Empagliflozin, metformin and insulin degludec, during pregnancy: a case report

Effects of GLP-1 agonists and SGLT2 inhibitors during pregnancy and lactation on offspring outcomes: a systematic review of the evidence

Aims/hypothesis

Glucagon-like peptide 1 (GLP-1) agonists and sodium-glucose co-transporter-2 (SGLT2) inhibitors are novel drugs which have recently seen rapid uptake in the treatment of type 2 diabetes and obesity. The paucity of data regarding their safety during pregnancy and lactation causes a dilemma for the physician. The aim of the present study was to systematically review all available data on the offspring effects of GLP-1 agonists and SGLT2 inhibitors during pregnancy and lactation.

Methods

We systematically searched PubMed, clinicaltrials.gov, FDA and EMA product information on GLP-1 agonists and SGLT2 inhibitors in pregnancy and lactation from inception up to 19 April 2022 without language restrictions. We approached both the Netherlands Pharmacovigilance Centre Lareb on January 17th 2023 and the Teratology Information Service (TIS) of Switzerland on February 6th 2023. Eligible studies investigating the safety (including congenital anomalies, fetal growth, perinatal demise) in animals or humans, or reporting the degree of transfer of these drugs to the fetus, breast milk or breastfed neonate. Two reviewers independently assessed and selected studies for inclusion and subsequently resolved discrepancies by discussion.

Results

We included 39 records (n=9 theoretical; based on drug properties, n=7 human; n=23 animal, including 76 human offspring, and an unknown number of animal offspring as these numbers could not be retrieved from the FDA and EMA product information). In animal studies, GLP1-agonists were associated with reduced fetal weight and/or growth, delayed ossification and skeletal variants, usually associated with a reduction in maternal weight gain and decreased food consumption. Exendin-4 (GLP1-agonist) was not transported across the maternal-fetal placental interface. In human studies, exenatide (GLP1-agonist) showed a fetal-to-maternal peptide concentration ratio of ≤ 0.017 in ex vivo human placental perfusion in a single placenta. Liraglutide (GLP1-agonist) showed no significant maternal to fetal transfer at least 3.5 hours after maternal exposure in a human study with one subject. In animal studies, GLP-1 agonists were excreted in breast milk; human data on excretion were not available. In animal studies, SGLT2 inhibitors were generally safe during the first trimester but exposure during postnatal day 21 to 90 in juvenile rats, a period coinciding with the late second and third trimester of human renal development, caused dilatation of the renal pelvis and tubules. Human data consisted of a pharmaceutical database of inadvertent pregnancies during SGLT2 inhibitor use, which found an increase in miscarriages and congenital malformations. In animal studies SGLT2 inhibitors were excreted in breast milk and affected neonatal growth, but human data are not available.

Conclusion/interpretation

We found evidence for adverse offspring effects of GLP-1 agonists and SGLT2 inhibitors also in human studies. Our findings broadly support the advice to discontinue GLP-1 agonists and SGLT2 inhibitors during pregnancy and lactation, and also support the ongoing registration of pregnancy outcomes in pharmacological databases since the amount of available data is scarce and mostly limited to animal studies.

Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=219877.

Empagliflozin induces apoptotic-signaling pathway in embryonic vasculature: In vivo and in silico approaches via chick’s yolk sac membrane model

The present investigation was conducted to evaluate the vascular-toxicity of empagliflozin (EMP) in embryonic vasculature. Firstly, the vascular-toxicity of the drug as well as its interaction with apoptotic regulator proteins was predicted via in silico approach. In the next step, the apoptotic-signaling pathway in embryonic vasculature was evaluated using a chick’s YSM model. In silico simulation confirmed vascular-toxicity of EMP. There was also an accurate affinity between EMP, Bax and Bcl-2 (−7.9 kcal/mol). Molecular dynamics assay revealed complex stability in the human body conditions. Furthermore, EMP is suggested to alter Bcl-2 more than BAX. Morphometric quantification of the vessels showed that the apoptotic activity of EMP in embryonic vasculature was related to a marked reduction in vessel area, vessel diameter and mean capillary area. Based on the qPCR and immunohistochemistry assays, enhanced expression level of BAX and reduced expression level of Bcl-2 confirmed apoptotic responses in the vessels of the YSM. We observed that induction of an apoptotic signal can cause the embryonic defect of the vascular system following EMP treatment. The acquired data also raised suspicions that alteration in apoptotic genes and proteins in the vasculature are two critical pathways in vascular-toxicity of EMP.

