This document discusses the pharmacological management of diabetes during pregnancy. It recommends discontinuing statins and ACE inhibitors/ARBs prior to or as soon as pregnancy is determined due to risks to the fetus. For dyslipidemia and hypertension, lifestyle modifications and alternative medications like calcium channel blockers are suggested. Insulin is indicated if blood glucose levels cannot be controlled through diet and exercise alone, with human insulin or rapid-acting analogues seen as safe options. Metformin may be used but more studies are needed on effects, while other oral hypoglycemic agents are not recommended due to lack of data.
2. Objectives
Discuss the safety of continuing pre-pregnancy
medications
Decide when antihyperglycemic medication is
required during pregnancy
Determine what antihyperglycemic medication to
use
Discuss initial dosing and adjustment of dose
Discuss insulin administration, storage
2
3. Lipids and Blood pressure
Statins must be stopped
Preferably prior to pregnancy or
As soon as pregnancy determined
ACE inhibitors and ARBs (angiotensin II
receptor blockers) must be stopped
Preferably prior to pregnancy or
As soon as pregnancy determined
ACEI/ ARBs may cause renal failure in the
fetus
CDA, 2013
Kitzmiller, Block et al, 2008 3
4. Replacements
Dyslipidemia
Reduction of saturated fat intake, no trans fat intake,
cholesterol intake < 200mg/day
Weight control
Physical activity
Hypertension
Reduce salt intake
Calcium channel blockers, labetalol, hydralazine and
methyldopa.
CDA, 2013
4
5. Triglycerides
Triglycerides may double by 20 weeks
Cholesterol, LDL and HDL may increase 10-20%
Initiate treatment if triglycerides over 1000mg/dl
Intensive glycemic control
Fish oil supplement
Fibrates and niacin are best avoided during pregnancy
Goldenberg, Benderly, Goldbourt, 2008
Kitzmiller, Block et al, 2008 5
6. Insulin
Indicated when target blood glucose levels not
attained with diet and physical activity after 2 weeks
Human insulin should be used – less transfer of insulin
antibodies
Rapid acting insulin analogues (lispro and aspart)
have been shown to be safe in pregnancy
Improve postprandial levels
Lower risk of postprandial hypoglycemia
Fetal outcomes the same with human insulin (soluble)
or rapid acting analogues
6
7. Insulin
Long acting insulin analogues
• detemir has been approved for use in pregnancy
• glargine has not yet been approved
Few studies on safety of long acting analogues in
pregnancy
Usual recommendation is to use NPH or detemir
as basal insulin
Premix insulins are an alternative but lack the
flexibility of a basal bolus regimen
7
8. Starting insulin in GDM
If fasting high – start NPH or detemir at bedtime
If postprandial high – start soluble or rapid acting
before meal.
Start with 4 units
Titrate 1-2 units/every 2 days until targets are reached
Educate
Administration
Storage
Hypoglycemia
8
11. Insulin Syringe
• Correct syringe must be used for the
strength of the insulin
• if using 100u/1 ml insulin then must have a
100u/1ml syringe,
• if using 40u/1ml insulin must have a 40u/1ml
syringe.
• Usually disposable – intended for 1 use
only
• Insulin pens are convenient alternatives to
syringes but are more expensive
• Easier to teach
• Fewer mistakes with dosages
11
13. Insulin Practicalities
Storage
• One month at room temperature once the vial has been opened or
kept in fridge
• Must never be frozen
• Store away from source of heat
• If refrigerator not available, store in clay pot
• May be damaged by direct sunlight or vigorous shaking
• Pre-drawn syringes can be kept for one month in fridge (provided
power supply reliable)
13
14. Precautions
• Insulin strength may vary (U40, U100)
• Ensure the syringe matches the strength!
