SOURCE: Yacoub T. Impact of improving postprandial glycemic control with intensifying insulin therapy in type 2 diabetes. Postgrad Med 2017;129:791-800.

One commonly advocated method for approaching correction of hyperglycemia in type 2 diabetes is “fix the fasting first.” Basal insulins have been used commonly to fix fasting glucose, but even with sensible combinations of insulin and oral agents, as many as 40% or more of patients will need to address postprandial glucose excursions (PPG) to attain desirable A1c goals.

In support of maintenance of PPG, epidemiologic data point to an association between PPG and cardiovascular disease risk. Whether management of PPG ameliorates consequences (independently from overall glucose control, especially fasting glucose) has been more difficult to confirm. Repaglinide is a rapid-acting oral agent producing prompt but short-lived insulin secretion from beta cells. Although the receptor site for repaglinide is the same as that for sulfonylureas (e.g., glipizide, glimepiride), it is in a distinct pharmacologic category because it differs structurally from sulfonylureas and lacks a sulfonamide group characteristic of sulfonylureas.

In a clinical trial comparing repaglinide with glyburide, PPG was reduced more with the former; repaglinide also was associated with greater carotid intima media thickness regression. When control of fasting glucose has been achieved but excessive PPG excursions remain, therapeutic choices include adding prandial insulin, alpha-glucosidase inhibitors (e.g., acarbose), or adding glucagon-like peptide-1 receptor agonists (e.g., liraglutide, exenatide). Currently, it is unclear what the preferred method of PPG control should be, but the most recent American Diabetes Association 2018 guidelines suggest that for persons with established cardiovascular disease who have not attained glucose goals, incorporation of agents that have shown cardiovascular risk reduction (i.e., canagliflozin, empagliflozin, liraglutide) should be a priority.