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Blankstein AR, Sigurdson SM, Frehlich L, Raizman Z, Donovan LE, Lemieux P, Pylypjuk C, Benham JL, Yamamoto JM. Pre-existing Diabetes and Stillbirth or Perinatal Mortality: A Systematic Review and Meta-analysis. Obstet Gynecol 2024:00006250-990000000-01125. [PMID: 39088826 DOI: 10.1097/aog.0000000000005682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/23/2024] [Indexed: 08/03/2024]
Abstract
OBJECTIVE Despite the well-recognized association between pre-existing diabetes mellitus and stillbirth or perinatal mortality, there remain knowledge gaps about the strength of association across different populations. The primary objective of this systematic review and meta-analysis was to quantify the association between pre-existing diabetes and stillbirth or perinatal mortality, and secondarily, to identify risk factors predictive of stillbirth or perinatal mortality among those with pre-existing diabetes. DATA SOURCES MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from inception to April 2022. METHODS OF STUDY SELECTION Cohort studies and randomized controlled trials in English or French that examined the association between pre-existing diabetes and stillbirth or perinatal mortality (as defined by the original authors) or identified risk factors for stillbirth and perinatal mortality in individuals with pre-existing diabetes were included. Data extraction was performed independently and in duplicate with the use of prespecified inclusion and exclusion criteria. Assessment for heterogeneity and risk of bias was performed. Meta-analyses were completed with a random-effects model. TABULATION, INTEGRATION, AND RESULTS From 7,777 citations, 91 studies met the inclusion criteria. Pre-existing diabetes was associated with higher odds of stillbirth (37 studies; pooled odds ratio [OR] 3.74, 95% CI, 3.17-4.41, I2=82.5%) and perinatal mortality (14 studies; pooled OR 3.22, 95% CI, 2.54-4.07, I2=82.7%). Individuals with type 1 diabetes had lower odds of stillbirth (pooled OR 0.81, 95% CI, 0.68-0.95, I2=0%) and perinatal mortality (pooled OR 0.73, 95% CI, 0.61-0.87, I2=0%) compared with those with type 2 diabetes. Prenatal care and prepregnancy diabetes care were significantly associated with lower odds of stillbirth (OR 0.26, 95% CI, 0.11-0.62, I2=87.0%) and perinatal mortality (OR 0.41, 95% CI, 0.29-0.59, I2=0%). CONCLUSION Pre-existing diabetes confers a more than threefold increased odds of both stillbirth and perinatal mortality. Maternal type 2 diabetes was associated with a higher risk of stillbirth and perinatal mortality compared with maternal type 1 diabetes. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022303112.
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Affiliation(s)
- Anna R Blankstein
- Department of Medicine, the Department of Obstetrics, Gynecology and Reproductive Sciences, and the Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, the Department of Community Health Sciences, the Department of Medicine, the Department of Obstetrics and Gynecology, the Alberta Children's Hospital Research Institute, the O'Brien Institute for Public Health, and the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, and the Department of Medicine, Université Laval, Quebec City, Quebec, Canada; and Stanford Lifestyle Medicine, Stanford University, Redwood City, California
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Castorino K, Osumili B, Lakiang T, Banerjee KK, Goldyn A, Piras de Oliveira C. Insulin Use During Gestational and Pre-existing Diabetes in Pregnancy: A Systematic Review of Study Design. Diabetes Ther 2024; 15:929-1045. [PMID: 38494573 PMCID: PMC11043323 DOI: 10.1007/s13300-024-01541-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/01/2024] [Indexed: 03/19/2024] Open
Abstract
INTRODUCTION Insulin is the first-line pharmacologic therapy for women with diabetes in pregnancy. However, conducting well-designed randomized clinical trials (RCTs) and achieving recommended glycemic targets remains a challenge for this unique population. This systematic literature review (SLR) aimed to understand the evidence for insulin use in pregnancy and the outcome metrics most often used to characterize its effect on glycemic, maternal and fetal outcomes in gestational diabetes mellitus (GDM) and in pregnant women with diabetes. METHODS An SLR was conducted using electronic databases in Medline, EMBASE via Ovid platform, evidence-based medicine reviews (2010-2020) and conference proceedings (2018-2019). Studies were included if they assessed the effect of insulin treatment on glycemic, maternal or fetal outcomes in women with diabetes in pregnancy. Studies on any type of diabetes other than gestational or pre-existing diabetes as well as non-human studies were excluded. RESULTS In women diagnosed with GDM or pre-existing diabetes, most studies compared treatment of insulin with metformin (n = 35) followed by diet along with lifestyle intervention (n = 24) and glibenclamide (n = 12). Most studies reporting on glycemic outcomes compared insulin with metformin (n = 22) and glibenclamide (n = 4). Fasting blood glucose was the most reported clinical outcome of interest. Among the studies reporting maternal outcomes, method of delivery and delivery complications were most commonly reported. Large for gestational age, stillbirth and perinatal mortality were the most common fetal outcomes reported. CONCLUSION This SLR included a total of 108 clinical trials and observational studies with diverse populations and treatment arms. Outcomes varied across the studies, and a lack of consistent outcome measures to manage diabetes in pregnant women was observed. This elucidates a need for global consensus on study design and standardized clinical, maternal and fetal outcomes metrics.
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S282-S294. [PMID: 38078583 PMCID: PMC10725801 DOI: 10.2337/dc24-s015] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Kazakou P, Paschou SA, Mitropoulou M, Vasileiou V, Sarantopoulou V, Anastasiou E. Comparison of treatment with insulin detemir and NPH in women with gestational diabetes mellitus: glycemic control and pregnancy outcomes. A retrospective study. Hormones (Athens) 2023; 22:695-701. [PMID: 37775682 PMCID: PMC10651542 DOI: 10.1007/s42000-023-00490-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 09/15/2023] [Indexed: 10/01/2023]
Abstract
PURPOSE The objective of this retrospective study was to compare glycemic control, pregnancy outcomes, and neonatal outcomes in women with gestational diabetes mellitus (GDM) treated with (a) insulin detemir and (b) insulin neutral protamine Hagedorn (NPH). METHODS A total of 192 women with GDM were included in the analysis. Ninety-eight women received detemir, while 94 women received NPH. Data regarding medical history, glycemic control, and time and mode of delivery, as well as neonatal outcomes, were recorded. RESULTS Baseline characteristics were comparable between the two groups. There were no differences with respect to the week of insulin initiation, total insulin dose, duration of insulin therapy, daily insulin dose/weight in early and late pregnancy, or the number of insulin injections per day. Maternal overall weight gain during pregnancy and weight gain per week did not differ either. The detemir group had slightly lower HbA1c levels at the end of gestation [median: det 5.2% (33 mmol/mol) vs NPH 5.4% (36 mmol/mol), p=0.035). There were no cases of hypoglycemia or allergic reactions in the two groups. There were also no differences regarding neonatal outcomes according to the available data, given that data in some cases were missing. CONCLUSION The use of insulin detemir was found to be equally effective and safe compared to NPH in women with GDM.
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Affiliation(s)
- Paraskevi Kazakou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Stavroula A Paschou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Mathiesen ER, Alibegovic AC, Corcoy R, Dunne F, Feig DS, Hod M, Jia T, Kalyanam B, Kar S, Kautzky-Willer A, Marchesini C, Rea RD, Damm P. Insulin degludec versus insulin detemir, both in combination with insulin aspart, in the treatment of pregnant women with type 1 diabetes (EXPECT): an open‑label, multinational, randomised, controlled, non-inferiority trial. Lancet Diabetes Endocrinol 2023; 11:86-95. [PMID: 36623517 DOI: 10.1016/s2213-8587(22)00307-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 01/08/2023]
Abstract
BACKGROUND Insulin degludec (degludec) is a second-generation basal insulin with an improved pharmacokinetic-pharmacodynamic profile compared with first-generation basal insulins, but there are few data regarding its use during pregnancy. In this non-inferiority trial, we aimed to compare the efficacy and safety of degludec with insulin detemir (detemir), both in combination with insulin aspart (aspart), in pregnant women with type 1 diabetes. METHODS This open-label, multinational, randomised, controlled, non-inferiority trial (EXPECT) was conducted at 56 sites (hospitals and medical centres) in 14 countries. Women aged at least 18 years with type 1 diabetes who were between gestational age 8 weeks (+0 days) and 13 weeks (+6 days) or planned to become pregnant were randomly assigned (1:1), via an interactive web response system, to degludec (100 U/mL) once daily or detemir (100 U/mL) once or twice daily, both with mealtime insulin aspart (100 U/mL), all via subcutaneous injection. Participants who were pregnant received the trial drug at randomisation, throughout pregnancy and until 28 days post-delivery (end of treatment). Participants not pregnant at randomisation initiated the trial drug before conception. The primary endpoint was the last planned HbA1c measurement before delivery (non-inferiority margin of 0·4% for degludec vs detemir). Secondary endpoints included efficacy, maternal safety, and pregnancy outcomes. The primary endpoint was assessed in all randomly assigned participants who were pregnant during the trial. Safety was assessed in all randomly assigned participants who were pregnant during the trial and exposed to at least one dose of trial drug. This study is registered with ClinicalTrials.gov, NCT03377699, and is now completed. FINDINGS Between Nov 22, 2017, and Nov 8, 2019, from 296 women screened, 225 women were randomly assigned to degludec (n=111) or detemir (n=114). Mean HbA1c at pregnancy baseline was 6·6% (SD 0·6%; approximately 49 mmol/mol; SD 7 mmol/mol) in the degludec group and 6·5% (0·8%; approximately 48 mmol/mol; 9 mmol/mol) in the detemir group. Mean last planned HbA1c measurement before delivery was 6·2% (SE 0·07%; approximately 45 mmol/mol; SE 0·8 mmol/mol) in the degludec group and 6·3% (SE 0·07%; approximately 46 mmol/mol; SE 0·8 mmol/mol) in the detemir group (estimated treatment difference -0·11% [95% CI -0·31 to 0·08]; -1·2 mmol/mol [95% CI: -3·4 to 0·9]; pnon-inferiority<0·0001), confirming non-inferiority. Compared with detemir, no additional safety issues were observed with degludec. INTERPRETATION In pregnant women with type 1 diabetes, degludec was found to be non-inferior to detemir. FUNDING Novo Nordisk.
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Affiliation(s)
- Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Departments of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | | | - Rosa Corcoy
- Servei d'Endocrinologia i Nutrició, Hospital de la Santa Creu i Sant Pau-Dos de Maig, Barcelona, Spain; CIBER-Bioengineering Biomaterials and Nanomedicine, Madrid, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Fidelma Dunne
- Clinical Research Facility, College of Medicine, Nursing and Health Sciences, University of Galway, Galway, Ireland
| | - Denice S Feig
- Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto and the Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada
| | - Moshe Hod
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ting Jia
- Novo Nordisk A/S, Søborg, Denmark
| | | | - Soumitra Kar
- Novo Nordisk Service Centre India Private, Bangalore, India
| | | | | | - Rustam D Rea
- Oxford Centre for Diabetes Endocrinology and Metabolism and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Departments of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Kautzky-Willer A, Winhofer Y, Weitgasser R, Lechleitner M, Harreiter J. [Clinical practice recommendations for diabetes in pregnancy (Update 2023)]. Wien Klin Wochenschr 2023; 135:129-136. [PMID: 37101033 PMCID: PMC10133056 DOI: 10.1007/s00508-023-02188-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2023] [Indexed: 04/28/2023]
Abstract
In 1989 the St. Vincent Declaration aimed to achieve comparable pregnancy outcomes in women with diabetes and those with normal glucose tolerance. However, currently women with pre-gestational diabetes still feature a higher risk of perinatal morbidity and even increased mortality. This fact is mostly ascribed to a persistently low rate of pregnancy planning and pre-pregnancy care with optimization of metabolic control prior to conception. All women should be experienced in the management of their therapy and on stable glycemic control prior to conception. In addition, thyroid dysfunction, hypertension as well as the presence of diabetic complications should be excluded or treated adequately before pregnancy in order to decrease the risk for a progression of complications during pregnancy as well as maternal and fetal morbidity. Near normoglycaemia and HbA1c in the normal range are targets for treatment, preferably without the induction of frequent resp. severe hypoglycaemic reactions. Especially in women with type 1 diabetes mellitus the risk of hypoglycemia is high in early pregnancy, but it decreases with the progression of pregnancy due to hormonal changes causing an increase of insulin resistance. In addition, obesity increases worldwide and contributes to higher numbers of women at childbearing age with type 2 diabetes mellitus and adverse pregnancy outcomes. Intensified insulin therapy with multiple daily insulin injections and pump treatment are equally effective in reaching good metabolic control during pregnancy. Insulin is the primary treatment option. Continuous glucose monitoring often adds to achieve targets. Oral glucose lowering drugs (Metformin) may be considered in obese women with type 2 diabetes mellitus to increase insulin sensitivity but need to be prescribed cautiously due to crossing the placenta and lack of long-time follow up data of the offspring (shared decision making). Due to increased risk for preeclampsia in women with diabetes screening needs to be performed. Regular obstetric care as well as an interdisciplinary treatment approach are necessary to improve metabolic control and ensure the healthy development of the offspring.