Two successful pregnancies and first use of empagliflozin during pregnancy in glycogen storage disease type Ib

Glycogen storage disease type Ib (GSD Ib) is caused by biallelic variants in SLC37A4. GSD Ib is characterized by hepatomegaly, recurrent hypoglycemia, neutropenia, and neutrophil dysfunction. Only seven pregnancies in four women with GSD Ib have been reported so far. We report on two further successful pregnancies in two patients with GSD Ib. One of these pregnancies was managed with empagliflozin, an SGLT2 inhibitor, repurposed for the treatment of neutropenia in GSD Ib. Both pregnancies were unremarkable and resulted in healthy offspring. Gestational care and pre‐ and perinatal management in GSD Ib are challenging and require close interdisciplinary metabolic and obstetric monitoring. In our patient, the use of empagliflozin during pregnancy was successful in the prevention of neutropenic symptoms and infections and enabled good wound healing after Cesarean section, while no adverse effects were observed.

Effects of a pinitol-rich Glycyrrhiza glabra L. leaf extract on insulin and inflammatory signaling pathways in palmitate-induced hypertrophic adipocytes

Glycyrrhiza glabra roots have been well studied for their pharmacological activities, whereas less research has been conducted on liquorice aerial parts. Leaves represent a good source of D-pinitol, useful in the treatment of insulin resistance-related pathologies. Herein, we analyzed the in vitro effects of a D-pinitol-rich methanolic extract from Glycyrrhiza glabra leaves (GGLME) against lipotoxicity-related hypertrophy, inflammation, and insulin resistance in 3T3-L1 adipocytes exposed to palmitic acid (PA), comparing its activity with D-pinitol. GGLME pretreatment decreased lipid deposition, PPAR-γ, and NF-κB pathway induced by PA, similarly to D-pinitol, and improved insulin sensitivity, in presence or not of PA, increasing PI3K, pAkt, and GLUT1 levels. This study confirms that liquorice leaves, considered a waste of resource, could potentially be reused, and support further in vivo studies on animal and human models. In conclusion, liquorice leaves extract represents a potential candidate for prevention of metabolically induced inflammation, frequently leading to metabolic disorders.

Effects of insulin combined with metformin on serum cystatin C, homocysteine and maternal and neonatal outcomes in pregnant women with gestational diabetes mellitus

Effects of insulin combined with metformin on serum cystatin C (Cys C), homocysteine (Hcy) and maternal and neonatal outcomes in pregnant women with gestational diabetes mellitus (GDM) were investigated. In total, 80 cases of pregnant women diagnosed with GDM in the Department of Obstetrics and Gynecology of Liaocheng Third People's Hospital from July 2015 to July 2017 were selected and divided into a study group (42 cases) and a control group (38 cases). The study group was treated with insulin combined with metformin, and the control group was treated with insulin. Fasting blood glucose (FBG) and postprandial blood glucose after 2 h (2hPG) of the two groups were compared before and after treatment. Levels of serum Cys C, Hcy, urinary protein (UmAlb), postpartum maternal outcomes and adverse reactions during pregnancy were compared in the two groups before and after treatment. After treatment, the level of FBG and 2hPG in the control group was higher than that in the treatment group (P<0.05). After treatment, the level of serum Cys C and Hcy in both groups were lower than that before the treatment, and the level in the study group was lower than that in the control group (P<0.05). The total incidence of neonatal adverse outcomes and the number of adverse pregnancies in GDM patients in the study group were significantly lower than those in the control group (P<0.05). There were no significant differences in adverse reactions during pregnancy between the two groups (P>0.05). In conclusion, insulin combined with metformin is more effective than insulin alone in reducing serum Cys C and Hcy levels, with significant effect on the improvement of maternal and neonatal outcomes.

