What are the desired goals of glucose values in type 2 diabetes mellitus (DM) and how should treatment change accordingly?

Updated: Oct 23, 2019
  • Author: Romesh Khardori, MD, PhD, FACP; Chief Editor: George T Griffing, MD  more...
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Answer

Some patients need reduction of their oral antidiabetic agent to prevent daytime hypoglycemia as the bedtime insulin is initiated or increased and the fasting glucose concentration decreases. If a GLP-1 agonist is used, the author monitors fasting and postprandial sugars, expecting a marked flattening of the postprandial rise in glucose concentrations.

Measurement of glucose patterns in patients with type 2 diabetes, particularly those who have central obesity and hepatic steatosis, often reveals that the highest preprandial glucose level of the day is before breakfast (because of disordered hepatic glucose production overnight), with a "stair-step" decrease during the day (after the usual postmeal rise). These higher-than-desired morning glucose values do not necessarily dictate abandonment of the current therapeutic regimen, provided that the HbA1c level is at target.

For patients trying to achieve near euglycemia, premeal glucose values of 80-120 mg/dL are the goal, with the patient going to sleep at night with a value at least 100 mg/dL. In patients with less stringent glycemic goals (eg, because of advanced age, advanced complications, or severe concomitant disease), preprandial glucose values of 100-140 mg/dL are desired. Because of the limitations of therapies, essentially no patient is able to achieve these goals all the time if, in fact, insulin is needed to treat their disease.

For patients who primarily have fasting hyperglycemia, basal insulin is the easiest way to correct this abnormality. Basal insulin is typically scheduled at bedtime but can be given at suppertime if that is more convenient for the patient.

The goal of a combined daytime oral agent plus once-a-day insulin is to lower the fasting glucose level to 100 mg/dL by titrating the insulin. When this target is achieved, the oral agents can be effective in maintaining preprandial and postprandial blood glucose levels throughout the day. If a regimen combining oral agents and insulin fails to lower glucose levels into the normal range, patients should be switched to a daily multiple-injection schedule with a premeal rapid-acting insulin and a longer-acting basal insulin.


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