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Affiliation(s)
- Alexandra Kautzky-Willer
- Gender Medicine Unit, Abt. für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Yvonne Winhofer
- Gender Medicine Unit, Abt. für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Raimund Weitgasser
- Abteilung für Innere Medizin/Diabetologie, Privatklinik Wehrle-Diakonissen, Salzburg, Österreich
- Universitätsklinik für Innere Medizin I, LKH Salzburg - Universitätsklinikum der Paracelsus Medizinischen Privatuniversität, Salzburg, Österreich
| | - Monika Lechleitner
- Avomed-Arbeitskreis für Vorsorgemedizin und Gesundheitsförderung in Tirol, Innsbruck, Österreich
| | - Jürgen Harreiter
- Gender Medicine Unit, Abt. für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Jeffrie Seley J, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 15. Management of Diabetes in Pregnancy: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S254-S266. [PMID: 36507645 PMCID: PMC9810465 DOI: 10.2337/dc23-s015] [Citation(s) in RCA: 108] [Impact Index Per Article: 108.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Wang J, Ji X, Liu T, Zhao N. Maternal and neonatal outcomes with the use of long acting, compared to intermediate acting basal insulin (NPH) for managing diabetes during pregnancy: a systematic review and meta-analysis. Diabetol Metab Syndr 2022; 14:154. [PMID: 36271431 PMCID: PMC9585834 DOI: 10.1186/s13098-022-00925-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 10/13/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To assess the impact of long-acting insulin analogues, compared to intermediate acting neutral protamine Hagedron (NPH), on maternal, perinatal and neonatal outcomes. METHODS Studies for inclusion in the review were identified using a structured search strategy in PubMed, Scopus and Cochrane Central Register of Controlled Trials (CENTRAL) database. Studies that were randomized controlled trials or observational in design were considered for inclusion. Eligible studies should have compared the maternal, perinatal and neonatal outcomes between pregnant women with gestational diabetes mellitus (GDM) managed by intermediate acting (NPH) and by long-acting insulin analogues. Statistical analysis was performed using STATA software. RESULTS We found 17 studies to be eligible for inclusion. The mean gestational weight gain and risk of maternal hypoglycaemia, hypertensive disorder, caesarean delivery, spontaneous abortion, endometritis and wound infection or dehiscence were similar among pregnant women with GDM managed using long-acting insulin analogues and NPH. Those receiving long-acting insulin analogues had significantly lower HbA1c values in the second (WMD - .09, 95% CI 0.12, - 0.06; N = 4) and third trimester (WMD - 0.08, 95% CI - 0.14, - 0.02; N = 12). The mean gestational age and birth weight and risk of perinatal mortality, prematurity, large for gestational age, small for gestational age, shoulder dystocia and congenital abnormalities was similar among babies in both groups. No statistically significant differences in risk of admission to neonatal intensive care unit, respiratory distress, neonatal hypoglycaemia, 5 min APGAR score of < 7, neonatal hyperbilirubinemia and sepsis was observed. The quality of pooled evidence, as per GRADE criteria, was judged to be "very low" for all the maternal and neonatal outcomes considered. CONCLUSIONS Findings suggest no significant differences in the maternal, perinatal and neonatal outcomes between intermediate and long-acting insulin analogues. The results provide support for use of long-acting insulin analogues in women with GDM. However, evidence is still needed from high quality randomized controlled trials to arrive at a recommendation for inclusion in routine clinical care.
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Affiliation(s)
- Jijiao Wang
- The Second Affiliated Hospital of Dalian Medical University, No 467, Zhongshan Road, Dalian, 116021, Liaoning Province, China
| | - Xiaochen Ji
- The Second Affiliated Hospital of Dalian Medical University, No 467, Zhongshan Road, Dalian, 116021, Liaoning Province, China
| | - Ting Liu
- The Second Affiliated Hospital of Dalian Medical University, No 467, Zhongshan Road, Dalian, 116021, Liaoning Province, China.
| | - Nan Zhao
- The Second Affiliated Hospital of Dalian Medical University, No 467, Zhongshan Road, Dalian, 116021, Liaoning Province, China.
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Modzelewski R, Stefanowicz-Rutkowska MM, Matuszewski W, Bandurska-Stankiewicz EM. Gestational Diabetes Mellitus—Recent Literature Review. J Clin Med 2022; 11:jcm11195736. [PMID: 36233604 PMCID: PMC9572242 DOI: 10.3390/jcm11195736] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 09/25/2022] [Accepted: 09/25/2022] [Indexed: 11/16/2022] Open
Abstract
Gestational diabetes mellitus (GDM), which is defined as a state of hyperglycemia that is first recognized during pregnancy, is currently the most common medical complication in pregnancy. GDM affects approximately 15% of pregnancies worldwide, accounting for approximately 18 million births annually. Mothers with GDM are at risk of developing gestational hypertension, pre-eclampsia and termination of pregnancy via Caesarean section. In addition, GDM increases the risk of complications, including cardiovascular disease, obesity and impaired carbohydrate metabolism, leading to the development of type 2 diabetes (T2DM) in both the mother and infant. The increase in the incidence of GDM also leads to a significant economic burden and deserves greater attention and awareness. A deeper understanding of the risk factors and pathogenesis becomes a necessity, with particular emphasis on the influence of SARS-CoV-2 and diagnostics, as well as an effective treatment, which may reduce perinatal and metabolic complications. The primary treatments for GDM are diet and increased exercise. Insulin, glibenclamide and metformin can be used to intensify the treatment. This paper provides an overview of the latest reports on the epidemiology, pathogenesis, diagnosis and treatment of GDM based on the literature.
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Affiliation(s)
- Robert Modzelewski
- Endocrinology, Diabetology and Internal Medicine Clinic, Department of Internal Medicine, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland
| | | | - Wojciech Matuszewski
- Endocrinology, Diabetology and Internal Medicine Clinic, Department of Internal Medicine, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland
| | - Elżbieta Maria Bandurska-Stankiewicz
- Endocrinology, Diabetology and Internal Medicine Clinic, Department of Internal Medicine, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland
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Athanasiadou KI, Paschou SA, Stamatopoulos T, Papakonstantinou E, Haidich AB, Goulis DG. Safety and efficacy of insulin detemir versus NPH in the treatment of diabetes during pregnancy: Systematic review and meta-analysis of randomized controlled trials. Diabetes Res Clin Pract 2022; 190:110020. [PMID: 35878788 DOI: 10.1016/j.diabres.2022.110020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 11/03/2022]
Abstract
AIMS To compare the safety and efficacy of insulin detemir versus neutral protamine Hagedorn (NPH) in pregnant women with diabetes. METHODS MEDLINE, CENTRAL, Google Scholar databases, and ClinicalTrials.gov registry were searched from inception to December 2021 to identify randomized controlled trials (RCTs) concerning adult women with singleton pregnancies, gestational or pregestational diabetes, and the need for insulin therapy. A systematic review and a meta-analysis (weighted data, random-effects model) were performed. Continuous outcomes were expressed as mean difference (MD) with 95% confidence interval (CI) (inverse variance method); dichotomous outcomes were expressed as risk ratio (RR) with 95% CI (Mantel-Haenszel method). Heterogeneity was quantified using the I2 index. RESULTS Five RCTs involving 1450 participants met the inclusion criteria. Outcomes that showed significant results in favor of insulin detemir over NPH were maternal hypoglycemic events (RR 0.64, 95% CI 0.48-0.86, p = 0.003; I2 = 0%) and gestational age at delivery (MD 0.48, 95% CI 0.16-0.81, p = 0.003; I2 = 0%). CONCLUSIONS Insulin detemir was associated with less maternal hypoglycemic events and decreased risk for prematurity compared with NPH insulin. More research should be conducted to reach a safe conclusion about the optimal insulin regimen for women with diabetes in pregnancy.
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Affiliation(s)
- Kleoniki I Athanasiadou
- 2(nd) Department of Internal Medicine and Diabetes Centre, 417 Veteran's Fund Military Hospital NIMTS, Athens, Greece.
| | - Stavroula A Paschou
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece
| | | | | | - Anna-Bettina Haidich
- Department of Hygiene, Social-Preventive Medicine and Medical Statistics, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece.
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1(st) Department of Obstetrics and Gynaecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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Hanif N, Wu H, Xu P, Li Y, Bibi A, Zulfiqar A, Iqbal MZ, Tahir M, Zhang X, Ali A. Proteomic Changes to the Updated Discovery of Engineered Insulin and Its Analogs: Pros and Cons. Curr Issues Mol Biol 2022; 44:867-888. [PMID: 35723344 PMCID: PMC8929101 DOI: 10.3390/cimb44020059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 11/17/2022] Open
Abstract
The destruction of β-cells of the pancreas leads to either insulin shortage or the complete absence of insulin, which in turn causes diabetes Mellitus. For treating diabetes, many trials have been conducted since the 19th century until now. In ancient times, insulin from an animal's extract was taken to treat human beings. However, this resulted in some serious allergic reactions. Therefore, scientists and researchers have tried their best to find alternative ways for managing diabetes with progressive advancements in biotechnology. However, a lot of research trials have been conducted, and they discovered more progressed strategies and approaches to treat type I and II diabetes with satisfaction. Still, investigators are finding more appropriate ways to treat diabetes accurately. They formulated insulin analogs that mimic the naturally produced human insulin through recombinant DNA technology and devised many methods for appropriate delivery of insulin. This review will address the following questions: What is insulin preparation? How were these devised and what are the impacts (both positive and negative) of such insulin analogs against TIDM (type-I diabetes mellitus) and TIIDM (type-II diabetes mellitus)? This review article will also demonstrate approaches for the delivery of insulin analogs into the human body and some future directions for further improvement of insulin treatment.
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Affiliation(s)
- Naeema Hanif
- State Key Laboratory of Crop Gene Exploration and Utilization in Southwest China, Rice Research Institute, Sichuan Agricultural University, Chengdu 611130, China; (N.H.); (P.X.)
- Department of Biomedical Sciences, National University of Science and Technology, Islamabad 44000, Pakistan
| | - Hezhou Wu
- Hunan Taohuayuan Agricultural Technologies Co., Ltd., Yueyang 415000, China;
| | - Peizhou Xu
- State Key Laboratory of Crop Gene Exploration and Utilization in Southwest China, Rice Research Institute, Sichuan Agricultural University, Chengdu 611130, China; (N.H.); (P.X.)
| | - Yun Li
- Chengdu Academy of Agricultural and Forestry Sciences, Chengdu 611130, China;
| | - Amir Bibi
- Department of Plant Breeding and Genetics, University of Agriculture, Faisalabad 38000, Pakistan;
| | - Asma Zulfiqar
- Department of Botany, Quaid-e-Azam Campus, University of Punjab, Lahore 05422, Pakistan;
| | - Muhammad Zafar Iqbal
- College of Grassland Science and Technology, Sichuan Agricultural University, Chengdu 611130, China; (M.Z.I.); (M.T.)
| | - Muhammad Tahir
- College of Grassland Science and Technology, Sichuan Agricultural University, Chengdu 611130, China; (M.Z.I.); (M.T.)
| | - Xiangyang Zhang
- Branch of China National Hybrid Rice Research and Development Centre, Sichuan Tiland Huizhi Biology Science and Technology Co., Ltd., Chengdu 611130, China
| | - Asif Ali
- State Key Laboratory of Crop Gene Exploration and Utilization in Southwest China, Rice Research Institute, Sichuan Agricultural University, Chengdu 611130, China; (N.H.); (P.X.)
