From the Guidelines
For high 2-hour postprandial blood glucose in diabetes mellitus patients, rapid-acting insulin analogs like insulin lispro, aspart, or glulisine are typically recommended as they work quickly to lower blood glucose after meals. These can be administered 0-15 minutes before meals at doses individualized to the patient's needs, typically starting at 4-6 units and adjusting based on glucose response 1. Alternatively, oral medications such as repaglinide or nateglinide (meglitinides) can be effective as they stimulate rapid insulin release when taken before meals. GLP-1 receptor agonists like exenatide or liraglutide may also help by slowing gastric emptying and reducing postprandial glucose spikes. For long-term management, adding an SGLT-2 inhibitor or adjusting the basal insulin regimen might be necessary, as suggested by the American Diabetes Association standards of medical care in diabetes 1. Key considerations include:
- Starting dose: 4 U per meal, 0.1 U/kg per meal, or 10% of the basal insulin dose per meal if the HbA1c level is less than 8% 1
- Adjusting basal insulin dose when adding mealtime insulin to avoid hypoglycemia
- Individualizing the treatment plan based on the patient's overall diabetes management plan, comorbidities, and preferences
- Considering cost and affordability of insulin products, particularly in the context of substantial price increases over the past decade 1. The choice of medication should prioritize reducing postprandial hyperglycemia, which significantly contributes to overall glycemic control and helps prevent complications of diabetes.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION There is no fixed dosage regimen for the management of diabetes mellitus with acarbose tablets or any other pharmacologic agent. If no further reduction in postprandial glucose or glycosylated hemoglobin levels is observed with titration to 100 mg t.i.d., consideration should be given to lowering the dose. Patients Receiving Sulfonylureas or Insulin Sulfonylurea agents or insulin may cause hypoglycemia. Acarbose tablets given in combination with a sulfonylurea or insulin will cause a further lowering of blood glucose and may increase the potential for hypoglycemia.
The medication that should be given if there is hyperglycemia (high 2-hour postprandial) in a Diabetes Mellitus (DM) patient is acarbose or other medications such as sulfonylureas or insulin.
- Acarbose can be initiated at a dose of 25 mg three times daily, with gradual dose escalation to a maximum of 100 mg three times daily.
- Sulfonylureas or insulin may also be used, but the dose should be adjusted to avoid hypoglycemia. It is essential to monitor blood glucose levels and adjust the medication dosage accordingly to achieve adequate glycemic control 2.
From the Research
Medication Options for Hyperglycemia in Diabetes Mellitus Patients
- The following medications can be used to manage hyperglycemia in Diabetes Mellitus (DM) patients:
- alpha-Glucosidase inhibitors like acarbose and miglitol, which attenuate the rate of absorption of sucrose by acting on the luminal enzymes 3
- Newer insulin secretagogues like third generation sulfonylureas (e.g. glimepiride) and nonsulfonylurea secretagogues (e.g. repaglinide and nateglinide), which mimic the physiological release of insulin and ameliorate postprandial hyperglycemia (PPHG) 3
- Rapid-acting insulin analogs, which have a faster onset of action and help to specifically target PPHG 3, 4, 5
- Amylin analogues like pramlintide, which reduce PPHG by slowing gastric emptying and delivery of nutrients to the absorbing surface of the gut 3, 4
- Meglitinide analogues like repaglinide, which stimulate endogenous insulin secretions and lower postprandial hyperglycaemic excursions when given before meals 4
- Oral insulin products like hexyl-insulin monoconjugate 2 (HIM2), which can control postprandial glycemia without causing peripheral hyperinsulinemia in patients with type 2 diabetes 6
- Insulin aspart, a rapid-acting human insulin analog, which provides more rapid absorption than regular human insulin after subcutaneous administration and improves postprandial glycemic control 5
Mechanisms of Action
- These medications work through various mechanisms to control hyperglycemia, including:
- Delaying glucose absorption
- Stimulating insulin secretion
- Reducing glucose production in the liver
- Improving insulin sensitivity
- Mimicking the physiological response to meals