Survey of glargine use in 115 pregnant women with Type 1 diabetes

Use of insulin glargine during pregnancy: A review

BACKGOUND AND AIMS

Hyperglycemia during pregnancy is increasing globally. Insulin therapy is considered the standard of care for its optimum management. Insulin glargine, in spite of widespread use in non-pregnant adults, lacks randomized controlled trial evidence as safe basal insulin during pregnancy. Aim of this review is to discuss major available evidences and recommendations on the use of insulin glargine during pregnancy.

METHODS

Evidences related to use of insulin glargine during pregnancy, including animal studies, placental transfer studies, case reports as well as observational studies were retrieved using PUBMED & Google scholar. Recommendations regarding use of insulin glargine during pregnancy by international and Indian organizations were reviewed.

RESULTS

Trans-placental transfer studies show that insulin glargine does not cross placenta when used at therapeutic concentrations. Although there are no randomized controlled trials on insulin glargine in pregnancy, it's use during pregnancy is not associated with any adverse maternal or neonatal outcomes as shown in many case reports and observational studies (both prospective and retrospective). It's use during pregnancy is hence considered safe by many organizations across the globe.

CONCLUSIONS

Insulin glargine can be continued safely during pregnancy in women who are already taking it prior to pregnancy and have achieved good glycemic control with it. However we require preferably randomized controlled trials or large prospective observational studies to establish it as first line or preferred basal insulin for management of hyperglycemia during pregnancy.

Effectiveness of Insulin Analogs Compared with Human Insulins in Pregnant Women with Diabetes Mellitus: Systematic Review and Meta-analysis

Diabetes during pregnancy has been linked to unfavorable maternal-fetal outcomes. Human insulins are the first drug of choice because of the proven safety in their use. However, there are still questions about the use of insulin analogs during pregnancy. The objective of the present study was to determine the effectiveness of insulin analogs compared with human insulin in the treatment of pregnant women with diabetes through a systematic review with meta-analysis. The search comprised the period since the inception of each database until July 2017, and the following databases were used: MEDLINE, CINAHL, EMBASE, ISI Web of Science, LILACS, Scopus, SIGLE and Google Scholar. We have selected 29 original articles: 11 were randomized clinical trials and 18 were observational studies. We have explored data from 6,382 participants. All of the articles were classified as having an intermediate to high risk of bias. The variable that showed favorable results for the use of insulin analogs was gestational age, with a mean difference of - 0.26 (95 % confidence interval [CI]: 0.03-0.49; p = 0.02), but with significant heterogeneity (Higgins test [I2] = 38%; chi-squared test [χ2] = 16.24; degree of freedom [DF] = 10; p = 0.09). This result, in the clinical practice, does not compromise the fetal well-being, since all babies were born at term. There was publication bias in the gestational age and neonatal weight variables. To date, the evidence analyzed has a moderate-to-high risk of bias and does not allow the conclusion that insulin analogs are more effective when compared with human insulin to treat diabetic pregnant women.

Inpatient Glycemic Management of the Pregnant Patient

PURPOSE OF REVIEW

There is a rising prevalence of type 1 diabetes (T1DM), type 2 diabetes (T2DM), and gestational diabetes (GDM) in pregnancy. Reaching and maintaining glycemic targets during and after this time are important for both the health of the mother and her baby.

RECENT FINDINGS

Based on recently published guidelines from various societies, we review the diagnosis of diabetes in pregnancy, types of therapies available to maintain euglycemia, important keys to management of T1DM, T2DM, and GDM, and strategies for reaching inpatient glycemic targets during the peripartum period. Care for pregnant patients with T1DM is especially challenging, and providers should be aware of the varying insulin requirements at different stages of pregnancy and how to reduce hypoglycemia and avoid diabetic ketoacidosis. Insulin sensitivity fluctuates throughout pregnancy due to physiologic changes, especially during labor and delivery and immediately post-partum. We review recommendations regarding how to manage this dynamic time and present our own institution's inpatient management protocol. Finally, we review management of diabetes post-partum, including medications, breast-feeding, and continued monitoring and screening. With the collaborative efforts of the patient and an interdisciplinary team and in-depth knowledge of the most up-to-date management principles, it is possible to achieve euglycemia during this critical time of a mother and baby's life.

Insulin analogues in pregnancy and specific congenital anomalies: a literature review

Insulin analogues are commonly used in pregnant women with diabetes. It is not known if the use of insulin analogues in pregnancy is associated with any higher risk of congenital anomalies in the offspring compared with use of human insulin. We performed a literature search for studies of pregnant women with pregestational diabetes using insulin analogues in the first trimester and information on congenital anomalies. The studies were analysed to compare the congenital anomaly rate among foetuses of mothers using insulin analogues with foetuses of mothers using human insulin. Of 29 studies, we included 1286 foetuses of mothers using short-acting insulin analogues with 1089 references of mothers using human insulin and 768 foetuses of mothers using long-acting insulin analogues with 685 references of mothers using long-acting human insulin (Neutral Protamine Hagedorn). The congenital anomaly rate was 4.84% and 4.29% among the foetuses of mothers using lispro and aspart. For glargine and detemir, the congenital anomaly rate was 2.86% and 3.47%, respectively. No studies on the use of insulin glulisine and degludec in pregnancy were found. There was no statistically significant difference in the congenital anomaly rate among foetuses exposed to insulin analogues (lispro, aspart, glargine or detemir) compared with those exposed to human insulin or Neutral Protamine Hagedorn insulin. The total prevalence of congenital anomalies was not increased for foetuses exposed to insulin analogues. The small samples in the included studies provided insufficient statistical power to identify a moderate increased risk of specific congenital anomalies.