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12
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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13
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Mathiesen ER, Ali N, Alibegovic AC, Anastasiou E, Cypryk K, de Valk H, Dores J, Dunne F, Gall MA, Garcia SD, Hanaire HP, Husemoen LLN, Ivanišević M, Kempe HP, McCance DR, Damm P. Risk of Major Congenital Malformations or Perinatal or Neonatal Death With Insulin Detemir Versus Other Basal Insulins in Pregnant Women With Preexisting Diabetes: The Real-World EVOLVE Study. Diabetes Care 2021; 44:2069-2077. [PMID: 34330786 PMCID: PMC8740922 DOI: 10.2337/dc21-0472] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 05/24/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare the risk of severe adverse pregnancy complications in women with preexisting diabetes. RESEARCH DESIGN AND METHODS Multinational, prospective cohort study to assess the prevalence of newborns free from major congenital malformations or perinatal or neonatal death (primary end point) following treatment with insulin detemir (detemir) versus other basal insulins. RESULTS Of 1,457 women included, 727 received detemir and 730 received other basal insulins. The prevalence of newborns free from major congenital malformations or perinatal or neonatal death was similar between detemir (97.0%) and other basal insulins (95.5%) (crude risk difference 0.015 [95% CI -0.01, 0.04]; adjusted risk difference -0.003 [95% CI -0.03, 0.03]). The crude prevalence of one or more congenital malformations (major plus minor) was 9.4% vs. 12.6%, with a similar risk difference before (-0.032 [95% CI -0.064, 0.000]) and after (-0.036 [95% CI -0.081, 0.009]) adjustment for confounders. Crude data showed lower maternal HbA1c during the first trimester (6.5% vs. 6.7% [48 vs. 50 mmol/mol]; estimated mean difference -0.181 [95% CI -0.300, -0.062]) and the second trimester (6.1% vs. 6.3% [43 vs. 45 mmol/mol]; -0.139 [95% CI -0.232, -0.046]) and a lower prevalence of major hypoglycemia (6.0% vs. 9.0%; risk difference -0.030 [95% CI -0.058, -0.002]), preeclampsia (6.4% vs. 10.0%; -0.036 [95% CI -0.064, -0.007]), and stillbirth (0.4% vs. 1.8%; -0.013 [95% CI -0.024, -0.002]) with detemir compared with other basal insulins. However, differences were not significant postadjustment. CONCLUSIONS Insulin detemir was associated with a similar risk to other basal insulins of major congenital malformations, perinatal or neonatal death, hypoglycemia, preeclampsia, and stillbirth.
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Affiliation(s)
- Elisabeth R Mathiesen
- Department of Endocrinology, Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark .,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Norsiah Ali
- Masjid Tanah Health Clinic, Malacca, Malaysia
| | | | - Eleni Anastasiou
- Department of Endocrinology-Diabetes Center, Princess Alexandra Hospital, Athens, Greece
| | - Katarzyna Cypryk
- Department of Internal Medicine and Diabetology, Medical University of Łódź, Łódź, Poland
| | - Harold de Valk
- Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Jorge Dores
- Department of Endocrinology, Centro Hospitalar e Universitário do Porto, Porto, Portugal
| | - Fidelma Dunne
- College of Medicine Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | | | | | - Hélène P Hanaire
- Department of Diabetology, Metabolic Diseases and Nutrition, University Hospital of Toulouse, University of Toulouse, Toulouse, France
| | | | - Marina Ivanišević
- Department of Obstetrics and Gynecology, State Referral Center for Diabetes in Pregnancy, Clinical Hospital Center Zagreb, Zagreb, Croatia
| | - Hans-Peter Kempe
- Centre for Diabetes and Nutrition Ludwigshafen, Ludwigshafen, Germany
| | | | - Peter Damm
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Obstetrics, Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
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14
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Kgosidialwa O, Bogdanet D, Egan A, Newman C, O'Shea PM, Biesty L, McDonagh C, O'Shea C, Devane D, Dunne F. A systematic review on outcome reporting in randomised controlled trials assessing treatment interventions in pregnant women with pregestational diabetes. BJOG 2021; 128:1894-1904. [PMID: 34258852 DOI: 10.1111/1471-0528.16842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pregestational diabetes mellitus (PGDM) is associated with adverse pregnancy outcomes. Studies assessing interventions to improve maternal and infant outcomes have increased exponentially over recent years. Several outcomes in this field of maternal diabetes are rare, making it difficult to synthesise evidence. OBJECTIVES To collect outcomes reported in studies assessing treatment interventions in pregnant women with PGDM. SEARCH STRATEGY CENTRAL, Web of Science, Medline, CINAHL, Embase and ClinicalTrials.gov from their inception until 27 January 2020. SELECTION CRITERIA Any randomised controlled trial assessing treatment interventions in pregnant women with PGDM reported in English. DATA COLLECTION AND ANALYSIS Two independent reviewers assessed the suitability of articles and retrieved the data. Outcomes extracted from the literature were broadly categorised into maternal, fetal/infant or other outcomes by the study advisory group. MAIN RESULTS Sixty-seven of the 1475 studies identified fulfilled the inclusion criteria. The median number of outcomes reported per study was 15 (range 1-46). The majority of studies were from North America and Europe. Insulin and metformin were the most commonly investigated pharmacological interventions. Glucose monitoring was the most assessed technological intervention. In all, 131 unique outcomes were extracted: maternal (n = 69), fetal/infant (n = 61) and other (n = 1). CONCLUSIONS Outcome reporting in treatment interventions trials of pregnant women with PGDM is varied, making it difficult to synthesise evidence, especially for rare outcomes. Systems are needed to standardise outcome reporting in future clinical trials and so facilitate evidence synthesis in this area of maternal diabetes. REGISTRATION The systematic review was registered prospectively with the International Prospective Register of Systematic Reviews (PROSPERO) database (Registration number CRD42020173549). TWEETABLE ABSTRACT Outcome reporting is heterogeneous in intervention trials of pregnant women with diabetes existing before pregnancy.
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Affiliation(s)
- O Kgosidialwa
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - D Bogdanet
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - A Egan
- Department of Endocrinology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - C Newman
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - P M O'Shea
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - L Biesty
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.,Ireland HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - C McDonagh
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - C O'Shea
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - D Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.,Ireland HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - F Dunne
- School of Medicine, National University of Ireland Galway, Galway, Ireland
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15
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Kgosidialwa O, Bogdanet D, Egan AM, O'Shea PM, Newman C, Griffin TP, McDonagh C, O'Shea C, Carmody L, Cooray SD, Anastasiou E, Wender-Ozegowska E, Clarson C, Spadola A, Alvarado F, Noctor E, Dempsey E, Napoli A, Crowther C, Galjaard S, Loeken MR, Maresh M, Gillespie P, de Valk H, Agostini A, Biesty L, Devane D, Dunne F. A core outcome set for the treatment of pregnant women with pregestational diabetes: an international consensus study. BJOG 2021; 128:1855-1868. [PMID: 34218508 PMCID: PMC9311326 DOI: 10.1111/1471-0528.16825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 12/21/2022]
Abstract
Objective To develop a core outcome set (COS) for randomised controlled trials (RCTs) evaluating the effectiveness of interventions for the treatment of pregnant women with pregestational diabetes mellitus (PGDM). Design A consensus developmental study. Setting International. Population Two hundred and five stakeholders completed the first round. Methods The study consisted of three components. (1) A systematic review of the literature to produce a list of outcomes reported in RCTs assessing the effectiveness of interventions for the treatment of pregnant women with PGDM. (2) A three-round, online eDelphi survey to prioritise these outcomes by international stakeholders (including healthcare professionals, researchers and women with PGDM). (3) A consensus meeting where stakeholders from each group decided on the final COS. Main outcome measures All outcomes were extracted from the literature. Results We extracted 131 unique outcomes from 67 records meeting the full inclusion criteria. Of the 205 stakeholders who completed the first round, 174/205 (85%) and 165/174 (95%) completed rounds 2 and 3, respectively. Participants at the subsequent consensus meeting chose 19 outcomes for inclusion into the COS: trimester-specific haemoglobin A1c, maternal weight gain during pregnancy, severe maternal hypoglycaemia, diabetic ketoacidosis, miscarriage, pregnancy-induced hypertension, pre-eclampsia, maternal death, birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, mode of birth, shoulder dystocia, neonatal hypoglycaemia, congenital malformations, stillbirth and neonatal death. Conclusions This COS will enable better comparison between RCTs to produce robust evidence synthesis, improve trial reporting and optimise research efficiency in studies assessing treatment of pregnant women with PGDM. 165 key stakeholders have developed #Treatment #CoreOutcomes in pregnant women with #diabetes existing before pregnancy.
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Affiliation(s)
- O Kgosidialwa
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - D Bogdanet
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - A M Egan
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - P M O'Shea
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C Newman
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - T P Griffin
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C McDonagh
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C O'Shea
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - L Carmody
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - S D Cooray
- Diabetes and Endocrinology Units, Monash Health, Clayton, Vic., Australia.,Monash Centre for Health Research and Implementation, Monash University, Clayton, Vic., Australia
| | - E Anastasiou
- Department Diabetes & Pregnancy Outpatients, Mitera Hospital, Athens, Greece
| | - E Wender-Ozegowska
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
| | - C Clarson
- Department of Paediatrics, University of Western Ontario, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - A Spadola
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA
| | - F Alvarado
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA
| | - E Noctor
- Division of Endocrinology, University Hospital Limerick, Limerick, Ireland
| | - E Dempsey
- INFANT Centre and Department of Paediatrics & Child Health, University College Cork, Cork, Ireland
| | - A Napoli
- Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, Sapienza, University of Rome, Rome, Italy
| | - C Crowther
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - S Galjaard
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - M R Loeken
- Section of Islet Cell and Regenerative Biology, Joslin Diabetes Center, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Mja Maresh
- Department of Obstetrics, St Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - P Gillespie
- Health Economics and Policy Analysis Centre (HEPAC), National University of Ireland, Galway, Ireland
| | - H de Valk
- Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A Agostini
- A.S.LViterbo Distretto A, Consultorio Montefiascone, Rome, Italy
| | - L Biesty
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
| | - D Devane
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland.,HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - F Dunne
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
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16
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Fishel Bartal M, Ward C, Blackwell SC, Ashby Cornthwaite JA, Zhang C, Refuerzo JS, Pedroza C, Lee KH, Chauhan SP, Sibai BM. Detemir vs neutral protamine Hagedorn insulin for diabetes mellitus in pregnancy: a comparative effectiveness, randomized controlled trial. Am J Obstet Gynecol 2021; 225:87.e1-87.e10. [PMID: 33865836 DOI: 10.1016/j.ajog.2021.04.223] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 04/06/2021] [Accepted: 04/08/2021] [Indexed: 01/24/2023]
Abstract
BACKGROUND Insulin detemir, being used increasingly during pregnancy, may have pharmacologic benefits compared with neutral protamine Hagedorn. OBJECTIVE We evaluated the probability that compared with treatment with neutral protamine Hagedorn, treatment with insulin detemir reduces the risk for adverse neonatal outcome among individuals with type 2 or overt type 2 diabetes mellitus (gestational diabetes mellitus diagnosed at <20 weeks' gestation). STUDY DESIGN We performed a multiclinic randomized controlled trial (September 2018 to January 2020), which included women with singleton gestation with type 2 or overt type 2 diabetes mellitus who sought obstetrical care at ≤21 weeks' gestation. Participants were randomized to receive either insulin detemir or neutral protamine Hagedorn by a clinic-stratified scheme. The primary outcome was a composite of adverse neonatal outcomes, including shoulder dystocia, large for gestational age, neonatal intensive care unit admission, respiratory distress (defined as the need of at least 4 hours of respiratory support with supplemental oxygen, continuous positive airway pressure or ventilation at the first 24 hours of life), or hypoglycemia. The secondary neonatal outcomes included gestational age at delivery, small for gestational age, 5-minute Apgar score of <7, lowest glucose level, need for intravenous glucose, respiratory distress syndrome, need for mechanical ventilation or continuous positive airway pressure, neonatal jaundice requiring therapy, brachial plexus injury, and hospital length of stay. The secondary maternal outcomes included hypoglycemic events, hospital admission for glucose control, hypertensive disorder of pregnancy, maternal weight gain, cesarean delivery, and postpartum complications. We used the Bayesian statistics to estimate a sample size of 108 to have >75% probability of any reduction in the primary outcome, assuming 80% power and a hypothesized effect of 33% reduction with insulin detemir. All analyses were intent to treat under a Bayesian framework with neutral priors (a priori assumed a 50:50 likelihood of either intervention being better; National Clinical Trial identifier 03620890). RESULTS There were 108 women randomized in this trial (57 in insulin detemir and 51 in neutral protamine Hagedorn), and 103 women were available for analysis of the primary outcome (n=5 for pregnancy loss before 24 weeks' gestation). Bayesian analysis indicated an 87% posterior probability of reduced primary outcome with insulin detemir compared with neutral protamine Hagedorn (posterior adjusted relative risk, 0.88; 95% credible interval, 0.61-1.12). Bayesian analyses for secondary outcomes showed consistent findings of lower adverse maternal outcomes with the use of insulin detemir vs neutral protamine Hagedorn: for example, maternal hypoglycemic events (97% probability of benefit; posterior adjusted relative risk, 0.59; 95% credible interval, 0.29-1.08) and hypertensive disorders (88% probability of benefit; posterior adjusted relative risk, 0.81; 95% credible interval, 0.54-1.16). CONCLUSION In our comparative effectiveness trial involving individuals with type 2 or overt type 2 diabetes mellitus, use of insulin detemir resulted in lower rates of adverse neonatal and maternal outcomes compared with neutral protamine Hagedorn.