Insulin Therapy and Diabetic Pregnancy

BACKGROUND

A good metabolic control before conception and throughout pregnancy with diabetes decreases the risk of short- and long-term adverse outcomes of the mothers and their offsprings. Insulin treatment remains the gold standard treatment recommended for any type of diabetes. New technologies including new insulins and insulin analogues, continuous subcutaneous insulin infusion without and with sensors, the low-glucose predictive suspension function, and closed-loop systems that persistently and automatically self-adjust according to patients' continuous glucose monitoring readings have expanded the offer to clinicians for achieving tight glucose control.

AREAS OF UNCERTAINTY

Unsafe effects of insulin and insulin analogues in pregnancy with diabetes could be linked with changes in insulin immunogenicity, teratogenicity, and mitogenicity. Second-generation insulin analogues need to be tested and proven. Effectiveness and safety of new insulin delivery systems in real life of diabetic women in pregnancy need further confirmations.

SOURCES

MEDLINE, EMBASE, Web of Science, Cochrane Library, randomized controlled trials, systematic review and meta-analysis, observational prospective and retrospective studies, case series reports for the most recent insulin analogues, published in English impacted journals, and consensus statements from scientific societies I excluded 60 from 221 papers as not suitable for the purpose of the subject.

RESULTS

Subcutaneous insulin infusion can be safely used during pregnancy and delivery of well-trained women. Sensors are increasingly accurate tools that improve the efficacy and safety of integrated systems' functioning. Continuous glucose monitoring provides metrics ("time in range" time in "hypoglycemia" and in "hyperglycemia," glucose variability, average glucose levels in different time intervals) used as a guide to diabetes management; these new metrics are object of discussion in special populations. Randomized controlled trials have shown that sensor-augmented pump therapy improves pregnancy outcomes in women with type 1 diabetes. Closed-loop insulin delivery provides better glycemic control than sensor-augmented pump therapy during pregnancy, before, and after delivery.

CONCLUSION

Second-generation insulin analogues and newer insulin infusion systems that automatically self-adjust according to patients continuous glucose monitor readings are important tools improving the treatment and quality of life of these women. Multi-institutional and disciplinary teams are working to develop and evaluate a pregnancy-specific artificial pancreas.

Improving pregnancy outcomes in women with diabetes mellitus: modern management

Women with pre-existing (type 1 or type 2) diabetes mellitus are at increased risk of pregnancy complications, such as congenital malformations, preeclampsia and preterm delivery, compared with women who do not have diabetes mellitus. Approximately half of pregnancies in women with pre-existing diabetes mellitus are complicated by fetal overgrowth, which results in infants who are overweight at birth and at risk of birth trauma and, later in life, the metabolic syndrome, cardiovascular disease and type 2 diabetes mellitus. Strict glycaemic control with appropriate diet, use of insulin and, if necessary, antihypertensive treatment is the cornerstone of diabetes mellitus management to prevent pregnancy complications. New technology for managing diabetes mellitus is evolving and is changing the management of these conditions in pregnancy. For instance, in Europe, most women with pre-existing diabetes mellitus are treated with insulin analogues before and during pregnancy. Furthermore, many women are on insulin pumps during pregnancy, and the use of continuous glucose monitoring is becoming more frequent. In addition, smartphone application technology is a promising educational tool for pregnant women with diabetes mellitus and their caregivers. This Review covers how modern diabetes mellitus management with appropriate diet, insulin and antihypertensive treatment in patients with pre-existing diabetes mellitus can contribute to reducing the risk of pregnancy complications such as congenital malformations, fetal overgrowth, preeclampsia and preterm delivery.