Management of Pregnant Women with Type 2 Diabetes Mellitus and the Consequences of Fetal Programming in Their Offspring

The obesity epidemic has fueled an epidemic of prediabetes and type 2 diabetes mellitus in women of childbearing age. This paper examines the state of the science on preconception and pregnancy management of women with type 2 diabetes to optimize outcomes for the women and their infants. In addition, the consequence of fetal programming as a result of suboptimal maternal glycemic control is discussed. The paper focuses on type 2 diabetes, not type 1 diabetes or gestational diabetes. Management of women with type 2 diabetes includes preconception counseling, preconception weight management and weight loss, proper weight gain during pregnancy, self-monitoring of blood glucose levels, medication, medical nutrition therapy, and exercise.

Diabetes and pregnancy: an endocrine society clinical practice guideline

OBJECTIVE

Our objective was to formulate a clinical practice guideline for the management of the pregnant woman with diabetes.

PARTICIPANTS

The Task Force was composed of a chair, selected by the Clinical Guidelines Subcommittee of The Endocrine Society, 5 additional experts, a methodologist, and a medical writer.

EVIDENCE

This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence.

CONSENSUS PROCESS

One group meeting, several conference calls, and innumerable e-mail communications enabled consensus for all recommendations save one with a majority decision being employed for this single exception.

CONCLUSIONS

Using an evidence-based approach, this Diabetes and Pregnancy Clinical Practice Guideline addresses important clinical issues in the contemporary management of women with type 1 or type 2 diabetes preconceptionally, during pregnancy, and in the postpartum setting and in the diagnosis and management of women with gestational diabetes during and after pregnancy.

The use of insulin analogues in pregnancy

Excellent glycaemic control is essential in pregnancy to optimise maternal and foetal outcomes. The aim of this review is to assess the efficacy and safety of insulin analogues in pregnancy. Insulin lispro and insulin aspart are safe in pregnancy and may improve post-prandial glycaemic control in women with type 1 diabetes. However, a lack of data indicating improved foetal outcomes would suggest that there is no imperative to switch to a short-acting analogue where the woman's diabetes is well controlled with human insulin. There are no reports of the use of insulin glulisine in pregnancy and so its use cannot be recommended. Most studies of insulin glargine in pregnancy are small, retrospective and include women with pre-existing diabetes and gestational diabetes. There appear to be no major safety concerns and so it seems reasonable to continue insulin glargine if required to achieve excellent glycaemic control. A head-to-head comparison between insulin detemir and NPH insulin in women with type 1 diabetes showed that while foetal outcomes did not differ, fasting plasma glucose improved with insulin detemir without an increased incidence of hypoglycaemia. The greater evidence base supports the use of insulin detemir as the first line long-acting analogue in pregnancy but the lack of definitive foetal benefits means that there is no strong need to switch a woman who is well controlled on NPH insulin. There seems little justification in using long acting insulin analogues in women with gestational diabetes or type 2 diabetes where the risk of hypoglycaemia is low.

The incidence of severe hypoglycaemia in pregnant women with type 1 diabetes mellitus can be reduced with unchanged HbA1c levels and pregnancy outcomes in a routine care setting

AIMS

To investigate whether the incidence of severe hypoglycaemia in pregnant women with type 1 diabetes can be reduced without deteriorating HbA1c levels or pregnancy outcomes in a routine care setting.

METHODS

Two cohorts (2004-2006; n=108 and 2009-2011; n=104) were compared. In between the cohorts a focused intervention including education of caregivers and patients in preventing hypoglycaemia was implemented. Women were included at median 8 (range 5-13) weeks. Severe hypoglycaemia (requiring assistance from others) was prospectively reported in structured interviews.

RESULTS

In the first vs. second cohort, severe hypoglycaemia during pregnancy occurred in 45% vs. 23%, p=0.0006, corresponding to incidences of 2.5 vs. 1.6 events/patient-year, p=0.04. Unconsciousness and/or convulsions occurred at 24% vs. 8% of events. Glucagon and/or glucose injections were given at 15% vs. 5% of events. At inclusion HbA1c was comparable between the cohorts while in the second cohort fewer women reported impaired hypoglycaemia awareness (56% vs. 36%, p=0.0006), insulin dose in women on multiple daily injections was lower (0.77 IU/kg (0.4-1.7) vs. 0.65 (0.2-1.4), p=0.0006) and more women were on insulin analogues (rapid-acting 44% vs. 97%, p<0.0001; long-acting 6% vs. 76%, p<0.0001) and insulin pumps (5% vs. 23%, p<0.0001). Pregnancy outcomes were similar in the two cohorts.

