial glucose. CONCLUSION: In conclusion, both fasting and post-prandial glucose contribute to the determination of HbA1c . Home glucose self-monitoring appears to provide a more accurate assessment of metabolic control than a single plasma glucose measurement in experimental conditions. Fasting glucose could provide a greater contribution to HbA1c in patients with lower HbA1c, while post-prandial glucose seems to play a major role in leaner Type 2 diabetic subjects.

PMID: 16957410 [PubMed - indexed for MEDLINE]

10: Diabetes Metab. 2005 Apr;31(2):101-9.

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An overview of the rationale for pharmacological strategies in type 2 diabetes: from the evidence to new perspectives.

Monnier L, Benichou M, Charra-Ebrard S, Boegner C, Colette C.

Department of Metabolism, Lapeyronie Hospital, 34295 Montpellier Cedex 5, France. l-monnier@chu-montpellier.fr

Therapeutic strategies in type 2 diabetic patients should not only integrate both the targets and indications of the different therapies but should be also a compromise between the patient's and physician's goals and willingnesses. The rationale for therapeutic targets is based on recommendations that differ from one country to another. Even though HbA1c remains the "gold standard", monitoring of blood glucose at fasting and postprandial time-points is a complementary tool for estimating both the quality and safety of diabetic control. Despite the lack of available strong evidence-based data it seems that achieving glucose levels < 130 mg/dl at fasting and < 180 mg/dl or < 140 mg/dl over postbreakfast or postlunch periods, respectively, might be a reasonable goal in most countries. The choice of appropriate strategies for treating type 2 diabetic patients should ideally be based on pathophysiological considerations. However for practical reasons, decisions for initiating or completing antidiabetic treatments are usually made by using such simple parameters as HbA1c and plasma glucose levels. The bridge between pathophysiological and clinical rationales can be obtained from the analysis of the relative contributions of fasting and postprandial glucose to the overall hyperglycaemia. In patients with HbA1c < 7.3%, postprandial glucose makes the major contribution to the overall hyperglycaemia, whereas the contribution of fasting glucose becomes progressively predominant in patients with HbA1c > 7.3%. As a consequence of these observations, initiation of antidiabetic treatments or implementation of second-line therapies should be aimed at reducing either postprandial excursions or fasting hyperglycaemia according to whether HbA1c levels are found respectively below or above a cut-off value of 7.3%.

Publication Types:

Review

PMID: 15959415 [PubMed - indexed for MEDLINE]

11: Clin Ther. 2003 Feb;25(2):515-29.

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Glycemic control in patients with type 2 diabetes mellitus switched from twice-daily immediate-release metformin to a once-daily extended-release formulation.

Fujioka K, Pans M, Joyal S.

Nutrition and Metabolic Research Center, Scripps Clinic Del Mar, San Diego, California 92310, USA. kfujioka@scrippsclinic.com

BACKGROUND: The extended-release formulation of metformin (MXR) prolongs drug absorption in the upper gastrointestinal tract and permits once-daily dosing in patients with type 2 diabetes mellitus. This newer formulation may enhance patient compliance with oral therapy and improve long-term control of diabetes compared with the conventional immediate-release formulation of metformin (MIR). OBJECTIVE: The goal of this study was to determine the effects on glycemic control of a switch to MXR therapy in patients with type 2 diabetes currently treated with MIR. METHODS: This was a multicenter, randomized, double-blind, parallel-group study in patients with established type 2 diabetes. Eligible patients were to have a glycated hemoglobin (HbA1c) value < or = 8.5% and mean fasting plasma glucose (FPG) concentrations < or = 200 mg/dL while receiving MIR 500 mg BID for at least 8 weeks. After a 2-week, single-blind lead-in period, patients were randomly assigned to receive MXR 1000 or 1500 mg QD for 24 weeks or to continue MIR 500 mg BID for 24 weeks. The primary efficacy variable was change in HbA1c from baseline to week 12. Other variables included change in FPG levels; change in HbA1c; distribution of HbA1c values; mean daily blood glucose concentrations (self-monitored); levels of fructosamine, serum insulin, and lipids; and body weight. RESULTS: Two hundred seventeen patients were randomized to treatment. The mean change from baseline in HbA1c values at weeks 12 and 24 were small and similar in the 3 treatment groups. At week 12, the mean change from baseline in HbA1c was 0.15% for MIR, 0.23% for MXR 1000 mg, and 0.04% for MXR 1500 mg. The corresponding mean changes at week 24 were 0.06%, 0.25%, and 0.14%. CONCLUSIONS: In this study, patients with type 2 diabetes who had been receiving twice-daily MIR achieved comparable glycemic control when therapy was switched to once-daily MXR at the same or a greater total daily dose.

Publication Types:

PMID: 12749511 [PubMed - indexed for MEDLINE]

: Blood glucose pre-prandial baseline decreases from morning to evening in type 2 diabetes: role of fasting blood glucose and influence on post-prandial excursions.