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17
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Xodo S, Londero AP, D’Agostin M, Novak A, Galasso S, Pittini C, Baccarini G, Grimaldi F, Driul L. Is Glycated Hemoglobin A1c Level Associated with Adverse Pregnancy Outcomes of Women Affected by Pre-Gestational Diabetes? MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57050461. [PMID: 34065046 PMCID: PMC8151463 DOI: 10.3390/medicina57050461] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 04/30/2021] [Accepted: 05/04/2021] [Indexed: 01/24/2023]
Abstract
Background and Objectives: This observational study aims to determine the correlation between glycemic control with the HbA1c value and adverse obstetric outcome in women affected by pre-gestational diabetes. Materials and Methods: A retrospective analysis has been performed at the University Hospital of Udine. Only patients with a singleton pregnancy, pre-gestational diabetes, and known level of Hb A1c throughout pregnancy were included in the study. Results: According to the HbA1c level, at the beginning of pregnancy, 49 patients with HbA1c ≤ 7.0% were compared with 45 patients with HbA1c > 7.0%. Maternal age at diagnosis of the disease was significantly higher in the group with HbA1c ≤ 7% than in the group with HbA1c > 7%, 26.00 (18.00–32.00) vs. 20.00 (12.50–27.00). Women with HbA1c ≤ 7.0% reached, at term of pregnancy, significantly lower levels of HbA1c, 5.8% (5.7–6.0) vs. 6.7% (6.3–7.3). Daily insulin units were statistically different between the two groups at the end of pregnancy (47.92 (39.00–67.30) vs. 64.00 (48.00–82.00)). Proteinuria was significantly higher in the group with HbA1c > 7.0%, who delivered at earlier gestational age (37.57 (35.57–38.00) vs. 38.14 (38.00–38.43). Moreover, women with HbA1c > 7.0% had a significantly higher prevalence of an adverse composite outcome. Of note, in multivariate logistic regression analysis, pregnancy complications were significantly correlated to pre-pregnancy HbA1c > 7.0% (OR 2.95 CI.95 1.16–7.48, p < 0.05) independently of age, insulin treatment, and type of diabetes. Conclusions: Our data, obtained from a single-center cohort study, suggest that starting pregnancy with poor glycemic control might predict more complex management of diabetes in the following trimesters.
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Affiliation(s)
- Serena Xodo
- Clinic of Gynecology and Obstetrics, University Hospital of Udine, 33100 Udine, Italy; (A.P.L.); (A.N.); (G.B.); (L.D.)
- Correspondence: ; Tel.: +39-0432-559635
| | - Ambrogio Pietro Londero
- Clinic of Gynecology and Obstetrics, University Hospital of Udine, 33100 Udine, Italy; (A.P.L.); (A.N.); (G.B.); (L.D.)
| | - Martina D’Agostin
- Department Medical Area, School of Medicine, University of Udine, 33100 Udine, Italy;
| | - Alice Novak
- Clinic of Gynecology and Obstetrics, University Hospital of Udine, 33100 Udine, Italy; (A.P.L.); (A.N.); (G.B.); (L.D.)
| | - Silvia Galasso
- Endocrinology and Metabolism Unit, University Hospital of Udine, 33100 Udine, Italy; (S.G.); (F.G.)
| | - Carla Pittini
- Unit of Neonatology, University Hospital of Udine, 33100 Udine, Italy;
| | - Giovanni Baccarini
- Clinic of Gynecology and Obstetrics, University Hospital of Udine, 33100 Udine, Italy; (A.P.L.); (A.N.); (G.B.); (L.D.)
| | - Franco Grimaldi
- Endocrinology and Metabolism Unit, University Hospital of Udine, 33100 Udine, Italy; (S.G.); (F.G.)
| | - Lorenza Driul
- Clinic of Gynecology and Obstetrics, University Hospital of Udine, 33100 Udine, Italy; (A.P.L.); (A.N.); (G.B.); (L.D.)
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18
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Mecacci F, Lisi F, Vannuccini S, Ottanelli S, Rambaldi MP, Serena C, Simeone S, Petraglia F. Different Gestational Diabetes Phenotypes: Which Insulin Regimen Fits Better? Front Endocrinol (Lausanne) 2021; 12:630903. [PMID: 33767671 PMCID: PMC7985539 DOI: 10.3389/fendo.2021.630903] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/18/2021] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Maternal characteristics and OGTT values of pregnancies complicated by gestational diabetes mellitus (GDM) were evaluated according to treatment strategies. The goal was to identify different maternal phenotypes in order to predict the appropriate treatment strategy. METHODS We conducted a retrospective study among 1,974 pregnant women followed up for GDM in a tertiary referral hospital for high-risk pregnancies (Careggi University Hospital, Florence, Italy) from 2013 to 2018. We compared nutritional therapy (NT) alone (n = 962) versus NT and insulin analogues (n = 1,012) group. Then, we focused on different insulin analogues groups: long acting (D), rapid acting (R), both D and R. We compared maternal characteristics of the three groups, detecting which factors may predict the use of rapid or long-acting insulin analogue alone versus combined therapy. RESULTS Among women included in the analysis, 51.3% of them needed insulin therapy for glycemic control: 61.8% D, 28.3% combined D and R, and 9.9% R alone. Age >35 years, pre-pregnancy BMI >30, family history of diabetes, previous GDM, altered fasting plasma glucose (FPG), hypothyroidism, and assisted reproductive technologies (ART) were identified as maternal variables significantly associated with the need of insulin therapy. Altered 1-h and 2-h glucose plasma glucose level at OGTT, age >35 years, and previous GDM were found as independent predicting factors for the use of combined therapy with rapid and long acting analogues for glycemic control. On the contrary, pre-pregnancy BMI <25 and normal fasting plasma glucose values at OGTT were found to be significantly associated to the use of rapid insulin analogue only. CONCLUSION A number of maternal and metabolic variables may be identified at the diagnosis of GDM, in order to identify different GDM phenotypes requiring a personalized treatment for glycemic control.
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Affiliation(s)
- Federico Mecacci
- Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
- High Risk Pregnancy Unit, Careggi University Hospital, Florence, Italy
| | - Federica Lisi
- Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Silvia Vannuccini
- High Risk Pregnancy Unit, Careggi University Hospital, Florence, Italy
- Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy
- *Correspondence: Silvia Vannuccini,
| | - Serena Ottanelli
- High Risk Pregnancy Unit, Careggi University Hospital, Florence, Italy
| | | | - Caterina Serena
- High Risk Pregnancy Unit, Careggi University Hospital, Florence, Italy
| | - Serena Simeone
- High Risk Pregnancy Unit, Careggi University Hospital, Florence, Italy
| | - Felice Petraglia
- Department of Biomedical, Experimental and Clinical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
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Jethwani P, Saboo B, Jethwani L, Chawla R, Maheshwari A, Agarwal S, Jaggi S. Use of insulin glargine during pregnancy: A review. Diabetes Metab Syndr 2021; 15:379-384. [PMID: 33540243 DOI: 10.1016/j.dsx.2021.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/09/2021] [Accepted: 01/11/2021] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
| | - B Saboo
- Diacare- Diabetes Care & Hormone Clinic, Ahmedabad, India
| | | | - R Chawla
- North Delhi Diabetes Centre, Rohini, New Delhi, India
| | - A Maheshwari
- Sri Harikamal Diabetes Clinic & Research Centre, Vikas Nagar, Lucknow, India
| | - S Agarwal
- Dept. of Medicine, Ruby Hall Clinic, Pune, India
| | - S Jaggi
- Lifecare Diabetes Centre, New Delhi, India
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Kgosidialwa O, Bogdanet D, Egan A, O'Shea PM, Biesty L, Devane D, Dunne F. Developing a core outcome set for the treatment of pregnant women with pregestational diabetes-a study protocol. Trials 2020; 21:1017. [PMID: 33308263 PMCID: PMC7730783 DOI: 10.1186/s13063-020-04910-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 11/16/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pregestational diabetes mellitus (PGDM) is associated with adverse pregnancy outcomes including increased rates of caesarean section birth, macrosomia, congenital malformation, prematurity, admission to the neonatal intensive care unit and stillbirth. As a result, there has been an increase in interventions to improve outcomes in both mother and infant. To date, meaningful comparisons between these studies are limited due to heterogeneity in outcome selection and reporting. The aim of this study is to develop a core outcome set (COS) for randomised controlled trials evaluating the effectiveness of interventions for the treatment of pregnant women with PGDM. METHODS The study consists of three steps. The first step is a systematic review of the literature to assess outcomes reported in randomised controlled trials assessing the effectiveness of interventions for the treatment of pregnant women with PGDM. The second step is a three round, online Delphi survey to prioritise these outcomes. In this step, stakeholders (including women with PGDM, healthcare workers, researchers and policymakers) will be asked to rank the importance of outcomes for inclusion in the COS using a 9-point Likert type scale. Outcomes that meet the inclusion criteria after completion of the Delphi surveys will be brought to the consensus meeting. The consensus meeting will be the third and final step, where the COS will be finalised. The consensus meeting will include members from each stakeholder group. DISCUSSION This paper describes the process used to develop a COS for the reporting of studies evaluating the effectiveness of interventions in pregnant women with PGDM. The COS will enable greater comparison between and information synthesis across RCTs in the treatment of PGDM. In addition, this COS will also help improve trial reporting and minimise research waste by prioritising the collection and reporting of outcomes that matter to all relevant stakeholder groups. TRIAL REGISTRATION This COS has been registered with the Core Outcome Measures in Effectiveness Trials (COMET) initiative ( http://www.comet-initiative.org/studies/details/1425 ) on the 4th of November 2019. The systematic review component of this study has also been registered with the International Prospective Register of Systematic Reviews (PROSPERO) ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020173549 ).
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Affiliation(s)
| | - Delia Bogdanet
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Aoife Egan
- Department of Endocrinology, Mayo Clinic Rochester, Rochester, MN, USA
| | - Paula M O'Shea
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Linda Biesty
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.,Ireland HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - Declan Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.,Ireland HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - Fidelma Dunne
- School of Medicine, National University of Ireland Galway, Galway, Ireland
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Abstract
BACKGROUND After 98 years of insulin therapy, issues of safety remain of concern. AREAS OF UNCERTAINTY Uncertainty has been expressed variously in regard of arterial cell wall proliferation, promotion of proliferative retinopathy, promotion of tumor growth, and for pregnancy. Immunological issues have been little studied since the advent of highly purified insulins in the 1970s. A specific topic is whether hypoglycemia, severe or otherwise, might promote cardiac thrombotic or dysrhythmic events. DATA SOURCES A literature review in these areas is difficult because nearly all clinical trials with insulin refer to adverse events. However, the specific topics aforementioned allow for some informed literature searching supplemented by finger-searching of published articles, notably in connection with the insulin analogues. THERAPEUTIC UNDERSTANDINGS Safety data for pregnancy are weak because of power problems, but there are no signals for added maternal or fetal risk. Clinical-outcome trials that assess insulin against other glucose-lowering therapies or with significantly different insulin preparations in different arms are few and are sometimes conducted at modest dosage but fail to suggest promotion of arterial disease. Concern over growth-promoting activity of insulin glargine turned out to be ill-founded when the circulating moiety after injection was noted to have a lower IGF-1:insulin activity than human insulin, and a direct study of retinopathy progression or meta-analysis of malignancy incidence failed to show signals of concern. It does seem that severe hypoglycemia can cause death in some people with type 1 diabetes, although the tissue mechanism is unknown, but reducing severe hypoglycemia in type 2 diabetes does not protect against arterial events. Both symptomatic and severe hypoglycemia can however be reduced by use of more recently marketed insulin analogues, and this improves tolerability if not safety. CONCLUSIONS In conclusion, although insulin therapy clearly gives health benefits, the evidence for long-term harm is absent or weak.