• Clear insulins
• Long acting insulin analogues
• Regular/soluble insulin
• Rapid acting insulin analogues
• Cloudy insulin (should not be used if clumps do not
dissolve on mixing
• NPH or N
• Premixed insulin
• Identify and differentiate insulin type
14
16. Glucose lowering medications
Sulfonylurea – glibenclamide (glyburide)
Minimal transfer across the placenta
Not associated with neonatal hypoglycemia
Must be balanced with meals and snacks to prevent
hypoglycemia
Higher incidence of pre-eclampsia
Good control achieved…but
Jacobson et al . 2005
16
17. However…
Latest evidence suggests:
glibenclamide is associated with worse
outcomes compared to insulin and metformin
Need more studies in this area
Hence glibenclamide is not recommended in the
routine management of GDM
Feig, Moses, 2011
Balsells et al, 2015 17
18. Glucose lowering medications
Metformin
Does cross the placenta
Does not appear to have adverse effects on the fetus
May be used in polycystic ovarian syndrome to improve
fertility and decrease spontaneous abortion rate
18
19. Metformin vs Insulin (MiG Trial)
Neonatal complications did not vary between the 2 subject groups.
• Less severe hypoglycemia in the infants of mothers on metformin.
• Women on metformin gained less weight
• Preterm birth was more common in the metformin group, but there
was no increase in other complications.
• 76% of women who used metformin were more likely to say they
would use metformin in a subsequent pregnancy than were women
on insulin (27.2%).
46.3% of women on metformin had to be on supplemental insulin as
well.
The conclusion of this study was that metformin
was a safe option for GDM, and it was more
agreeable to the patient.
Rowan Hague Gao et al. 2008
19
20. However…
What is the effect on the babies?
Unknown as to whether the use of metformin
during pregnancy is
Beneficial
Neutral
Deleterious
Need more studies in this area
Metformin is therefore not recommended as a first
line therapy for GDM
Feig, Moses, 2011
20
21. Other oral agents
There is insufficient data on the use of other
antidiabetic agents such as
• meglitinides,
• alpha glucosidase inhibitors,
• thiazolidinediones,
• GLP-1 agonists and DPP-4 inhibitors
The use of these agents in pregnancy cannot
be recommended
21
22. Final word on oral agents
22
If a woman is on oral agents when diagnosed with
GDM
-Discontinue them
-Start diet and exercise plan
-Monitor blood glucose
-Start insulin
23. References
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013
Clinical practice guidelines for the prevention and management of diabetes in Canada; Diabetes and pregnancy. Can J
of Diabetes. 2013;37(suppl 1):S168-183.
Feig DS, Moses RG. Metformin during pregnancy. Diabetes Care. 2011;34:2329
Goldenberg I, Benderly M, Goldbourt U. Update on the use of fibrates: focus on bezafibrate. Vasc Health Risk Manag.
2008 February;4(1):131–141.
Jacobson et al - Comparison of glyburide and insulin for the management of gestational diabetes in a large managed
care organization, American Journal of Obstetrics and Gynecology 2005
Kitzmiller JL, Block JM, Catalano PM, et al. Managing preexisting diabetes for pregnancy: Summary of evidence and
consensus recommendations for care. Diabetes Care. 2008;31(5):1060-1079.
Rowan JA, Hague WM, Gao W. et al. Metformin versus Insulin for the Treatment of Gestational Diabetes. NEJM
2008;358:2003-15
23
Editor's Notes
If a woman comes to the service and is pregnant and taking these medications, they should be stopped immediately and she should be switched to something safe for use in pregnancy.
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical practice guidelines for the prevention and management of diabetes in Canada; Diabetes and pregnancy. Can J of Diabetes. 2013;37(suppl 1):S168-183.
Kitzmiller JL, Block JM, Catalano PM, et al. Managing preexisting diabetes for pregnancy: Summary of evidence and consensus recommendations for care. Diabetes Care. 2008;31(5):1060-1079.
Dyslipidemia – it is important to remember that cholesterol is essential for fetal development (myelin sheaths, hormones) therefore women should be advised they need to have some cholesterol intake.
Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical practice guidelines for the prevention and management of diabetes in Canada; Diabetes and pregnancy. Can J of Diabetes. 2013;37suppl 1):S168-183.
Kitzmiller JL, Block JM, Catalano PM, et al. Managing preexisting diabetes for pregnancy: Summary of evidence and consensus recommendations for care. Diabetes Care. 2008;31(5):1060-1079.
Goldenberg I, Benderly M, Goldbourt U. Update on the use of fibrates: focus on bezafibrate. Vasc Health Risk Manag. 2008 February; 4(1): 131–141.
Some sources sya that if a woman is already on glargine when she becomes pregnant she should be continued on it and does not have to be switched to detemir.
These are some of the factors that affect the absorption and therefore the time action of insulin. For example, in the presence of lipohypertrophy an abnormal build up of fat under the skin in areas of repeated injection.