CONCLUSIONS

A 36% reduction in the incidence of severe hypoglycaemia in pregnancy with unchanged HbA1c levels and pregnancy outcomes was observed after implementation of focused intervention against severe hypoglycaemia in a routine care setting. Improved insulin treatment, increased health professional education and fewer women with impaired hypoglycaemia awareness may contribute.

Insulin analogues in the treatment of diabetes in pregnancy

Pregnancy affects both maternal and fetal metabolism, and even in non-diabetic women, it exerts a diabetogenic effect. Among pregnant women, 2% to 14% develop gestational diabetes. Pregnancy can also occur in women with preexisting diabetes, which may predispose the fetus to many alterations in organogenesis, restrict growth, and the mother, to some diabetes-related complications, such as retinopathy and nephropathy, or to acceleration of the course of these complications, if they are already present. Women with gestational diabetes generally start their treatment with diet and lifestyle changes; when these changes are not enough for optimal glycemic control, insulin therapy must then be considered. Women with type 2 diabetes using oral hypoglycemic agents are advised to change to insulin therapy. Those with preexisting type 1 diabetes should start intensive glycemic control. As basal insulin analogues have frequently been used off-label in pregnant women, there is a need to evaluate their safety and efficacy. The aim of this review is to report the use of both short- and long-acting insulin analogues during pregnancy and to enable clinicians, obstetricians, and endocrinologists to choose the best insulin treatment for their patients.

Future of newer basal insulin

Basal insulin have been developed over the years. In recent times newer analogues have been added to the armanentarium for diabetes therapy. This review specifically reviews the current status of different basal insulins.

Treatment with the long-acting insulin analogues detemir or glargine during pregnancy in women with type 1 diabetes: comparison of glycaemic control and pregnancy outcome

OBJECTIVE

To compare glycaemic control and pregnancy outcome in women with type 1 diabetes treated with the long-acting insulin analogues detemir or glargine.

METHODS

Retrospective study of singleton pregnancies from 2007 to 2011 in women with type 1 diabetes with a single living fetus at 22 weeks using either insulin detemir (n = 67) or glargine (n = 46) from conception.

RESULTS

Baseline characteristics were similar in the detemir and glargine groups. Haemoglobin A1c was comparable at 8 weeks (median 6.6% (range 5.6-9.8) vs. 6.8% (5.4-10.1), p = 0.15) and at 33 weeks (6.1% (5.1-7.6) vs. 6.2% (4.8-7.2), p = 0.38). The incidence of severe hypoglycaemia was comparable (15 (23%) vs. 10 (23%), p = 0.98). Pre-eclampsia occurred in 9 (14%) vs. 8 (18%), p = 0.52, pre-term delivery in 21 (31%) vs. 16 (35%), (p = 0.70) and 33 (49%) vs. 14 (30%) infants were large for gestational age (p = 0.046). No perinatal deaths were observed. One offspring in each group was born with a major congenital malformation.

CONCLUSIONS

Glycaemic control and pregnancy outcome were comparable in women using insulin detemir or glargine, except for a lower prevalence of large for gestational age infants in women on glargine. The use of both long-acting insulin analogues during pregnancy seems safe.

Managing type 1 diabetes mellitus in pregnancy--from planning to breastfeeding

Type 1 diabetes mellitus in pregnant women increases the risk of adverse outcomes for mother and offspring. Careful preconception counselling and screening is important, with particular focus on glycaemic control, indications for antihypertensive therapy, screening for diabetic nephropathy, diabetic retinopathy and thyroid dysfunction, as well as review of other medications. Supplementation with folic acid should be initiated before conception in order to minimize the risk of fetal malformations. Obtaining and maintaining tight control of blood glucose and blood pressure before and during pregnancy is crucial for optimizing outcomes; however, the risk of severe hypoglycaemia during pregnancy is a major obstacle. Although pregnancy does not result in deterioration of kidney function in women with diabetic nephropathy and normal serum creatinine levels, pregnancy complications such as pre-eclampsia and preterm delivery are more frequent in these women than in women with T1DM and normal kidney function. Rapid-acting insulin analogues are considered safe to use in pregnancy and studies on long-acting insulin analogues have provided reassuring results. Immediately after delivery the insulin requirement declines to approximately 60% of the prepregnancy dose, and remains 10% lower than before pregnancy during breastfeeding.

Hypoglycaemia during pregnancy in women with Type 1 diabetes

AIMS

To explore incidence, risk factors, possible pathophysiological factors and clinical management of hypoglycaemia during pregnancy in women with Type 1 diabetes.

METHODS

Literature review.

