Variabilité glycémique et hyperglycémie postprandiale : quelle importance au-delà del'HbA1c?

The dysglycemia of diabetes mellitus can be depictedas the 'glycemic triumvirate' with its three components : the sustained chronic ('ambient') hyperglycemia assessed from HbA1c measurements, glucose variability, and hypoglycemic episodes. Postprandial glucose excursions are additional glycemic disorders that should be integrated both in the 'ambient' hyperglycemia and glucose variability. Reducing chronic glucose exposure as assessed by HbA1cassays is one of the main targets in the treatment of diabetes, even though this position is not consensually accepted by every one. More controversial are the roles of glucose variability and postprandial glucose excursions. At present, these two disorders remain a subject of debate. Arguments based on surrogate markers seem to indicate that both are key players in the development and progression of diabetic complications. However, we are sadly lacking of data based on long-term interventional trials with assessment of such 'hard' outcomes as major cardiovascularevents. Nevertheless, it remains thatexcess of glucose fluctuations is a causative risk factor for hypoglycemic episodes irrespective of diabetes types. A clear response to the possible harmful effects of glucose variability, postprandial glucose surges and hypoglycemic episodes will be only provided by interventional trials such as the ongoing FLAT-SUGAR study, a proof-of-concept trial, which is a necessary step prior to any planning of larger and harder outcomes trials. Awaiting the results of such studies does not mean that due consideration should not be given to antidiabe-tic therapeutic strategies aimed at reducing the ambient hyperglycemia and glucose variability concomitantly. Some classes of medications such as the 'incretin-based therapies' seem to be appropriate for achieving the two aforementioned objectives. However the experience shows that this side of the story has never been thoroughly addressed either in the recent past or currently.