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Ji J, He Z, Yang Z, Mi Y, Guo N, Zhao H, Gao J, Ma Z, Luo X, Han Z. Comparing the efficacy and safety of insulin detemir versus neutral protamine hagedorn insulin in treatment of diabetes during pregnancy: a randomized, controlled study. BMJ Open Diabetes Res Care 2020; 8:8/1/e001155. [PMID: 32265255 PMCID: PMC7254127 DOI: 10.1136/bmjdrc-2019-001155] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 02/01/2020] [Accepted: 03/03/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To compare the efficacy and safety of insulin detemir (IDet) versus neutral protamine Hagedorn (NPH) insulin used in pregnant women with diabetes. RESEARCH DESIGN AND METHODS A randomized study was conducted in diabetic pregnant women (n=240) (including 132 with pregestational diabetes and 108 with gestational diabetes). All patients were randomly divided into two groups: IDet group (n=120) treated with IDet plus short acting insulin Novolin-R before three meals (RRR-IDet plan), and NPH group treated with NPH plus Novolin-R before three meals (RRR-NPH plan). Patients were enrolled during 12-28 gestation weeks and followed up until delivery. RESULTS Basal characteristics, such as age, enrollment gestational weeks, average HbA1c, fasting plasma glucose (FPG) and oral glucose tolerance test (OGTT) were similar between two groups. After 1 week of treatment, the FPG of IDet group were significantly lower than NPH group (p<0.05) and the time required to reach the targeted blood glucose level was significantly shorter (p<0.001). After 3 months of treatment, the HbA1c level in the two groups was normalized but there was no significant difference in HbA1c level. Maternal and neonatal outcomes were comparable between the two therapeutic approaches; however, the incidence of hypoglycemia in IDet group was remarkably lower than that of NPH group (p<0.05). The adverse drug reactions were rare and similar between the two groups. CONCLUSIONS For the treatment of gestational diabetes, both RRR-IDet plan and RRR-NPH plan were reported to control blood glucose effectively. Compared with NPH, IDet could control blood glucose and reached the targets faster and more effectively, thus reducing the number of insulin injections and the incidence of hypoglycemia in pregnant women without increasing adverse birth outcomes. Therefore, for pregnant women with gestational diabetes, who require insulin therapy, IDet would be an ideal basal insulin being worthy of promotion in clinical settings.
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Affiliation(s)
- Jing Ji
- Department of Obstetrics and Gynecology, Northwest Women's and Children's Hospital, Xi'an, China
| | - Zhangya He
- Department of Nutrition and Food Safety, School of Public Health, Xi'an Jiaotong University, Xi'an, China
| | - Zhao Yang
- Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Yang Mi
- Department of Obstetrics and Gynecology, Northwest Women's and Children's Hospital, Xi'an, China
| | - Na Guo
- Department of Obstetrics and Gynecology, Northwest Women's and Children's Hospital, Xi'an, China
| | - Hong Zhao
- Department of Obstetrics and Gynecology, Northwest Women's and Children's Hospital, Xi'an, China
| | - Jiayi Gao
- Department of Nutrition and Food Safety, School of Public Health, Xi'an Jiaotong University, Xi'an, China
| | - Zhengfeei Ma
- Department of Health and Environmental Sciences, Xi'an Jiaotong-Liverpool University, Suzhou, China
| | - Xiaoqin Luo
- Department of Nutrition and Food Safety, School of Public Health, Xi'an Jiaotong University, Xi'an, China
| | - Zhen Han
- Department of Obstetrics and Gynecology, the First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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López-Tinoco C, Jiménez-Blázquez JL, Larrán-Escandón L, Roca-Rodríguez MDM, Bugatto F, Aguilar-Diosdado M. Effect of Different Insulin Therapies on Obstetric-Fetal Outcomes. Sci Rep 2019; 9:17650. [PMID: 31776421 PMCID: PMC6881342 DOI: 10.1038/s41598-019-54164-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 11/01/2019] [Indexed: 12/24/2022] Open
Abstract
To evaluate the effectiveness of the different insulin therapies on obstetrics-fetal outcomes in women with pregestational diabetes mellitus. We enrolled 147 pregnant women with pre-existing type 1 or 2 diabetes mellitus. Clinical and biochemical parameters were analysed in relation to obstetric and fetal outcomes. 14.2% received treatment with Neutral Protamine Hagedorn insulin and short-acting insulin analogues; 19% with premixed human insulin; 40.1% with insulin glargine and lispro, 6.2% with detemir and aspart and 20% with continuous subcutaneous insulin infusion. All 5 types of treatment achieved a reduction of the mean HbA1c during pregnancy (p = 0.01). Pre-pregnancy care was carried out for 48% of patients. We found no statistically significant differences between the different insulin therapies and the obstetric-fetal outcomes. In conclusión, the different insulin therapies used in patients with pregestational diabetes mellitus does not seem to affect obstetric-fetal outcomes.
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Affiliation(s)
- Cristina López-Tinoco
- Department of Endocrinology, Puerta del Mar Hospital Cádiz/ Department of Medicine, University of Cádiz, Av. Ana de Viya 21 CP:11009 Cádiz/Dr. Marañón, 3 CP: 11002, Cádiz, Spain.
| | | | - Laura Larrán-Escandón
- Department of Endocrinology, Puerta del Mar Hospital, Av. Ana de Viya 21, CP: 11009, Cádiz, Spain
| | | | - Fernando Bugatto
- Department of Obstetrics and Gynaecology, Puerta del Mar Hospital, Cádiz, Av. Ana de Viya 21, CP: 11009, Cádiz, Spain
| | - Manuel Aguilar-Diosdado
- Department of Endocrinology, Puerta del Mar Hospital Cádiz/ Department of Medicine, University of Cádiz, Av. Ana de Viya 21 CP:11009 Cádiz/Dr. Marañón, 3 CP: 11002, Cádiz, Spain
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Abstract
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.
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Abstract
In 1989 the St. Vincent Declaration aimed to achieve comparable pregnancy outcomes in diabetic and non-diabetic women. However, currently women with pre-gestational diabetes still feature a higher risk of perinatal morbidity and even increased mortality. This fact is mostly ascribed to a persistently low rate of pregnancy planning and pre-pregnancy care with optimization of metabolic control prior to conception. All women should be experienced in the management of their therapy and on stable glycemic control prior to the conception. In addition, thyroid dysfunction, hypertension as well as the presence of diabetic complications should be excluded before pregnancy or treated adequately in order to decrease the risk for a progression of complications during pregnancy as well as maternal and fetal morbidity. Especially in women with type 1 diabetes mellitus in early pregnancy the risk of hypoglycemia is highest and decreases with the progression of pregnancy due to hormonal changes causing steady increase of insulin resistance. In addition, obesity increases worldwide and contributes to increasing numbers of women at childbearing age with type 2 diabetes mellitus and further deterioration of pregnancy outcomes in diabetic women. Maternal glycemic control should aim to achieve normoglycemia and normal HbA1c levels, possibly without hypoglycemia, but is associated with the development of diabetic embryopathy and fetopathy if dysglycemia occurs. Intensified insulin therapy with multiple daily insulin injections and pump treatment are effective in reaching good metabolic control during pregnancy. Oral glucose lowering drugs (Metformin) may be considered in obese women with type 2 diabetes mellitus to increase insulin sensitivity but should be also prescribed cautiously due to crossing the placenta and lack of long-time follow up data of the offspring.
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Frier BM, Ratzki‐Leewing A, Harris SB. Reporting of hypoglycaemia in clinical trials of basal insulins: A need for consensus. Diabetes Obes Metab 2019; 21:1529-1542. [PMID: 30924567 PMCID: PMC6767397 DOI: 10.1111/dom.13732] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 03/13/2019] [Accepted: 03/26/2019] [Indexed: 12/31/2022]
Abstract
Hypoglycaemia is a common side-effect of diabetes therapies, particularly insulin, and imposes a substantial burden on individuals and healthcare systems. Consequently, regulatory approval of newer basal insulin (BI) therapies has relied on demonstration of a balance between achievement of good glycaemic control and less hypoglycaemia. Randomized controlled trials (RCTs) are the gold standard for assessing efficacy and safety, including hypoglycaemia risk, of BIs and are invaluable for obtaining regulatory approval. However, their highly selected patient populations and their conditions lead to results that may not be representative of real-life situations. Real-world evidence (RWE) studies are more representative of clinical practice, but they also have limitations. As such, data both from RCTs and RWE studies provide a fuller picture of the hypoglycaemia risk with BI therapies. However, substantial differences exist in the way hypoglycaemia is reported across these studies, which confounds comparisons of hypoglycaemia frequency among different BIs. This problem is ongoing and persists in recent trials of second-generation BI analogues. Although they provide a lower risk of hypoglycaemia when compared with earlier BIs, they do not eliminate it. This review describes differences in the way hypoglycaemia is reported across RCTs and RWE studies of second-generation BI analogues and examines potential reasons for these differences. For studies of BIs, there is a need to standardize aspects of design, analysis and methods of reporting to better enable interpretation of the efficacy and safety of such insulins among studies; such aspects include length of follow-up, glycaemic targets, hypoglycaemia definitions and time intervals for determining nocturnal events.
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Affiliation(s)
- Brian M. Frier
- British Heart Foundation Centre for Cardiovascular ScienceThe Queen's Medical Research Institute, University of EdinburghEdinburghUK
| | - Alexandria Ratzki‐Leewing
- Department of Epidemiology and BiostatisticsSchulich School of Medicine and Dentistry, Western UniversityLondonOntario, Canada
| | - Stewart B. Harris
- Department of Family MedicineSchulich School of Medicine and Dentistry, Western UniversityLondonOntario, Canada
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Ringholm L, Damm P, Mathiesen ER. Improving pregnancy outcomes in women with diabetes mellitus: modern management. Nat Rev Endocrinol 2019; 15:406-416. [PMID: 30948803 DOI: 10.1038/s41574-019-0197-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark.
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark.
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Bonora BM, Avogaro A, Fadini GP. Exposure to insulin degludec during pregnancy: report of a small series and review of the literature. J Endocrinol Invest 2019; 42:345-349. [PMID: 30043095 DOI: 10.1007/s40618-018-0926-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 07/17/2018] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- B M Bonora
- Division of Metabolic Diseases, Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - A Avogaro
- Division of Metabolic Diseases, Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy
| | - G P Fadini
- Division of Metabolic Diseases, Department of Medicine, University of Padova, Via Giustiniani 2, 35128, Padua, Italy.
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Santos LL, Santos JL, Barbosa LT, Silva IDND, de Sousa-Rodrigues CF, Barbosa FT. Effectiveness of Insulin Analogs Compared with Human Insulins in Pregnant Women with Diabetes Mellitus: Systematic Review and Meta-analysis. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2019; 41:104-115. [PMID: 30786308 PMCID: PMC10418821 DOI: 10.1055/s-0038-1676510] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 10/09/2018] [Indexed: 10/27/2022] Open
Abstract
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.
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Abstract
OBJECTIVE To evaluate the pregnancy outcomes in mothers with controlled Type 1 diabetes mellitus (T1DM). MATERIALS AND METHODS Thirty seven pregnant patients with controlled T1DM were included in the study. RESULTS Twenty (54%) out of 37 patients had preterm delivery (<37 weeks of gestation). The type of delivery was induced vaginal delivery in 9 (24.3%) patients and cesarean section in 27 (72.9%) patients. Preeclampsia developed in 6 (16.2%) patients. Macrosomia was found in 9 (24%) patients. Two antenatal death occured. CONCLUSION Even in the most favorable conditions, the pregnant patients with T1DM would have a great risk for preterm delivery and cesarean section, moderate risk for macrosomia, preeclampsia, and an undefined risk for antenatal death.
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Toledano Y, Hadar E, Hod M. Pharmacotherapy for hyperglycemia in pregnancy - The new insulins. Diabetes Res Clin Pract 2018; 145:59-66. [PMID: 29730391 DOI: 10.1016/j.diabres.2018.04.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/18/2018] [Indexed: 02/08/2023]
Abstract
Hyperglycemia in pregnancy may lead to adverse maternal, fetal and neonatal outcomes. Tight glycemic control is prudent in order to reduce pregnancy complications. For many years, the gold standard pharmacological therapy during pregnancy was human insulin. Recently, insulin analogues were also introduced to clinical use in pregnancy. This brief review aims to summarize the information on the efficacy and safety of insulin analogue therapy during gestation. The strengths and pitfalls of insulin analogue administration during gestation, compared with human insulin, are presented. According to studies in pregnant women with type 1 diabetes, insulins lispro, aspart and detemir are efficacious and safe. Correspondingly, the FDA has reclassified them for the treatment of pregnant women with diabetes from category C to category B. Although large and prospective data on insulin glargine in gestation are still lacking, no major safety concerns were documented. No controlled trials with insulins glulisine and degludec were conducted in pregnancy. In sum, insulin analogues are practical therapeutic options for hyperglycemia in pregnancy, mainly due to their hypoglycemia risk reduction. More research for their use in pregnant women with gestational diabetes or type 2 diabetes should be conducted. Overall, their efficacy and safety is possibly comparable to human insulin.