RESULTS

In women with Type 1 diabetes, severe hypoglycaemia occurs three to five times more frequently in early pregnancy than in the period prior to pregnancy, whereas in the third trimester the incidence of severe hypoglycaemia is lower than in the year preceding pregnancy. The frequency distribution of severe hypoglycaemia is much skewed, as 10% of the pregnant women account for 60% of all recorded events. Risk factors for severe hypoglycaemia during pregnancy include a history with severe hypoglycaemia in the year preceding pregnancy, impaired hypoglycaemia awareness, long duration of diabetes, low HbA(1c) in early pregnancy, fluctuating plasma glucose values (≤ 3.9 mmol/l or ≥ 10.0 mmol/l) and excessive use of supplementary insulin injections between meals. Pregnancy-induced nausea and vomiting seem not to be contributing factors.

CONCLUSIONS

Striving for near-normoglycaemia with focus on reduction of plasma glucose fluctuations during pregnancy should have high priority among clinicians with the persistent aim of improving pregnancy outcome among women with Type 1 diabetes. Pre-conception counselling, carbohydrate counting, use of insulin analogues, continuous subcutaneous insulin infusion (insulin pump) therapy and real-time continuous glucose monitoring with alarms for low glucose values might be relevant tools to obtain near-normoglycaemia without episodes of severe hypoglycaemia.

Insulins: past, present, and future

This article highlights selected milestones in insulin discovery and its continued development as a pivotal therapy for diabetes. The last 90 years have witnessed tremendous progress in insulin therapy, from the initial crude, yet life-saving, animal insulin extracts to novel human insulin analogues. Although the complete physiologic replacement of insulin is inherently difficult to achieve with open-loop subcutaneously administered insulin, the continued development of improved injectable insulin formulations with superior pharmacokinetics and pharmacodynamics will enhance glucose control, and represents important clinical advances in the treatment of both type 1 and type 2 diabetes.

Contraception, and pregnancy in adolescents with type 1 diabetes: a review

Adolescence is a critical period for girls with type 1 diabetes mellitus (T1D). Reproductive issues, such as menstrual abnormalities, risk of an unplanned pregnancy, and contraception, should be addressed during this phase of life. This paper reviews several reproductive issues that are important in the care of adolescents, including pubertal development, menstrual abnormalities, ovulatory function, reproductive problems, the effects of hyperglycemia, contraception, and treatment of an unplanned pregnancy. A review of the literature was conducted. A MEDLINE search January 1966 to March 2011 was performed using the following MESH terms: puberty, menarche, ovary, polycystic ovary syndrome, menstruation, contraception, contraception-barrier, contraceptives-oral-hormonal, sex education, family planning services, and pregnancy in adolescence. This literature search was cross-referenced with an additional search on diabetes mellitus-type 1, diabetes complications, and pregnancy in diabetes. All published studies were searched regardless of the language of origin. Bibliographies were reviewed to extract additional relevant sources.

Insulin pumps in pregnancy: using technology to achieve normoglycemia in women with diabetes

Poorly controlled diabetes before conception and during pregnancy among women with pre-existing diabetes can cause major birth defects and spontaneous abortions, as wells as abnormal fetal growth and development including an offspring who is small or large for gestational age, or predisposed to obesity, type 2 diabetes, and metabolic syndrome in his/her lifetime. Conversely, for a woman with pre-existing diabetes, optimizing blood glucose levels before and during early pregnancy can reduce these risks dramatically. As insulin pump technology has evolved, continuous subcutaneous insulin infusion has become a safe and reliable method for treating diabetes during pregnancy. Although pump therapy is often preferred by patients and some experts, insulin pumps have not yet been shown to be superior to multiple daily injections of insulin during pregnancy. In this review of the literature we focus on the use of insulin pumps in the management of diabetes in pregnancy.

Pregnancy management of women with pregestational diabetes

Optimal glycemic control is pivotal to the successful outcome of diabetic pregnancy. The goals for glycemic control include levels for preprandial and postprandial glucose and HbA1c as well as avoidance of severe hypoglycemia. These goals are best obtained with diet, exercise, and insulin treatment, often a multiple-dose insulin regimen or insulin pump. A focus on blood pressure, microalbuminuria, diabetic nephropathy, and diabetic retinopathy is needed.

Basal insulin analogues in diabetic pregnancy: a literature review and baseline results of a randomised, controlled trial in type 1 diabetes

As basal insulin analogues are being used off-label, there is a need to evaluate their safety (maternal hypoglycaemia and fetal and perinatal outcomes) and efficacy [haemoglobin A1c(HbA1c), fasting plasma glucose, and maternal weight gain]. The aim of this review is to provide an overview of the current literature concerning basal insulin analogue use in diabetic pregnancy, and to present the design and preliminary, non-validated baseline characteristics of a currently ongoing randomized, controlled, open-label, multicentre, multinational trial comparing insulin detemir with neutral protamine hagedorn insulin, both with insulin aspart, in women with type 1 diabetes planning a pregnancy (n = 306) or are already pregnant (n = 164). Inclusion criteria include type 1 diabetes > 12 months' duration; screening HbA1c ≤ 9.0% (women recruited prepregnancy), or pregnant with gestational age 8-12 weeks and HbA1c ≤ 8.0% at randomization. At confirmation of pregnancy all subjects must have HbA1c ≤ 8.0%. Exclusion criteria include impaired hepatic function, cardiac problems, and uncontrolled hypertension. Subjects are randomized to either insulin detemir or neutral protamine hagedorn insulin, both with prandial insulin aspart. The results are expected mid-2011 with full publications expected later this year. Baseline characteristics show that basal insulin analogues are already frequently used in pregnant women with type 1 diabetes. This study will hopefully elucidate the safety and efficacy of the basal insulin analogue detemir in diabetic pregnancy.

