The means and tools to improve excessive postprandial blood glucose excursions belong to one of three categories: dietary manipulations, nonspecific and specific drug interventions.
The dietary manipulations to improve postprandial blood glucose levels include: (1) global limitations of carbohydrate intake but not below 45% of the daily caloric needs, (2) dividing the carbohydrate-rich foods into different snacks and meals, and (3) limitation of the carbohydrate intake in meals known to be particularly hyperglycemic, like breakfasts, with a shift towards other meals known to be less hyperglycemic, very often lunches and afternoon snacks. In the same line, foods rich in dietary fibers and/or with low GI should be considered.
Drugs Not Specifically Affecting Postprandial Blood Glucose Excursions
In this category, we find metformin, thiazolidinediones, short- or long-acting sulfonylureas and long-acting insulin. These drugs mainly affect the fasting and interprandial blood glucose levels with a minimal or no effect on the relative elevation of postprandial blood glucose levels compared to the preprandial blood glucose levels; in other words, the above drugs modify the set point of the daily blood glucose curve without significantly affecting the postprandial incremental levels.
Drugs Specifically Affecting Postprandial Blood Glucose Excursions
The three main therapies used to improve specifically postprandial blood glucose excursions are a-glucosidase inhibitors, glinides and bolus prepran-dial administration of rapid insulin.
• a-glucosidase inhibitors (Glucor®) are very effective drugs. They are wrongly regarded as drugs difficult to use due to undesirable gastrointestinal side effects. A strategy of a very progressive introduction of low dose tablets with a slowly progressive increase over weeks most of the time permits a very good tolerance profile. We recommend to start with as low as 25 mg once a day for 2 or 3 weeks with an increase step by step, meal by meal, and to stop the increase for one given meal if unbearable flatulence occurs or if the target postprandial delta (blood glucose) excursion is attained, i.e. between 30 and 50mg/dl. This strategy often leads to something like 100 mg Glucor being prescribed before breakfast, 25 mg before lunch and 50 mg before dinner.
• Glinides (Novonorm®, Starlix®) are also often considered as weak oral hyoglycemic agents but seem to us compounds which are very easy to handle and which are perfect as a second-line treatment in addition to a-glucosidase inhibitors or as first-line therapy.
• Bolus preprandial administration of rapid insulin: The most frequent use of preprandial bolus insulin is, nowadays, given using rapid insulin analogues (Humalog®, NovoRapid®, Apidra®). These kinds of insulin are administered either with a syringe, a pen or a pump. Less common ways of administering preprandial insulin bolus are the intranasal or the pulmonary routes of administration. These methods have yet to be fully investigated to become widely used.
Other drugs are very promising in specifically modifying postprandial blood glucose levels, particularly GLP-1 and amyline analogues.
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