Trovati M, Ponziani MC, Massucco P, Anfossi G, Mularoni EM, Burzacca S, Tassone F, Perna P, Traversa M, Cavalot F.

Diabetes Unit, Department of Clinical and Biological Sciences, University of Turin, San Luigi Gonzaga Hospital, 10043 Orbassano, Turin, Italy. mariella.trovati@unito.it

BACKGROUND: To know the relationships between pre- and postprandial blood glucose (BG), i.e. BG profile shape, is a requisite for an appropriate therapy for type 2 diabetic patients. In non diabetic subjects, pre-breakfast, pre-lunch and pre-dinner BG are similar, so that BG postprandial excursions are superimposed on a stable BG preprandial baseline. We aimed to clarify: (a) whether BG preprandial baseline is stable also in type 2 diabetes and (b) whether fasting BG (FBG) influences the slope of BG preprandial baseline and the relationships between pre- and postprandial BG. DESIGN: We evaluated self-measured BG profiles of 237 type 2 diabetic patients on diet alone (M/F, 152/85; age 58.6 +/- 0.7 years; years from diagnosis 4.8 +/- 0.6; BMI 28.0 +/- 0.3 kg m-2): 536 profiles containing preprandial BG (corresponding HbA1c 6.8 +/- 0.06%) and 208 profiles containing both pre- and postprandial BG (corresponding HbA1c 6.8 +/- 0.09%). The profiles, measured by nurses, of 866 type 2 diabetic patients on diet alone were also considered (corresponding HbA1c 6.7 +/- 0.04%). RESULTS: In self-measured profiles containing only preprandial BG: (i) FBG (6.77 +/- 0.07 mmol L(-1)) is higher than pre-lunch BG (6.09 +/- 0.07 mmol L(-1)), P = 0.0001) and pre-dinner BG (5.84 +/- 0.06 mmol L(-1)), P =0.0001); (ii) the delta value between FBG and pre-dinner BG is correlated with FBG (r = 0.57, P = 0.0001), the highest FBG, the steepest the fall of BG preprandial baseline throughout the day. This trend is confirmed in profiles measured by nurses. In profiles containing both pre- and postprandial BG: (i) there is a trend to preprandial BG fall (P = 0.0001) and to postprandial BG increase (P = 0.0001) from morning to evening; (ii) postprandial excursions are influenced and sometimes masked by the slope of BG preprandial baseline, thus, in profiles with FBG < or = 6.7 mmol L(-1), all postprandial values are higher than FBG (P = 0.0001), whereas in profiles with FBG > 7.8 mmol L(-1), postprandial values are not significantly higher than FBG. CONCLUSION: In type 2 diabetes, the shape of BG profiles changes in relation to FBG, because it deeply influences the slope of BG preprandial baseline on which postprandial excursions are superimposed. Thus, before planning treatment policies, not only the extent of fasting and postprandial hyperglycaemia, but also the shape of profiles should be considered, to safely correct hyperglycaemia without inducing hypoglycaemia.

PMID: 11895469 [PubMed - indexed for MEDLINE]

: Partial androgen deficiency in aging type 2 diabetic men and its relationship to glycemic control.

Corrales JJ, Burgo RM, Garca-Berrocal B, Almeida M, Alberca I, Gonzalez-Buitrago JM, Orfao A, Miralles JM.

departamento de Medicina, Universidad de Salamanca, Salamanca, Spain.

Aging in the male is associated with both a higher incidence of type 2 diabetes and hypogonadism. However, little information is available about the complex of symptoms and hormonal changes related to partial androgen deficiency in aging (called andropause) in type 2 diabetic men. Here, for the first time, we used a combination of clinical and hormonal criteria to define andropause and to analyze the relationships between the androgen environment and glucose metabolism in 55 type 2 diabetic men (63.6 +/- 7.9 years, mean +/- SD). Low plasma levels of total testosterone (< or =3.4 ng/mL) and free testosterone (< or =11 pg/mL) were found in 20% and 54.5%, respectively, of the diabetic men. The fraction of diabetic men with subnormal levels of total testosterone increased with aging: 14.2% (50 to 59 years), 17.4% (60 to 69 years) and 36% (> 70 years). The corresponding figures for subnormal values of free testosterone were 38%, 69.6%, and 54.5%, respectively. In the whole group of type 2 diabetic men, no significant linear correlations between total or free testosterone with fasting plasma glucose, insulin, C-peptide, or fructosamine values could be established. Total testosterone was positively correlated with glycosylated haemoglobin (HbA(1c)) levels (r =.322, P =.01). Although fasting plasma glucose was marginally higher in aging type 2 diabetic patients with andropause than in those without andropause (162 +/- 6.9 v 139 +/- 8.9, mean +/- SEM, P =.05), there were no differences between both subgroups for plasma fasting insulin, C-peptide, fructosamine, or HbA(1c) levels. Replacement therapy (150 mg intramuscular [IM] of enanthate of testosterone every 14 days for 6 months) was applied in 10 type 2 diabetic men with clinical features of andropause associated with subnormal concentrations of serum testosterone. The treatment induced significant increases in total plasma testosterone (baseline: 3.9 +/- 0.3; at 6 months: 7.1 +/- 0.9 ng/mL, mean +/- SEM, P =.003) and free testosterone (baseline: 9.3 +/- 0.6; at 6 months 17.6 +/- 2.4 pg/mL, P =.003), but had a neutral effect on overall glycemic control. These data show a high prevalence of andropause in aging type 2 diabetic men and suggest that the endogenous androgen environment, as well as correction of the partial androgen deficiency, do not have a meaningful effect on glycemic control.