Basal insulin treatment in type 2 diabetes

Insulin glargine is the first 24-h recombinant DNA insulin analog introduced to the market. Substitution of glycine for asparagine and addition of two arginine residues raise the isoelectric point of insulin glargine and result in microprecipitates, delaying absorption from subcutaneous tissue. This delayed absorption result in fairly flat 24-h insulin concentration profiles with no discernible peak. Large, multicenter, randomized, controlled trials in patients with type 2 diabetes show that although NPH insulin and insulin glargine are equally effective in lowering glycosylated hemoglobin (A1c) and fasting blood glucose, there is a clear advantage of insulin glargine over NPH insulin in reducing nocturnal and overall hypoglycemia. Lower risk of hypoglycemia with glargine was also consistently demonstrated by trials comparing insulin glargine and premixed analog insulins. These studies also showed greater reduction in A1c with twice-daily premixed insulins compared with glargine, when insulin glargine was administered without mealtime insulin coverage. Insulin glargine was also compared with another insulin analog, insulin detemir. Trials showed that both insulin analogs are equally effective in lowering A1c and have comparable risk of hypoglycemia. Trials comparing insulin glargine with glucagon-like peptide-1 agonists showed comparable significant reductions in A1c with both regimens. Insulin glargine is well tolerated, has low immunogenicity, reduced risks for acute myocardial infarction, and a lower risk of hypoglycemia compared with NPH insulin in individuals with type 2 diabetes.

Managing diabetes during pregnancy with insulin lispro: a safe alternative to human insulin

OBJECTIVE

To assess the safety of the use of insulin lispro during pregnancy on the basis of published literature and to report on any related efficacy findings.

METHODS

The National Center for Biotechnology Information Entrez Database PubMed (http://www.ncbi. nlm.nih.gov/pubmed/) was used to search for citations from MEDLINE in the November 2009 time frame that contained safety data and efficacy results on the use of insulin lispro during pregnancy.

RESULTS

From the MEDLINE search, we identified a total of 27 publications (with 1,265 pregnancies) with relevant information, which were included in this report. No statistically significant differences in the rates of occurrence of congenital anomalies or spontaneous abortions associated with the use of insulin lispro during pregnancy, in comparison with the use of human insulin, were reported. Moreover, in comparison with human insulin, insulin lispro was reported to result in improved glycemic control, as demonstrated by lower postprandial glucose concentrations and hemoglobin A1c levels.

CONCLUSION

The current review of the published literature indicates that insulin lispro is a safe alternative to human insulin with similar perinatal outcomes and potentially improved glycemic control in the management of diabetes during pregnancy.

Type 1 diabetes control and pregnancy outcomes in women treated with continuous subcutaneous insulin infusion (CSII) or with insulin glargine and multiple daily injections of rapid-acting insulin analogues (glargine-MDI)

AIM

The best way to treat pregnant patients who have type 1 diabetes is still unclear. For this reason, the present study compared metabolic control and maternal-fetal outcomes in patients treated with continuous subcutaneous infusions of rapid-acting insulin analogues (CSII) or with insulin glargine and multiple daily injections of rapid-acting insulin analogues (glargine-MDI).

METHODS

This retrospective multicentre study involved 144 women with type 1 diabetes, 100 of whom were using CSII and 44 glargine-MDI. Outcomes analyzed were metabolic control, diabetes complications, pregnancy outcome, perinatal morbidity and mortality, and fetal malformations.

RESULTS

The two groups were comparable for age, prepregnancy BMI, primiparous rate and diabetes complications, although patients using CSII had longer duration of diabetes (P=0.03) and higher White classifications (P=0.04). In both groups, metabolic control improved during pregnancy, but good control was reached earlier among patients using CSII. At parturition, patients using CSII had lower HbA(1c) (6.2±0.7% vs 6.5±0.8%; P=0.02) and required less insulin (P<0.01). Weight gain was similar in both groups, and maternal-fetal outcomes did not differ.

CONCLUSION

In pregnant patients with type 1 diabetes, MDI and CSII are equivalent in terms of metabolic control and fetal-maternal outcomes, although patients using CSII achieved good control earlier and with less insulin.

Use of insulin lispro during pregnancy in women with pregestational diabetes mellitus

BACKGROUND AND OBJECTIVE

To assess the safety and efficacy of insulin analogues versus human insulin in pregnant women with pregestational diabetes.