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Affiliation(s)
- Yoel Toledano
- Division of Maternal Fetal Medicine, Helen Schneider Women's Hospital, Rabin Medical Center, Israel.
| | - Eran Hadar
- Division of Maternal Fetal Medicine, Helen Schneider Women's Hospital, Rabin Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Moshe Hod
- Division of Maternal Fetal Medicine, Helen Schneider Women's Hospital, Rabin Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Abstract
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.
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Affiliation(s)
- Siobhán Bacon
- Mount Sinai Hospital, 60 Murray St, #5027, Toronto, Ontario, M5T 3L9, Canada
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Denice S Feig
- Mount Sinai Hospital, 60 Murray St, #5027, Toronto, Ontario, M5T 3L9, Canada.
- Department of Medicine, University of Toronto, Toronto, Canada.
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Martis R, Crowther CA, Shepherd E, Alsweiler J, Downie MR, Brown J. Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2018; 8:CD012327. [PMID: 30103263 PMCID: PMC6513179 DOI: 10.1002/14651858.cd012327.pub2] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Successful treatments for gestational diabetes mellitus (GDM) have the potential to improve health outcomes for women with GDM and their babies. OBJECTIVES To provide a comprehensive synthesis of evidence from Cochrane systematic reviews of the benefits and harms associated with interventions for treating GDM on women and their babies. METHODS We searched the Cochrane Database of Systematic Reviews (5 January 2018) for reviews of treatment/management for women with GDM. Reviews of pregnant women with pre-existing diabetes were excluded.Two overview authors independently assessed reviews for inclusion, quality (AMSTAR; ROBIS), quality of evidence (GRADE), and extracted data. MAIN RESULTS We included 14 reviews. Of these, 10 provided relevant high-quality and low-risk of bias data (AMSTAR and ROBIS) from 128 randomised controlled trials (RCTs), 27 comparisons, 17,984 women, 16,305 babies, and 1441 children. Evidence ranged from high- to very low-quality (GRADE). Only one effective intervention was found for treating women with GDM.EffectiveLifestyle versus usual careLifestyle intervention versus usual care probably reduces large-for-gestational age (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.50 to 0.71; 6 RCTs, N = 2994; GRADE moderate-quality).PromisingNo evidence for any outcome for any comparison could be classified to this category.Ineffective or possibly harmful Lifestyle versus usual careLifestyle intervention versus usual care probably increases the risk of induction of labour (IOL) suggesting possible harm (average RR 1.20, 95% CI 0.99 to 1.46; 4 RCTs, N = 2699; GRADE moderate-quality).Exercise versus controlExercise intervention versus control for return to pre-pregnancy weight suggested ineffectiveness (body mass index, BMI) MD 0.11 kg/m², 95% CI -1.04 to 1.26; 3 RCTs, N = 254; GRADE moderate-quality).Insulin versus oral therapyInsulin intervention versus oral therapy probably increases the risk of IOL suggesting possible harm (RR 1.3, 95% CI 0.96 to 1.75; 3 RCTs, N = 348; GRADE moderate-quality).Probably ineffective or harmful interventionsInsulin versus oral therapyFor insulin compared to oral therapy there is probably an increased risk of the hypertensive disorders of pregnancy (RR 1.89, 95% CI 1.14 to 3.12; 4 RCTs, N = 1214; GRADE moderate-quality).InconclusiveLifestyle versus usual careThe evidence for childhood adiposity kg/m² (RR 0.91, 95% CI 0.75 to 1.11; 3 RCTs, N = 767; GRADE moderate-quality) and hypoglycaemia was inconclusive (average RR 0.99, 95% CI 0.65 to 1.52; 6 RCTs, N = 3000; GRADE moderate-quality).Exercise versus controlThe evidence for caesarean section (RR 0.86, 95% CI 0.63 to 1.16; 5 RCTs, N = 316; GRADE moderate quality) and perinatal death or serious morbidity composite was inconclusive (RR 0.56, 95% CI 0.12 to 2.61; 2 RCTs, N = 169; GRADE moderate-quality).Insulin versus oral therapyThe evidence for the following outcomes was inconclusive: pre-eclampsia (RR 1.14, 95% CI 0.86 to 1.52; 10 RCTs, N = 2060), caesarean section (RR 1.03, 95% CI 0.93 to 1.14; 17 RCTs, N = 1988), large-for-gestational age (average RR 1.01, 95% CI 0.76 to 1.35; 13 RCTs, N = 2352), and perinatal death or serious morbidity composite (RR 1.03; 95% CI 0.84 to 1.26; 2 RCTs, N = 760). GRADE assessment was moderate-quality for these outcomes.Insulin versus dietThe evidence for perinatal mortality was inconclusive (RR 0.74, 95% CI 0.41 to 1.33; 4 RCTs, N = 1137; GRADE moderate-quality).Insulin versus insulinThe evidence for insulin aspart versus lispro for risk of caesarean section was inconclusive (RR 1.00, 95% CI 0.91 to 1.09; 3 RCTs, N = 410; GRADE moderate quality).No conclusions possibleNo conclusions were possible for: lifestyle versus usual care (perineal trauma, postnatal depression, neonatal adiposity, number of antenatal visits/admissions); diet versus control (pre-eclampsia, caesarean section); myo-inositol versus placebo (hypoglycaemia); metformin versus glibenclamide (hypertensive disorders of pregnancy, pregnancy-induced hypertension, death or serious morbidity composite, insulin versus oral therapy (development of type 2 diabetes); intensive management versus routine care (IOL, large-for-gestational age); post- versus pre-prandial glucose monitoring (large-for-gestational age). The evidence ranged from moderate-, low- and very low-quality. AUTHORS' CONCLUSIONS Currently there is insufficient high-quality evidence about the effects on health outcomes of relevance for women with GDM and their babies for many of the comparisons in this overview comparing treatment interventions for women with GDM. Lifestyle changes (including as a minimum healthy eating, physical activity and self-monitoring of blood sugar levels) was the only intervention that showed possible health improvements for women and their babies. Lifestyle interventions may result in fewer babies being large. Conversely, in terms of harms, lifestyle interventions may also increase the number of inductions. Taking insulin was also associated with an increase in hypertensive disorders, when compared to oral therapy. There was very limited information on long-term health and health services costs. Further high-quality research is needed.
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Affiliation(s)
- Ruth Martis
- The University of AucklandLiggins InstitutePark RoadGraftonAucklandNew Zealand1142
| | - Caroline A Crowther
- The University of AucklandLiggins InstitutePark RoadGraftonAucklandNew Zealand1142
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Emily Shepherd
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Jane Alsweiler
- Auckland HospitalNeonatal Intensive Care UnitPark Rd.AucklandNew Zealand
| | - Michelle R Downie
- Southland HospitalDepartment of MedicineKew RoadInvercargillSouthlandNew Zealand9840
| | - Julie Brown
- The University of AucklandDepartment of Obstetrics and GynaecologyPark RdGraftonAucklandNew Zealand1142
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Feig DS, Berger H, Donovan L, Godbout A, Kader T, Keely E, Sanghera R. Diabetes and Pregnancy. Can J Diabetes 2018; 42 Suppl 1:S255-S282. [DOI: 10.1016/j.jcjd.2017.10.038] [Citation(s) in RCA: 108] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Pande A, Aggarwal A, Wadhwa R. Reduced Efficacy of Insulin Detemir in Controlling Hyperglycemia during Pregnancy: An Interesting Case Report. Indian J Endocrinol Metab 2018; 22:292-295. [PMID: 29911051 PMCID: PMC5972494 DOI: 10.4103/ijem.ijem_41_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Arun Pande
- Department of Endocrinology, Sahara Hospital, Lucknow, Uttar Pradesh, India
| | - Ajay Aggarwal
- Department of Endocrinology, Fortis Hospital, Shalimar Bagh, New Delhi, India
| | - Roopak Wadhwa
- Department of Endocrinology, Fortis Hospital, Shalimar Bagh, New Delhi, India
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Wang H, Wender-Ozegowska E, Garne E, Morgan M, Loane M, Morris JK, Bakker MK, Gatt M, de Walle H, Jordan S, Materna-Kiryluk A, Nelen V, Thys G, Wiesel A, Dolk H, de Jong-van den Berg LTW. Insulin analogues use in pregnancy among women with pregestational diabetes mellitus and risk of congenital anomaly: a retrospective population-based cohort study. BMJ Open 2018; 8:e014972. [PMID: 29478010 PMCID: PMC5855464 DOI: 10.1136/bmjopen-2016-014972] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES To evaluate the risk of major congenital anomaly associated with first-trimester exposure to insulin analogues compared with human insulin in offspring of women with pregestational diabetes. DESIGN AND SETTING A population-based cohort of women with pregestational diabetes (n=1661) who delivered between 1996 and 2012 was established retrospectively from seven European regions covered bythe European Surveillance of Congenital Anomalies (EUROCAT) congenital anomaly registries. PRIMARY OUTCOME MEASURES The risk of non-chromosomal major congenital anomaly in live births, fetal deaths and terminations for a fetal anomaly exposed to insulin analogues in the first trimester of pregnancy was compared with the risk in those exposed to human insulin only. RESULTS During the first trimester, 870 fetuses (52.4%) were exposed to human insulin only, 397 fetuses (23.9%) to insulin analogues only and 394 fetuses (23.7%) to both human insulin and insulin analogues. The risk of major congenital anomaly in fetuses exposed to insulin analogues only was lower than those exposed to human insulin only; the relative risk adjusted for glycaemic control and region was 0.56 (95% CI 0.29 to 1.06). The significantly lower risk related to exposure of insulin analogues only was observed in congenital heart defects: adjusted relative risk 0.14 (95% CI 0.03 to 0.62). CONCLUSIONS In this retrospective population-based cohort study across Europe, first-trimester exposure to insulin analogues did not increase the risk of major congenital anomaly compared with exposure to human insulin. A possible lower risk of congenital heart defects among fetuses exposed to insulin analogues only deserves further investigation.
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Affiliation(s)
- Hao Wang
- Pharmacoepidemiology and Pharmacoeconomics, University of Groningen, Groningen, The Netherlands
| | | | - Ester Garne
- Paediatric Department, Hospital Lillebaelt, Kolding, Denmark
| | - Margery Morgan
- Obstetrician & Gynaecologist, Singleton Hospital, Swansea, UK
| | - Maria Loane
- School of Nursing, Ulster University, Northern Ireland, UK
| | | | - Marian K Bakker
- Faculty of Medical Science, University Medical Centre Groningen, Groningen, The Netherlands
| | - Miriam Gatt
- Department of Health Information and Research, Ministry of Health, Valletta, Malta
| | - Hermien de Walle
- Faculty of Medical Science, University Medical Centre Groningen, Groningen, The Netherlands
| | - Susan Jordan
- School of Nursing, Swansea University, Swansea, UK
| | - Anna Materna-Kiryluk
- Department of Medical Genetics, Poznan University of Medical Sciences, Poznan, Poland
| | - Vera Nelen
- Provinciaal Instituut voor Hygiene, Antwerp, Belgium
| | - Guy Thys
- Provinciaal Instituut voor Hygiene, Antwerp, Belgium
| | - Awi Wiesel
- Birth Registry Mainz Model, Children’s Hospital, University Medical Center of Mainz, Mainz, Germany
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Hedrington MS, Davis SN. The care of pregestational and gestational diabetes and drug metabolism considerations. Expert Opin Drug Metab Toxicol 2017; 13:1029-1038. [PMID: 28847172 DOI: 10.1080/17425255.2017.1372423] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Normal pregnancy development involves gradual decline in insulin sensitivity, which sometimes requires pharmacotherapy. Insulin is the drug of choice for gestational and pregestational diabetes. Metabolism of traditional insulins results in inadequate onset and duration of action and marked peak activity. These properties increase risk of excessive glucose excursions, which are especially undesirable during pregnancy. Insulin analogs have been emerging as a safer and more effective treatment of diabetes during pregnancy. Areas covered: This manuscript reviews currently used antihyperglycemic agents: fast and long-acting insulins, metformin and glyburide. Trials demonstrating their efficacy and safety during pregnancy are described. Certain drug metabolism considerations (e.g. affinity to IGF-1) are emphasized. Expert opinion: The theories that insulin analogs bind to immunoglobulin and cross placenta have been disproved. Lispro, aspart, glargine and detemir do not transfer across the placenta and do not result in adverse maternal and neonatal outcomes. In addition, favorable pharmacokinetic profiles (rapid onset and 24-hour near peakless activity) substantially reduce blood glucose variability including hypoglycemia. We believe that insulin analogs should be given strong consideration for the treatment of diabetes during pregnancy. Metformin has also proven to be safe and may be considered as an initial single agent for milder gestational diabetes.
