Postprandial Glycemic Control Diabetes Mellitus Case Study

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¶ … Postprandial Glycemic Control

Diabetes Mellitus

In this case study a 55-year-old female with type 2 diabetes mellitus is concerned about a dramatic postprandial spike in her blood glucose levels. Having been diagnosed with diabetes 20 years ago, it seems safe to assume that the postprandial spikes exceed current clinical recommendations for adequate glycemic control. This essay will review the significance of this sign and its etiology.

Glycemic Control

O'Keefe and colleagues (2011) begin their review of glycemic control by discussing the strong epidemiological evidence that links uncontrolled hyperglycemia to cardiovascular disease. Essentially, for every 1% increase in glycated hemoglobin (HbA1c) an individual will incur an 8 and 9% increase in the risk of myocardial infarction and stroke, respectively. HbA1c is an indicator of how well a person has been controlling their blood glucose levels over the long-term. In light of these findings, the patient's concern seems warranted.

Newly diagnosed type 2 diabetes patients are typically advised to try controlling blood glucose levels through lifestyle changes (Owens, 2013). These changes can include regular exercise, if the patient is physically capable, and a high-fiber, low-fat diet (Seggelke, S. & Evenhart, 2013). Research has shown that even minor improvements in BMI, from 5 to 10%, will significantly lower HbA1c levels.

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If lifestyle changes are not sufficient to maintain HbA1c levels below 7%, then oral anti-hyperglycemic medications (OEMs) are typically prescribed (Robbins et al., 2013). The most common OEM prescribed for patients with type 2 diabetes is metformin, a biguanide that decreases gluconeogenesis in the liver and promotes peripheral glucose uptake (Seggelke, S. & Evenhart, 2013). The overall effect is to lower fasting and postprandial glucose levels to below 126 mg/dL and 200 mg/dL, respectively.

Case Study on Postprandial Glycemic Control Diabetes Mellitus Assignment

If HbA1c levels fail to go below 7% with metformin monotherapy within 3 months of beginning treatment then metformin can be combined with a number of other agents, including sulphonylurea, thiazolidinedione, dipeptidyl peptidase-4 (DPP-4) inhibitors, or glucagon-like peptide-1 (GLP-1) receptor agonists (Owens, 2013). The first three months of therapy typically involves a two-drug combination, but if this fails to lower HbA1c levels sufficiently within 3 months then a three-drug combination can be tried for another 3 months. These drug combinations may include the use of an insulin analog once daily (basal insulin). If the various drug combinations fail to achieve glycemic control or are not well tolerated, then a combination of basal and prandial insulin can be tried. This treatment approach has been termed 'basal-plus.' If this fails to achieve glycemic goals, then a full basal-bolus strategy can be tried.

Etiology and Importance of Postprandial Hyperglycemia

In healthy people a postprandial spike in blood glucose can reach 70 to 110 mg/dL after a night of fasting (American Diabetes Association, 2001). This increase is caused by the absorption of carbohydrates and begins about 10 minutes after the start of the meal. Peak levels are reached about an hour later and return to basal levels within about 2-3 hours. This pattern is controlled by the composition of the meal, secretion of insulin and glucagon from the pancreas, and hepatic and peripheral glucose metabolism. In general, the best time to measure postprandial glucose is about 2 hours after the start of a meal.

By contrast, insulin secretion in persons with type 2 diabetes will be delayed and blood glucose levels will exceed normal values (American Diabetic Association, 2001). Postprandial glucose levels that exceed 200 mg/dl are sufficient for a clinical diagnosis of diabetes (Seggelke, S. & Evenhart, 2013); however, the importance of managing postprandial excursions is controversial. A postprandial excursion is generally defined as the difference in blood glucose levels pre- and post-meal (American Diabetes Association, 2001). The most accepted marker of long-term glycemic control is HbA1c levels and a number of large studies have found fasting, postprandial, and mean serum glucose levels are strongly associated with HbA1c; however the same cannot be concluded about postprandial glucose excursions (American Diabetes Association, 2001; Blaak et al., 2012).

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