PATIENTS AND METHODS

We collected data on pregnant women with type 1 or type 2 diabetes who were attended at the Diabetes and Pregnancy Unit between January 1998 and April 2008 (N=351). Two hundred and forty one patients were treated with regular insulin and NPH and 110 were treated with different combinations of insulins including an insulin analogue (most of them with NPH and lispro).

RESULTS

There was no significant difference in terms of congenital malformation rate between groups (3.3% and 3.6%). The group on insulin analogue had slightly higher mean HbA1c during the first trimester than the group on human insulin (6.6 [1.0]% vs 6.9 [1.1]%; P=0,022) and needed smaller insulin doses during whole pregnancy. Severe hypoglycaemia was significantly less frequent among women treated with a rapid insulin analogue (2.3 vs 10.0%; P=0,025). Neonatal hypoglycaemia was significantly more frequent in the group treated with a rapid insulin analogue (34.9 vs 23.6%; P=0.043) due to the concomitant use of an insulin pump. Other obstetric and neonatal variables were not different between the two groups.

CONCLUSION

Our study shows that insulin analogues are safe during pregnancy in women with pregestational diabetes mellitus. Overall, glycaemic control, maternal and foetal outcome were similar to those with human insulin. The main advantage with respect to human insulin was to importantly reduce maternal severe hypoglycaemia.

Pregnancy and Diabetes Management: Advances and Controversies

BACKGROUND

The treatment of diabetes in pregnancy has potentially far-reaching benefits for both pregnant women with diabetes and their children and may provide a cost-effective approach to the prevention of obesity, type 2 diabetes mellitus, and metabolic syndrome. Early and accurate diagnosis of diabetes in pregnancy is necessary for optimizing maternal and fetal outcomes.

CONTENT

Optimal control of diabetes in pregnancy requires achieving normoglycemia at all stages of a woman's pregnancy, including preconception and the postpartum period. In this review we focus on new universal guidelines for the screening and diagnosis of diabetes in pregnancy, including the 75-g oral glucose tolerance test, as well as the controversy surrounding the guidelines. We review the best diagnostic and treatment strategies for the pregestational and intrapartum periods, labor and delivery, and the postpartum period, and discuss management algorithms as well as the safety and efficacy of diabetic medications for use in pregnancy.

SUMMARY

Global guidelines for screening, diagnosis, and classification have been established, and offer the potential to stop the cycle of diabetes and obesity caused by hyperglycemia in pregnancy. Normoglycemia is the goal in all aspects of pregnancy and offers the benefits of decreased short-term and long-term complications of diabetes.

Insulin analogues in the management of the pregnancy complicated by diabetes mellitus

Since their introduction, insulin analogues are the preferred choice for short-acting insulin due to their superior pharmacologic profiles, leading to greater flexibility and convenience of dosing and, thus, greater patient satisfaction and improved quality of life. Over the past few years, clinical experience with insulin analogues in pregnancy has increased. The most studied, insulin lispro, has been shown to be a safe and clinically effective option in the treatment of the diabetic gravida. Studies of the other insulin analogues are limited, but promising. Further research is warranted to evaluate safety and efficacy of these analogues.

Placental transfer of the insulin analog glargine in the ex vivo perfused placental cotyledon model

OBJECTIVE

The aim was to characterize the transfer of the insulin analog glargine across the placenta using the placental perfusion model.

METHODS

Placentas were obtained and selected cotyledons were cannulated and dually perfused. Glargine, 50 mU/L (n = 2) and 200 mU/L (n = 1), and a reference marker, antipyrine (50 μg/mL), were added to the maternal circulation. Samples were taken from the maternal and fetal compartments.

RESULTS

Glargine was not detected in the fetal compartment. In the maternal compartment, the steady state concentration was 50% lower than the starting concentration.

CONCLUSIONS

Glargine probably does not cross the human placenta. Reduced maternal steady state concentrations may suggest insulin uptake by the placenta.