PMID: 15131775 [PubMed - indexed for MEDLINE]

14: Diabetes Care. 2000 Sep;23(9):1236-41.

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Comment in:

ACP J Club. 2001 May-Jun;134(3):88.

Therapy focused on lowering postprandial glucose, not fasting glucose, may be superior for lowering HbA1c. IOEZ Study Group.

Bastyr EJ 3rd, Stuart CA, Brodows RG, Schwartz S, Graf CJ, Zagar A, Robertson KE.

Lilly Research Laboratories, Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana 46285, USA. ejbIII@lilly.com

OBJECTIVE: To compare the overall efficacy of combination therapies focused on fasting or postprandial blood glucose in patients with type 2 diabetes not adequately controlled with oral sulfonylurea agents alone. RESEARCH DESIGN AND METHODS: A total of 135 patients were randomly assigned for 3 months to 1 of 3 combination regimens with glyburide (G) that addressed postprandial blood glucose with insulin lispro (L+G), premeal blood glucose with metformin (M+G), or fasting blood glucose (FBG) with bedtime NPH insulin (NPH+G). RESULTS: At end point, HbA1c was significantly lower with all therapies (P = 0.001) and was significantly lower for L+G (7.68+/-0.88%) compared with either NPH+G (8.51+/-1.38%, P = 0.003) or M+G (8.31+/-1.31%, P = 0.025). FBG at end point was significantly lower for NPH+G (8.49+/-2.36 mmol/l) compared with either L+G (10.57+/-1.97 mmol/l, P = 0.001) or M+G (9.69+/-2.89 mmol/l, P = 0.029). The mean 2-h postprandial glucose after a test meal was significantly lower for L+G (10.87+/-2.88 mmol/l) versus NPH+G (12.21+/-3.12 mmol/, P = 0.052) or versus M+G (12.72+/-3.26 mmol/l, P = 0.009). The overall rate of hypoglycemia (episodes per 30 days) was low and not statistically significant between groups (P = 0.156). CONCLUSIONS: Adding a second antihyperglycemic agent, regardless of its timing of action, lowers HbA1c and glucose values. However, when insulin lispro was used to focus on postprandial blood glucose, there was a greater impact on overall metabolic control. These data support the importance of lowering postprandial blood glucose to optimize overall glycemic control and thus improve long-term outcomes.

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PMID: 10977012 [PubMed - indexed for MEDLINE]

15: Curr Med Res Opin. 2003;19(7):635-41.

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Clinical significance of targeting postprandial and fasting hyperglycemia in managing type 2 diabetes mellitus.

Fonseca V.

Tulane University Health Sciences Center, 1430 Tulane Avenue--SL 53, New Orleans, LA 70112, USA. vfonseca@tulane.edu

Measurement of glycosylated hemoglobin (HbA1c) remains the gold standard for the assessment of glycemic control in patients with type 2 diabetes. Recent investigations have studied the correlations between HbA1c levels and other aspects of glucose metabolism, specifically, postprandial glucose (PPG) and fasting plasma glucose (FPG). The results suggest that PPG is also important to overall glycemic control and may be a better index of glucose regulation than FPG. Further, elevated PPG values have been associated with cardiovascular complications and cardiovascular mortality. Such evidence has led to recommendations that PPG levels be monitored as part of type 2 diabetes management, in addition to HbA1c and FPG. These glycemic parameters are differentially affected by the various classes of oral antidiabetic agents used in the treatment of type 2 diabetes--sulfonylureas, meglitinides, insulin sensitizers and alpha-glucosidase inhibitors. The sulfonylureas, for example, lower HbA1c, PPG and FPG, while the meglitinides have virtually no effect on FPG. The insulin sensitizer metformin, on the other hand, does not affect PPG levels, whereas the alpha-glucosidase inhibitors, in the presence of a high-carbohydrate diet, can effectively lower PPG. Many patients receive combination therapy, thereby benefiting from multiple mechanisms of glucose control, although in most cases insulin must later be added to the regimen in order to effectively suppress FPG. Thus, all aspects of glucose metabolism appear to be clinically relevant and should be monitored for effective diabetes management. Further study will more precisely define the clinical significance of PPG.

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Review

PMID: 14606987 [PubMed - indexed for MEDLINE]