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Affiliation(s)
- Maka S Hedrington
- a Department of Medicine , University of Maryland School of Medicine , Baltimore , MD , USA
| | - Stephen N Davis
- a Department of Medicine , University of Maryland School of Medicine , Baltimore , MD , USA
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O'Neill SM, Kenny LC, Khashan AS, West HM, Smyth RMD, Kearney PM. Different insulin types and regimens for pregnant women with pre-existing diabetes. Cochrane Database Syst Rev 2017; 2:CD011880. [PMID: 28156005 PMCID: PMC6464609 DOI: 10.1002/14651858.cd011880.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Insulin requirements may change during pregnancy, and the optimal treatment for pre-existing diabetes is unclear. There are several insulin regimens (e.g. via syringe, pen) and types of insulin (e.g. fast-acting insulin, human insulin). OBJECTIVES To assess the effects of different insulin types and different insulin regimens in pregnant women with pre-existing type 1 or type 2 diabetes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 October 2016), ClinicalTrials.gov (17 October 2016), the WHO International Clinical Trials Registry Platform (ICTRP; 17 October 2016), and the reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared different insulin types and regimens in pregnant women with pre-existing diabetes.We had planned to include cluster-RCTs, but none were identified. We excluded quasi-randomised controlled trials and cross-over trials. We included studies published in abstract form and contacted the authors for further details when applicable. Conference abstracts were superseded by full publications. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, conducted data extraction, assessed risk of bias, and checked for accuracy. We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS The findings in this review were based on very low-quality evidence, from single, small sample sized trial estimates, with wide confidence intervals (CI), some of which crossed the line of no effect; many of the prespecified outcomes were not reported. Therefore, they should be interpreted with caution. We included five trials that included 554 women and babies (four open-label, multi-centre, two-arm trials; one single centre, four-arm RCT). All five trials were at a high or unclear risk of bias due to lack of blinding, unclear methods of randomisation, and selective reporting of outcomes. Pooling of data from the trials was not possible, as each trial looked at a different comparison.1. One trial (N = 33 women) compared Lispro insulin with regular insulin and provided very low-quality evidence for the outcomes. There were seven episodes of pre-eclampsia in the Lispro group and nine in the regular insulin group, with no clear difference between the two groups (risk ratio (RR) 0.68, 95% CI 0.35 to 1.30). There were five caesarean sections in the Lispro group and nine in the regular insulin group, with no clear difference between the two groups (RR 0.59, 95% CI 0.25 to 1.39). There were no cases of fetal anomaly in the Lispro group and one in the regular insulin group, with no clear difference between the groups (RR 0.35, 95% CI 0.02 to 8.08). Macrosomia, perinatal deaths, episodes of birth trauma including shoulder dystocia, nerve palsy, and fracture, and the composite outcome measure of neonatal morbidity were not reported.2. One trial (N = 42 women) compared human insulin to animal insulin, and provided very low-quality evidence for the outcomes. There were no cases of macrosomia in the human insulin group and two in the animal insulin group, with no clear difference between the groups (RR 0.22, 95% CI 0.01 to 4.30). Perinatal death, pre-eclampsia, caesarean section, fetal anomaly, birth trauma including shoulder dystocia, nerve palsy and fracture and the composite outcome measure of neonatal morbidity were not reported.3. One trial (N = 93 women) compared pre-mixed insulin (70 NPH/30 REG) to self-mixed, split-dose insulin and provided very low-quality evidence to support the outcomes. Two cases of macrosomia were reported in the pre-mixed insulin group and four in the self-mixed insulin group, with no clear difference between the two groups (RR 0.49, 95% CI 0.09 to 2.54). There were seven cases of caesarean section (for cephalo-pelvic disproportion) in the pre-mixed insulin group and 12 in the self-mixed insulin group, with no clear difference between groups (RR 0.57, 95% CI 0.25 to 1.32). Perinatal death, pre-eclampsia, fetal anomaly, birth trauma including shoulder dystocia, nerve palsy, or fracture and the composite outcome measure of neonatal morbidity were not reported.4. In the same trial (N = 93 women), insulin injected with a Novolin pen was compared to insulin injected with a conventional needle (syringe), which provided very low-quality evidence to support the outcomes. There was one case of macrosomia in the pen group and five in the needle group, with no clear difference between the different insulin regimens (RR 0.21, 95% CI 0.03 to 1.76). There were five deliveries by caesarean section in the pen group compared with 14 in the needle group; women were less likely to deliver via caesarean section when insulin was injected with a pen compared to a conventional needle (RR 0.38, 95% CI 0.15 to 0.97). Perinatal death, pre-eclampsia, fetal anomaly, birth trauma including shoulder dystocia, nerve palsy, or fracture, and the composite outcome measure of neonatal morbidity were not reported.5. One trial (N = 223 women) comparing insulin Aspart with human insulin reported none of the review's primary outcomes: macrosomia, perinatal death, pre-eclampsia, caesarean section, fetal anomaly, birth trauma including shoulder dystocia. nerve palsy, or fracture, or the composite outcome measure of neonatal morbidity.6. One trial (N = 162 women) compared insulin Detemir with NPH insulin, and supported the outcomes with very low-quality evidence. There were three cases of major fetal anomalies in the insulin Detemir group and one in the NPH insulin group, with no clear difference between the groups (RR 3.15, 95% CI 0.33 to 29.67). Macrosomia, perinatal death, pre-eclampsia, caesarean section, birth trauma including shoulder dystocia, nerve palsy, or fracture and the composite outcome of neonatal morbidity were not reported. AUTHORS' CONCLUSIONS With limited evidence and no meta-analyses, as each trial looked at a different comparison, no firm conclusions could be made about different insulin types and regimens in pregnant women with pre-existing type 1 or 2 diabetes. Further research is warranted to determine who has an increased risk of adverse pregnancy outcome. This would include larger trials, incorporating adequate randomisation and blinding, and key outcomes that include macrosomia, pregnancy loss, pre-eclampsia, caesarean section, fetal anomalies, and birth trauma.
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Affiliation(s)
- Sinéad M O'Neill
- University College CorkIrish Centre for Fetal and Neonatal Translational Research (INFANT)5th Floor, Cork University Maternity HospitalWiltonCorkMunsterIreland
| | - Louise C Kenny
- University College CorkIrish Centre for Fetal and Neonatal Translational Research (INFANT)5th Floor, Cork University Maternity HospitalWiltonCorkMunsterIreland
| | - Ali S Khashan
- University College CorkIrish Centre for Fetal and Neonatal Translational Research (INFANT)5th Floor, Cork University Maternity HospitalWiltonCorkMunsterIreland
- University College CorkDepartment of Epidemiology and Public HealthCorkIreland
| | - Helen M West
- The University of LiverpoolInstitute of Psychology, Health and SocietyLiverpoolUK
| | - Rebecca MD Smyth
- The University of ManchesterSchool of Nursing, Midwifery and Social WorkJean McFarlane BuildingOxford RoadManchesterUKM13 9PL
| | - Patricia M Kearney
- University College CorkDepartment of Epidemiology and Public HealthCorkIreland
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Mathiesen ER, Andersen H, Kring SII, Damm P. Design and rationale of a large, international, prospective cohort study to evaluate the occurrence of malformations and perinatal/neonatal death using insulin detemir in pregnant women with diabetes in comparison with other long-acting insulins. BMC Pregnancy Childbirth 2017; 17:38. [PMID: 28100192 PMCID: PMC5241954 DOI: 10.1186/s12884-016-1177-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 12/02/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are a lack of data regarding the effect of basal insulin analogues on rates of events like congenital malformation and perinatal mortality in diabetic pregnancy. METHODS The present study is a prospective, non-interventional, multicentre cohort study conducted in seven countries, designed to assess the safety of insulin detemir during pregnancy, and to monitor the health status of resulting infants (exposed in utero) up to 1 year of age. The study population includes women with type 1 or type 2 diabetes, who are pregnant and being treated with insulin. Data will be collected in the context of routine practice. The primary endpoint is the proportion of pregnancies in women treated with insulin detemir, compared with other basal insulin regimens, which do not result in any of the following events: major congenital malformations, perinatal death or neonatal death. A sample size of 3075 pregnancies was calculated to provide an 80% power to detect a difference of 3.5% between groups in the primary endpoint at a 5% level. DISCUSSION The study will also examine other important maternal endpoints (e.g., incidences of severe hypoglycaemia and pre-eclampsia) and perinatal outcomes such as overweight neonates, as well as infant outcomes at 1 year of age. It has a fixed recruitment period from 2013 to 2018, enrolling all eligible patients, and is expected to inform future prescribing with basal insulins in diabetic pregnancy. TRIAL REGISTRATION ClinicalTrials.gov: NCT01892319 (date registered: 27.06.2013).
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Affiliation(s)
- Elisabeth R Mathiesen
- Department of Endocrinology, Center for Pregnant Women with Diabetes, Rigshospitalet, Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2100, Copenhagen, Denmark. .,Department of Obstetrics, Center for Pregnant Women with Diabetes, Rigshospitalet, Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | | | - Sofia I I Kring
- Epidemiology Department, Global Development, Novo Nordisk A/S, Bagsværd, Denmark
| | - Peter Damm
- Department of Endocrinology, Center for Pregnant Women with Diabetes, Rigshospitalet, Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, DK-2100, Copenhagen, Denmark.,Department of Obstetrics, Center for Pregnant Women with Diabetes, Rigshospitalet, Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Mathiesen ER. Pregnancy Outcomes in Women With Diabetes-Lessons Learned From Clinical Research: The 2015 Norbert Freinkel Award Lecture. Diabetes Care 2016; 39:2111-2117. [PMID: 27879355 DOI: 10.2337/dc16-1647] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Among women with diabetes, the worst pregnancy outcome is seen in the subgroup of women with diabetic nephropathy. Development of severe preeclampsia that leads to early preterm delivery is frequent. Predictors and pathophysiological mechanisms for the development of preeclampsia among women with diabetes and observational studies that support antihypertension treatment for pregnant women with microalbuminuria or diabetic nephropathy preventing preeclampsia and early preterm delivery are presented here. Obtaining and maintaining strict glycemic control before and during pregnancy is paramount to prevent preterm delivery. The cornerstones of diabetes management are appropriate diet and insulin, although the risk of severe hypoglycemia always needs to be taken into account when tailoring a diabetes treatment plan. Pathophysiological mechanisms of the increased risk of hypoglycemia during pregnancy are explored, and studies evaluating the use of insulin analogs, insulin pumps, and continuous glucose monitoring to improve pregnancy outcomes and to reduce the risk of severe hypoglycemia in pregnant women with type 1 diabetes are reported. In addition to strict glycemic control, other factors involved in fetal overgrowth are explored, and restricting maternal gestational weight gain is a promising treatment area. The optimal carbohydrate content of the diet is discussed. In summary, the lessons learned from this clinical research are that glycemic control, gestational weight gain, and antihypertension treatment all are of importance for improving pregnancy outcomes in pregnant women with preexisting diabetes. An example of how to use app technology to share the recent evidence-based clinical recommendations for women with diabetes who are pregnant or planning pregnancy is given.
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Affiliation(s)
- Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes and Faculty of Health and Medical Sciences, Department of Endocrinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Abstract
Gestational diabetes mellitus (GDM) is one of the most common morbidities complicating pregnancy, with short- and long-term consequences to the mothers, fetuses, and newborns. Management and treatment are aimed to achieve best possible glycemic control, while avoiding hypoglycemia and ensuring maternal and fetal safety. It involves behavioral modifications, nutrition and medications, if needed; concurrent with maternal and fetal surveillance for possible adverse outcomes. This review aims to elaborate on the pharmacological options for GDM therapy. We performed an extensive literature review of different available studies, published during the last 50 years, concerning pharmacological therapy for GDM, dealing with safety and efficacy, for both fetal and maternal morbidity consequences; as well as failure and success in establishing appropriate metabolic and glucose control. Oral medication therapy is a safe and effective treatment modality for GDM and in some circumstances may serve as first-line therapy when nutritional modifications fail. When oral agents fail to establish glucose control then insulin injections should be added. Determining the best oral therapy in inconclusive, although it seems that metformin is slightly superior to glyburide, in some aspects. As for parenteral therapy, all insulins listed in this article are considered both safe and effective for treatment of hyperglycemia during pregnancy. Importantly, a better safety profile, with similar efficacy is documented for most analogues. As GDM prevalence rises, there is a need for successful monitoring and treatment for patients. Caregivers should know the possible and available therapeutic options.