Insulin during pregnancy, labour and delivery

Optimal glycaemic control is of the utmost importance to achieve the best possible outcome of a pregnancy complicated by diabetes. This holds for pregnancies in women with preconceptional type 1 or type 2 diabetes as well as for pregnancies complicated by gestational diabetes. Glycaemic control is conventionally expressed in the HbA1c value but the HbA1c value does not completely capture the complexity of glycaemic control. The daily glucose profile measured by the patients themselves through measurements performed in capillary blood obtained by finger stick provides valuable information needed to adjust insulin therapy. Hypoglycaemia is the major threat to the pregnant woman or the woman with tight glycaemic control in the run-up to pregnancy. Repetitive hypoglycaemia can lead to hypoglycaemia unawareness, which is reversible with prevention of hypoglycaemia. A delicate balance should be struck between preventing hyperglycaemia and hypoglycaemia. Insulin requirements are not uniform across the day: it is low during the night with a more or less pronounced rise at dawn, followed by a gradual decrease during the remainder of the day. A basal amount of insulin is needed to regulate the endogenous glucose production, short-acting insulin shots are needed to handle exogenous glucose loads. Insulin therapy means two choices: the type of insulin used and the method of insulin administration. Regarding the type of insulin, the choice is between human and analogue insulins. The analogue short-acting insulin aspart has been shown to be safe during pregnancy in a randomised trial and has received registration for this indication; the short-acting analogue insulin lispro has been shown to be safe in observational studies. No such information is available on the long-acting insulin analogues detemir and glargine and both are prescribed off-label with human long-acting insulin as obvious alternatives. Randomised trials have not been able to show superiority of continuous subcutaneous insulin administration (CSII (insulin pump)) over intensive insulin injection therapy (multiple-dose insulin (MDI)) on any maternal or foeto-neonatal end point. However, group sizes were far too small to allow assessment of superiority and issues such as manageability of the disease and quality of life were never assessed. These two issues are of major importance to patients. The first trimester is often the period of most hypoglycaemic events, and insulin therapy should be especially closely monitored and adjusted in this period. After midterm, insulin requirements increase. Continuous glucose monitoring can offer better insights into the glycaemic profile than self-monitoring of blood glucose levels by the patients but the place of these new monitoring techniques has yet to be established more clearly. Insulin therapy during labour means short-acting insulin adjusted to achieve glucose levels between 4 and 8 mmol l(-1) to prevent neonatal hypoglycaemia as much as possible. After delivery, glycaemic control must be relaxed to prevent hypoglycaemia, especially in women who breastfeed.

Pregestational diabetes

The prevalence of preexisting diabetes in pregnancy is increasing largely because of an increase in type 2 diabetes. Outcomes of diabetic pregnancies for mother and newborn have improved greatly in recent decades from advances in understanding the disease process, improved education, and new treatment modalities delivered in a team approach. Nausea and vomiting from pregnancy and pregnancy-associated insulin resistance can make glycemic control a challenge. Care of women with preexisting diabetes demands careful monitoring in the preconception, prenatal, and peripartum periods.

Hypoglycemics: pharmacokinetic considerations during pregnancy

A wide range of physiological and hormonal changes occur during pregnancy. Most begin early in the first trimester and increase by the last trimester. These changes can significantly affect pharmacokinetics and pharmacodynamics of drugs and thus may alter their safety and efficacy. Approximately 5% of pregnant women are affected by some form of diabetes, with gestational diabetes being the most prevalent. Several classes of antidiabetic drugs are currently available for the treatment of diabetes, including human insulin, its short and long analogues, and oral hypoglycemic agents. Maternal and fetal responses to these drugs can be affected by changes in absorption, distribution, and elimination in both the mother and the placental-fetal unit. This can dictate the amount of drug that can cross and the amount that is metabolized or eliminated by the placenta. Further studies are needed on the safety of antidiabetic drugs in pregnancy to clarify the extent of their transplacental passage. Specifically, in vitro placental perfusion studies in combination with controlled trials and cord blood measurements can provide insight in to the pharmacokinetics of drug transport across the placenta. This article reviews common types of antidiabetic drugs, focusing on pharmacokinetic considerations that need to be incorporated into the decision on treatment in pregnancy.

Insulin glargine safety in pregnancy: a transplacental transfer study

OBJECTIVE

Insulin glargine (Lantus) is an extended-action insulin analog with greater stability and duration of action than regular human insulin. The long duration of action and decreased incidence of hypoglycemia provide potential advantages for its use in pregnancy. However, the placental pharmacokinetics of insulin glargine have not been studied. Therefore, the objective of this study was to determine whether insulin glargine crosses the human placenta using the human perfused placental lobule technique.

RESEARCH DESIGN AND METHODS

Placentae were obtained with informed consent after elective cesarean section delivery of noncomplicated term pregnancies. Insulin glargine, at a therapeutic concentration of 150 pmol/l (20 microU/ml) was added to the maternal circulation. Additional experiments were carried out at insulin glargine concentrations 1,000-fold higher than therapeutic levels (150, 225, and 300 nmol/l). A subsequent perfusion for which the maternal circuit remained open and insulin glargine was continuously infused at 150 pmol/l was completed for further confirmation of findings. The appearance of insulin glargine in the fetal circulation was analyzed by a chemiluminescence immunoassay.

RESULTS

Results from perfusions carried out at therapeutic concentrations (150 pmol/l) of insulin glargine showed no detectable insulin glargine in the fetal circuit. After perfusion with very high insulin glargine concentrations of 150, 225, and 300 nmol/l, the rate of transfer remained low at 0.079 +/- 0.01, 0.14, and 0.064 pmol . min(-1) . g tissue(-1), respectively.

CONCLUSIONS

Insulin glargine, when used at therapeutic concentrations, is not likely to cross the placenta.