Exposure to insulin degludec during pregnancy: report of a small series and review of the literature

BACKGROUND

Good glycaemic control during pregnancy is key to reduce maternal and foetal complications. Insulin degludec, an ultralong acting analogue with a "peakless" and stable pharmacokinetic profile, has the potential advantage of reducing hypoglycaemia and glucose variability compared to other basal insulins. Therefore, degludec could be a reasonable therapeutic option for pregnant women with type 1 diabetes (T1D). However, degludec is not licensed for use during pregnancy owing to the lack of safety data.

METHODS AND RESULTS

We herein report details on pregnancy and foetal outcomes in three women with uncontrolled T1D treated with insulin degludec during the first trimester or the whole pregnancy. In addition, we report an updated review of similar cases reported in literature. Overall, no congenital neonatal malformation was observed in the six cases described. Three babies required neonatal intensive care unit admission for respiratory distress, apnoeas, bilirubin increase or hypoglycaemia. However, the observed neonatal complications were deemed unlikely to be related to degludec treatment.

CONCLUSIONS

In summary, while awaiting for the results of an ongoing randomized controlled trial, data on six cases of degludec exposure during pregnancy reassuringly suggest no embryo-foetal toxicity. More information is needed before degludec can be safely recommended during pregnancy.

Successful Outcomes with Insulin Degludec in Pregnancy: A Case Series

Optimal glycaemic control pre-conception and throughout pregnancy is paramount to achieve the best outcomes and to minimise the risk of complications for the mother and baby. Current long-acting insulin analogues that have been approved by the National Institute for Health and Care Excellence in the UK for use in pregnancy include glargine and detemir. In many patients, these treatments have limitations because of their pharmacokinetic properties thus not enabling optimal glycaemic control. Efforts at rapidly achieving the recommended blood glucose targets with these analogues can be associated with recurrent and/or disabling hypoglycaemia. Degludec is a second-generation ultra-long-acting insulin analogue, which has been shown to mimic endogenous basal insulin production by the pancreas. This may offer patients better control with less hypoglycaemia where first-generation insulins fail. There are currently no randomised controlled studies to support the use of insulin degludec in pregnancy. We report three cases of women who were on insulin degludec during pregnancy and achieved successful outcomes. Two of them were commenced on this during pregnancy because of hypoglycaemia with licenced insulin therapy. All the women showed an improvement in glycaemic control during pregnancy. There was attenuation of a wide glycaemic variability as demonstrated by a continuous glucose monitoring (CGM) system in one of the patients. They all delivered healthy babies. This case series highlights the urgent need for large randomised control trials to establish the safety and efficacy of insulin degludec in pregnancy.

Glucose Targets and Insulin Choice in Pregnancy: What Has Changed in the Last Decade?

PURPOSE OF REVIEW

To review current glycaemic targets and the potential use of newer insulin formulations in pregnancy.

RECENT FINDINGS

The impact of stricter glycaemic control on perinatal outcomes remains controversial, showing conflicting results. Current ongoing randomised trials investigating the role of tighter glucose targets in pregnancy should help clarify the benefit of tighter glucose control. Optimal timing for self-monitoring blood glucose (SMBG) remains debatable. Data suggest that post-prandial SMBG, particularly at 1 h, offers the best prediction of adverse perinatal outcome. To achieve these targets, insulin is the standard therapy. Novel insulin formulations offer benefits outside of pregnancy. Recent data on the use of new insulins in pregnancy (e.g. insulin degludec and glargine (U 300)) is limited to case reports. Glycaemic targets have remained unchanged in the last decade. Studies using stricter glycaemic targets may improve perinatal outcomes. Newer insulin formulations may offer increased flexibility and glycaemic control. Clinicians caring for women with diabetes striving to minimise adverse perinatal outcomes will find this review of interest.