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Affiliation(s)
- Riki Bergel
- Helen Schneider's Hospital for Women, Rabin Medical Center, Petah-Tikva, 39 Zabotinski St., 49100, Petah-Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, POB 39040, 6997801, Tel Aviv, Israel
| | - Eran Hadar
- Helen Schneider's Hospital for Women, Rabin Medical Center, Petah-Tikva, 39 Zabotinski St., 49100, Petah-Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, POB 39040, 6997801, Tel Aviv, Israel
| | - Yoel Toledano
- Helen Schneider's Hospital for Women, Rabin Medical Center, Petah-Tikva, 39 Zabotinski St., 49100, Petah-Tikva, Israel
- The Sackler Faculty of Medicine, Tel Aviv University, POB 39040, 6997801, Tel Aviv, Israel
| | - Moshe Hod
- Helen Schneider's Hospital for Women, Rabin Medical Center, Petah-Tikva, 39 Zabotinski St., 49100, Petah-Tikva, Israel.
- The Sackler Faculty of Medicine, Tel Aviv University, POB 39040, 6997801, Tel Aviv, Israel.
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Koren R, Ashwal E, Hod M, Toledano Y. Insulin detemir versus glyburide in women with gestational diabetes mellitus. Gynecol Endocrinol 2016; 32:916-919. [PMID: 27597308 DOI: 10.1080/09513590.2016.1209479] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
AIM To evaluate the safety, efficacy and pregnancy outcomes of insulin detemir (IDet) versus glyburide treatment in women with gestational diabetes mellitus (GDM). METHODS We conducted a retrospective cohort study of women with GDM who were treated with either glyburide or IDet for GDM in a university-affiliated tertiary hospital. RESULTS Ninety-one patients with GDM were enrolled, 62 were administered glyburide and 29 IDet. Maternal age, pregestational body mass index (BMI) and rate of abnormal oral glucose tolerance test (OGTT) blood glucose values were not significantly different between groups. Good glycemic control rates were comparable. Hypoglycemic episodes were reported only in the glyburide group (19.4% versus 0%, p = 0.01). Maternal weight gain during pregnancy was significantly higher among women in the glyburide group (8.8 ± 5.1 kg, p < 0.001) compared to those in the IDet group (2.1 ± 19.9 kg, p = 0.71). CONCLUSIONS To the best of our knowledge, this is the first study on IDet treatment in patients with GDM. By our preliminary results, IDet is a viable treatment option in women with GDM. Further large prospective studies are needed to determine the efficacy and safety of IDet in GDM patients.
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Affiliation(s)
- Ronit Koren
- a Institute of Endocrinology, Rabin Medical Center, Beilinson Hospital , Petah Tikva , Israel
- b Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv , Israel
| | - Eran Ashwal
- c Division of Maternal Fetal Medicine , Helen Schneider Women's Hospital, Rabin Medical Center , Petah Tikva , Israel
| | - Moshe Hod
- b Sackler Faculty of Medicine, Tel-Aviv University , Tel-Aviv , Israel
- c Division of Maternal Fetal Medicine , Helen Schneider Women's Hospital, Rabin Medical Center , Petah Tikva , Israel
| | - Yoel Toledano
- c Division of Maternal Fetal Medicine , Helen Schneider Women's Hospital, Rabin Medical Center , Petah Tikva , Israel
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Chico A, Herranz L, Corcoy R, Ramírez O, Goya M, Bellart J, González-Romero S, Codina M, Sánchez P, Cortázar A, Acosta D, Picón M, Rubio J, Megía A, Sancho M, Balsells M, Solá E, González N, López-López J. Glycemic control and maternal and fetal outcomes in pregnant women with type 1 diabetes according to the type of basal insulin. Eur J Obstet Gynecol Reprod Biol 2016; 206:84-91. [DOI: 10.1016/j.ejogrb.2016.07.490] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 07/08/2016] [Accepted: 07/26/2016] [Indexed: 10/21/2022]
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Pettus J, Santos Cavaiola T, Tamborlane WV, Edelman S. The past, present, and future of basal insulins. Diabetes Metab Res Rev 2016; 32:478-96. [PMID: 26509843 DOI: 10.1002/dmrr.2763] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 07/23/2015] [Accepted: 10/04/2015] [Indexed: 12/14/2022]
Abstract
Insulin production by the pancreas follows a basic pattern where basal levels of insulin are secreted during fasting periods, with prandial increases in insulin associated with food ingestion. The aim of insulin therapy in patients with diabetes is to match the endogenous pattern of insulin secretion as closely as possible without causing hypoglycaemia. There are several optimal pharmacokinetic and pharmacodynamic properties of long-acting basal insulins that can help to achieve this aim, namely, as follows: activity that is flat and as free of peaks as possible, a duration of action of ≥24-h, and as little day-to-day variation as possible. The long-acting basal insulins are a fundamental therapy for patients with type 1 and type 2 diabetes, and those that are currently available have many benefits; however, the development of even longer-acting insulins and improved insulin delivery techniques may lead to better glycemic control for patients in the future. Established long-acting basal insulins available in the United States and Europe include insulin glargine 100 units/mL and insulin detemir, both of which exhibit similar glycemic control to that of the intermediate-acting neutral protamine Hagedorn insulin, but with a reduction in hypoglycaemia. Newer insulin products available include new insulin glargine 300 units/mL (United States and Europe) and the ultra-long-acting insulin degludec (Europe) with basal insulin peglispro currently in development. These new insulins demonstrate different pharmacokinetic/pharmacodynamic profiles and longer durations of action (>24 h) compared with insulin glargine 100 units/mL, which may lead to potential benefits. The introduction of biosimilar insulins may also broaden access to insulins by reducing treatment costs. Copyright © 2015 John Wiley & Sons, Ltd.
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Affiliation(s)
- Jeremy Pettus
- Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA, USA
| | - Tricia Santos Cavaiola
- Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA, USA
| | | | - Steven Edelman
- Division of Endocrinology and Metabolism, University of California San Diego, San Diego, CA, USA
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Martis R, Brown J, Alsweiler J, Downie MR, Crowther CA. Treatments for women with gestational diabetes mellitus: an overview of Cochrane systematic reviews. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2016. [DOI: 10.1002/14651858.cd012327] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Ruth Martis
- The University of Auckland; Liggins Institute; Park Road Grafton Auckland New Zealand 1142
| | - Julie Brown
- The University of Auckland; Liggins Institute; Park Road Grafton Auckland New Zealand 1142
| | - Jane Alsweiler
- Auckland Hospital; Neonatal Intensive Care Unit; Park Rd. Auckland New Zealand
| | - Michelle R Downie
- Southland Hospital; Department of Medicine; Kew Road Invercargill Southland New Zealand 9840
| | - Caroline A Crowther
- The University of Auckland; Liggins Institute; Park Road Grafton Auckland New Zealand 1142
- The University of Adelaide; ARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and Gynaecology; Women's and Children's Hospital 72 King William Road Adelaide South Australia Australia 5006
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Abstract
Women with type 1 diabetes (T1DM) have unique needs during the preconception, pregnancy, and postpartum periods. Preconception counseling is essential for women with T1DM to minimize pregnancy risks. The goals of preconception care should be tight glycemic control with a hemoglobin A1c (A1C) < 7 % and as close to 6 % as possible, without significant hypoglycemia. This will lower risks of congenital malformations, preeclampsia, and perinatal mortality. The safety of medications should be assessed prior to conception. Optimal control of retinopathy, hypertension, and nephropathy should be achieved. During pregnancy, the goal A1C is near-normal at <6 %, without excessive hypoglycemia. There is no clear evidence that continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI) is superior in achieving the desired tight glycemic control of T1DM during pregnancy. Data regarding continuous glucose monitoring (CGM) in pregnant women with T1DM is conflicting regarding improved glycemic control. However, a recent CGM study does provide some distinct patterns of glucose levels associated with large for gestational age infants. Frequent eye exams during pregnancy are essential due to risk of progression of retinopathy during pregnancy. Chronic hypertension treatment goals are systolic blood pressure 110-129 mmHg and diastolic blood pressure 65-79 mmHg. Labor and delivery target plasma glucose levels are 80-110 mg/dl, and an insulin drip is recommended to achieve these targets during active labor. Postpartum, insulin doses must be reduced and glucoses closely monitored in women with T1DM because of the enhanced insulin sensitivity after delivery. Breastfeeding is recommended and should be highly encouraged due to maternal benefits including increased insulin sensitivity and weight loss and infant and childhood benefits including reduced prevalence of overweight. In this article, we discuss the care of pregnant patients with T1DM.
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Affiliation(s)
- Anna Z Feldman
- Joslin Diabetes Center, 1 Joslin Place, Boston, MA, 02115, USA
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Toledano Y, Hadar E, Hod M. Safety of insulin analogues as compared with human insulin in pregnancy. Expert Opin Drug Saf 2016; 15:963-73. [DOI: 10.1080/14740338.2016.1182153] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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de Jong J, Garne E, Wender-Ozegowska E, Morgan M, de Jong-van den Berg LTW, Wang H. Insulin analogues in pregnancy and specific congenital anomalies: a literature review. Diabetes Metab Res Rev 2016; 32:366-75. [PMID: 26431249 DOI: 10.1002/dmrr.2730] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Accepted: 09/11/2015] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Josta de Jong
- Department of Pharmacoepidemiology and Pharmacoeconomics, University of Groningen, Groningen, The Netherlands
| | - Ester Garne
- Paediatric Department, Hospital Lillebaelt, Kolding, Denmark
| | - Ewa Wender-Ozegowska
- Department of Obstetrics and Women's Diseases, Poznan University of Medical Sciences, Poznań, Poland
| | - Margery Morgan
- Congenital Anomaly Register and Information Service for Wales, Singleton Hospital, Swansea, UK
| | | | - Hao Wang
- Department of Pharmacoepidemiology and Pharmacoeconomics, University of Groningen, Groningen, The Netherlands
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Kautzky-Willer A, Harreiter J, Weitgasser R, Lechleitner M. [Clinical practice recommendations for diabetes in pregnancy (Diabetes and Pregnancy Study Group of the Austrian Diabetes Association)]. Wien Klin Wochenschr 2016; 128 Suppl 2:S113-8. [PMID: 27052227 DOI: 10.1007/s00508-015-0943-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Twenty-six years ago the St. Vincent Declaration aimed for an achievement of a comparable pregnancy outcome in diabetic and non-diabetic women. However, current surveys clearly show that women with pre-gestational diabetes still feature a much higher risk of perinatal morbidity and even increased mortality. This fact is mostly ascribed to a persistently low rate of pregnancy planning and pre-pregnancy care with optimization of metabolic control prior to conception. In addition, obesity increases worldwide, contributing to a growing number of women with type 2 diabetes at a childbearing age, and a further deterioration in outcome in diabetic women. Development of diabetic embryopathy and fetopathy are known to be related to maternal glycemic control (target: normoglycemia and normal HbA1c, if possible without hypoglycemia). The risk for hypoglycemia is at its greatest in early pregnancy and decreases with the progression of pregnancy due to the hormonal changes leading to a marked increase of insulin resistance. Intensified insulin therapy with multiple daily insulin injections and pump treatment are equally effective in reaching good metabolic control during pregnancy. All women should be experienced in the management of their therapy and on stable glycemic control prior to the conception. In addition, thyroid dysfunction, hypertension as well as the presence of diabetic complications should be excluded before pregnancy or treated adequately in order to decrease the risk for a progression of complications during pregnancy as well as for maternal and fetal morbidity.
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Affiliation(s)
- Alexandra Kautzky-Willer
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Gender Medicine Unit, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich.
| | - Jürgen Harreiter
- Klinische Abteilung für Endokrinologie und Stoffwechsel, Gender Medicine Unit, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Raimund Weitgasser
- Abteilung für Innere Medizin, Privatklinik Werhle-Diakonissen, Salzburg, Österreich.,Universitätsklinik für Innere Medizin I, Landeskrankenhaus Salzburg - Universitätsklinikum, Paracelsus Medizinische Privatuniversität, Salzburg, Österreich
| | - Monika Lechleitner
- Interne Abteilung, Landeskrankenhaus Hochzirl - Natters, Hochzirl, Österreich
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Vellanki P, Umpierrez G. Detemir is non-inferior to NPH insulin in women with pregestational type 2 diabetes and gestational diabetes mellitus. ACTA ACUST UNITED AC 2016; 21:104-5. [DOI: 10.1136/ebmed-2015-110309] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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