Insulin Therapy in Pregnant Women
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Insulin Therapy in Pregnant Women

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PDA Echo

PDA Echo

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Insulin Therapy in Pregnant Women Insulin Therapy in Pregnant Women Presentation Transcript

  • PDA ECHO: INSULIN THERAPY IN PREGNANT WOMENCynthia Halili-Manabat, M.D., PhD
    Internal Medicine
    October 2010
  • abstract
    goal in pregnancy complicated by diabetes is to maintain maternal glucose levels as near normal as possible throughout the pregnancy because near normal glycemia has been shown to decrease the prevalence of neonatal hypoglycaemia, macrosomia, intra-uterine death and caesarean delivery
    steps to achieve normal glucose during pregnancy include medical nutrition therapy and the additional of insulin, if goals are not met
  • abstract
    only human NPH insulin, regular human insulin and the rapid acting insulin analogs, lispro and aspart, are approved for use during pregnancy
    Lispro or Aspart is preferable to regular human insulin
    fifty percent of the insulin is given as a basal dose using NPH insulin and the other 50% as boluses before meals with lispro or aspart.
  • abstract
    the total daily insulin dose may be computed based on the current weight of the patient and stage of pregnancy as follows:
    prepregnancy, 0.6 U/kg/d
    first trimester (wk 1-12), 0.7 U/kg/d
    second trimester (wk 13-28), 0.8 U/kg/d
    third trimester (wk 29-34), 0.9 U/kg/d
    term (wk 35-39), 1.0 U/kg/d
    these doses are only starting doses and need to be adjusted based on results of home glucose monitoring
  • Fetal Hyperinsulinemia
    LGA or macrosomia are associated with birth trauma (shoulder dystocia)
    0.6-1.4% in fetuses weighing 2500-4000g
    5-9% in fetuses weighing >4000g
    Associated with neonatal hypoglycemia after infant is delivered and no longer exposed to maternal hyperglycemia
  • Management of Hyperglycemia in Pregnancy
    CGMS
    mean fasting glucose 75mg/dL
    peak post-prandial glucose 110mg/dL
    Medical Nutrition Therapy
    Weight control
    Carbohydrate restriction
    Frequent self-monitoring of blood glucose
    Insulin
  • When to Start Insulin
    When MNT fails
    Glycemic goals:
    Premeals 60-90mg/dL
    1-hour postprandial <140mg/dL
    2-hour postprandial <120-130mg/dL
  • Insulin and Insulin Analogs
  • Problem with Regular Insulin
    Slow onset of activity
    Inconvenient for patient (administered 30-60minutes prior to meal)
    Long duration of activity
    Potential for late postprandial (4-6hours) hypoglycemia
    Lasts up to 12hours
  • Insulin Lispro in Pregnancy
    More efficacious than human regular insulin to normalize blood glucose levels in gestational and pre-gestational diabetic women
    Rapidly lowered postprandial glucose levels, thereby decreasing A1c levels, with fewer hypoglycemic episodes, and without increasing anti-insulin antibody levels
    Similar neonatal outcomes versus regular insulin
    Improved patient satisfaction
    Especially helpful in women with hyperemesis or gastroparesis because they can be dosed after meals
  • Insulin Aspart in Pregnancy
    The overall safety and effectiveness of insulin aspart is comparable to regular human insulin in pregnant women with GDM/pregestational DM.
    Insulin aspart was more effective than regular insulin in providing postprandial glycemic control.
    Patients showed greater treatment satisfaction with Aspart.
  • Insulin Glulisine in Pregnancy
    There is inadequate data on glulisine use in pregnancy.
  • Insulin Glargine in Pregnancy
    Glycemic control, birthweight, and prevalence of macrosomia and neonatal morbidity were similar to human insulin
    Rate of congenital malformations comparable to NPH insulin
    Glargine is not approved for use in pregnancy
  • NN304-1687: Insulin Detemir in Pregnancy Study
    Randomised, parallel-group, open-labelled, multinational trial comparing the efficacy and safety of insulin detemir versus NPH insulin, used in combination with aspart as bolus insulin, in the treatment of pregnant women with type 1 diabetes
    Expected number of 240 completed pregnancies with 120 subjects in each arm
    To be completed 2010
  • How to Give Insulin
    50% of total daily insulin as basal insulin using NPH, 50% as boluses before meals with rapid analog
    Predicted total daily insulin requirement
    Prepregnancy 0.6u/kg/d
    First trimester 0.7u/kg/d
    Second trimester 0.8u/kg/d
    Third trimester 0.9u/kg/d
    Term (wk 35-39) 1.0u/kg/d
    Rapidly adjust dose based on SMBG
  • How to Give Insulin
    NPH: 1/6 of total daily insulin dose administered every 8hours
    Lispro or Aspart: 1/6 of total daily insulin dose given before meals
    Monitor BGs before and 1hour after meals
    Goals:
    65-90 mg/dL before meals
    <120 mg/dL after meals
  • Continuous Subcutaneous Insulin Infusion Pump
    CSII versus MDI in pregnancy
    RCTs show equivalent glycemic control and maternal and perinatal outcomes
    CSII- multiple adjustable basal rates can be especially useful for patients with daytime or nocturnal hypoglycemia or a prominent dawn phenomenon
    Disadvantages of CSII: cost, potential for marked hyperglycemia and risk of DKA as a consequence of insulin delivery failure
  • Glycemic Control and Insulin Treatment during Delivery
    Goal: maintain normoglycemia in order to prevent neonatal hypoglycemia
    Target CGBs 80-110 mg/dL during labor
    CBG every hour during labor, or every 2-4 hours if stable
    CBG >100mg/dL: NS or LR at 100cc/hr
    CBG <100mg/dL: supplemental 5% dextrose infusion at 100cc/hr
  • Glycemic Control and Insulin Treatment during Delivery
    CBG >120mg/dL: 2-4 units regular insulin IV every hour that CBG >120mg/dL (or RI incorporated into IV)
    After expulsion of placenta, requirement of insulin will fall precipitously
    Postpartum requirements drop to 1/3 to ½ of their previous insulin dosages; no insulin in first 24-48hours
  • Postpartum
    During lactation: postprandial glucose goals <150mg/dL to minimize high glucose levels in breast milk
    Stimulate hyperinsulinemia and accelerate hunger in the infant
    Contribute to excessive weight gain, obesity, and metabolic syndrome later in life
    Human insulin and insulin analogs appear in breastmilk directly proportional to serum levels in maternal blood, but they are not absorbed in the gut
  • Summary
    Rapid achievement of normoglycemia with limited weight gain is critical to optimize maternal and fetal outcomes in all women with diabetes during pregnancy.
    Lispro and Aspart have been tested and found to be safe and effective during pregnancy. Their use over regular insulin has been shown to result in improved glycemic control, fewer hypoglycemic episodes, and improved patient satisfaction.
    2 to 3 doses of NPH insulin may be used to provide basal insulin needs. Neither glargine nor detemir is approved for use in pregnancy.
  • Thank You!