Insulin analogs and pregnancy: an update

It is well known that good metabolic control maintained throughout pregnancy reduces maternal and fetal complications in diabetes. Before conception and throughout pregnancy, insulin therapy needs to be optimized and, in this context, the insulin analogs currently available in the market may help to achieve good metabolic control. We therefore review here what is known about the potential benefits and risks related to the use of these new insulins in pregnancy. Clinical and experimental data on insulin aspart and lispro strongly suggest that they have no adverse maternal or fetal effects during pregnancy in women with pregestational and gestational diabetes, and that their use results in improved glycemic control, fewer hypoglycemic episodes, and improved patient satisfaction. At present there are no published data on the use of glulisine in pregnancy. Insulin glargine during pregnancy is not recommended but, in the last years, larger surveys (retrospective and case-control studies) have been published on this field and, to date, results of about 335 pregnancies with type 1 diabetes are available showing an incidence of congenital malformation similar to that obtained with human insulin. There are no published data concerning the use of detemir in pregnancy but the results of a prospective study are expected in 2010.

TYPE 1 DIABETES IN PREGNANCY; INFLUENCES ON MOTHER AND FETUS

Type 1 diabetes complicates around 1 in 200 to 300 pregnancies in the United Kingdom. Historically maternal type 1 diabetes carried very high risks for mother and child. Introduction of insulin led to an immediate, marked decline in the previously very high rates of maternal mortality; in contrast an improvement in perinatal outcomes occurred more slowly but was nevertheless dramatic. This is strikingly demonstrated by the temporal decline in perinatal mortality in offspring of mothers with type 1 diabetes which was virtually universal before use of insulin in the 1920's, likely remained in excess of 20% even in the 1960's and fell to under 4% by the 1990's. The reasons for this more gradual improvement in perinatal outcomes cannot be defined with precision but will have been influenced by improved glycaemic management with use of intensive, multiple dose insulin treatment and home glucose monitoring; improvements in obstetric and neonatal management, and better management of complications of diabetes before and during pregnancy. In 1989 the St Vincent declaration proposed that pregnancy outcomes in women with type 1 diabetes should approximate those of the non-diabetic population. While the long term improvements in fetal outcomes have been dramatic, contemporary surveys confirm a persistent doubling or more of rates of congenital anomaly and a three to four fold increase in perinatal mortality in the UK and other European countries which will require further clinical innovation to overcome.

Insulin glargine and its role in glycaemic management of Type 2 diabetes

BACKGROUND

Insulin glargine (Lantus) was the first recombinant-DNA long-acting insulin analogue to be licensed for use in the treatment of diabetes mellitus.

OBJECTIVE

This review considers the use of insulin glargine in the treatment of type 2 diabetes (T2DM).

METHODS

Medline, Cochrane and Embase databases were searched for relevant papers from the year 2000 onwards.

RESULTS/CONCLUSION

Overall glargine provides at least equivalent glycaemic control and is associated with less hypoglycaemia, especially nocturnal hypoglycaemia owing to its 24 h peakless profile, which allows more aggressive titration to achieve glycaemic targets. Glargine has been shown to be safely initiated both individually and within a group setting and titration algorithms self-managed by patients are effective in achieving diabetes control. Despite these advantages, caution is needed as clinical guidelines do not advocate its use in all people with T2DM until clinical efficacy and cost effectiveness have been proved. However, insulin glargine is a welcome addition to the plethora of treatment options available for T2DM.

Type 2 diabetes in pregnancy: importance of optimized care before, during and after pregnancy

Women with Type 2 diabetes (T2DM) are an increasingly important part of the practice of obstetric medicine. The rising rates of obesity and advanced maternal age have resulted in a surge in the number of pregnant women with T2DM. The hyperglycaemia and associated conditions of the metabolic syndrome lead to poor obstetric outcome and impact on the long-term health of the mother and offspring. It is essential that women and care-givers recognize the seriousness of T2DM in pregnancy and strive to improve prepregnancy care, obstetric outcome and the long-term health of both the mother and child.

Perinatal outcomes associated with the use of glargine during pregnancy

AIMS

Insulin glargine (IG), with its non-peaking action profile, might be useful in diabetic pregnancy. However, data on its safety are limited and its use during pregnancy is not recommended. This study focused on the effects of IG on perinatal outcome, particularly to estimate the rate of congenital anomalies and birthweight.

METHODS

This retrospective study included women with pre-gestational diabetes who used IG before (at least 1 month) and during pregnancy. For all women we recorded data regarding maternal glycaemic control and pregnancy outcome. We also compared women treated with IG throughout pregnancy and women who stopped taking IG at an earlier stage.

RESULTS

From 27 centres, 107 Type 1 diabetic pregnancies were identified. IG was started 10.3 +/- 6.9 months before conception and in 57.4% of cases was stopped during the first trimester; 42.6% of women continued using it until the end of pregnancy. There were six abortions (four spontaneous and two induced) and five newborns (4.9%) with congenital anomalies. Glycaemic control, birthweight and the prevalence of macrosomia and neonatal morbidity were similar in women who used IG for the full term compared with those who stopped IG earlier during pregnancy.

CONCLUSIONS

This study, although limited, suggests that IG is safe and effective; the rate of congenital malformations was within the range expected for diabetic pregnancies treated with more traditional forms of insulin. IG used throughout pregnancy did not seem to influence birthweight or increase adverse outcomes.