Larger volumes of injected insulin are known to affect insulin absorption by prolonging or delaying the insulin’s peak effect (sometimes, if a person is on a dose of more than 50 units, and blood glucose levels are not at target, it can be beneficial to split the dose into two injections).
Insulin may be absorbed at faster or slower rates from some sites than others, although this may not be as true for the insulin analogues.
Exercising the area of injection may cause the insulin to be absorbed more quickly due to increased blood flow to the exercising limb.
In higher temperatures or when the area is warmed, such as by rubbing it, the insulin may be absorbed more quickly.
Insulin type will also affect absorption. In general, the insulin analogues have less variability than conventional insulins. However, the absorption of NPH insulin is highly variable, especially with incomplete re-suspension of the insulin.
Insulin should be injected into subcutaneous tissue. In some people who are very thin, this may present a problem. A pocket into which the insulin can be injected may be provided by pinching an inch of skin and lifting it off the muscle.
Insulin at room temperature is felt less by the individual and causes less pain than cold insulin taken straight from the fridge.
Depending on the length of the needle, it should be inserted at a 45o to 90º angle (see next slide). If it is given at an angle of less than 45o, it will not be absorbed as well and may cause irritation at the site (if it is injected intradermally instead of subcutaneously).
A thin person should inject at 45o to avoid injecting into the muscle. Injections into muscle hurt more and, due to increased blood flow to the muscle, will be absorbed faster.
Swabbing with alcohol is not routinely used prior to injection in the home setting. However, if the person is living or working in an environment that is not clean, the area should be washed. If used, alcohol should be allowed to dry before the injection.
The timing of the shorter-acting insulins in relation to a meal is important in order to maximise the effect of the insulin.
Short acting (soluble or regular) insulin takes time to be absorbed. Therefore it should be injected 30-45 minutes before a meal.
Rapid-acting insulin is absorbed quickly so it should be injected no more than 15 minutes before a meal. Ideally, it should be injected immediately prior to the meal.
In some cases, such as when people are unsure of the amount to be eaten – as in young children – the rapid-acting insulin can be injected after the meal. In this way the insulin dose can be adjusted to appropriately cover the amount eaten.
Intermediate- or long-acting insulin can be taken at any time and does not need to be taken in relation to food.
All insulin vials or cartridges have expiry dates printed on them. The expiry date indicates the date before which the unopened vial or cartridge should be used.
Once the vial or cartridge is opened it should be discarded after one month, even if some insulin remains, as the potency of insulin will be lost over time.
The potency of the insulin is also affected by cold and heat. Therefore insulin should not be frozen or stored in direct sunlight or heated areas.
If a person is unable to prepare their own syringes, a family member can pre-draw the syringes and these can be stored in the fridge for up to one month. However, syringes should be rotated many times to re-suspend the insulin before the injection is given.
Insulin is made in several countries using several different manufacturing processes. Therefore, it is not all made to the same strength.
The strength is denoted by the U system. U-40 means there are 40 units of insulin in 1 ml of solution. U-100 mean there are 100 units of insulin in every 1 ml of solution and so on.
When using insulin of different strength, it is essential that the correct and matched unit syringes are used otherwise the person with diabetes may either over- or under-dose.
The long-acting insulin analogues are clear, as are the soluble insulins. Therefore, it is very important when teaching people about their insulin to develop a way to differentiate the bottles.
Hypoglycaemia can occur in anyone using insulin therapy; however, it is more likely to occur in a person with type 1 diabetes, especially those who have a diminished counter-regulatory response.
Insulin decreases fat breakdown and increases fat formation. Therefore weight gain is often associated with commencement or intensification of insulin therapy. It is also associated with excessive insulin doses. Therefore all people with diabetes commencing insulin therapy should be reviewed by a dietitian to minimise excessive or inappropriate weight gain.
Lipohypertrophy is an abnormal build up of fat under the skin which can occur in areas of repeated insulin injection. This is a common side effect which can be minimised by asking people to rotate insulin injection sites.
Lipoatrophy occurs due to loss of subcutaneous fat as a result of repeated injection. It is rarely seen with the use of human insulin.
Other rare side effects include insulin oedema and insulin allergy.
Insulin oedema is associated with commencement or intensification of insulin therapy in people with diabetes who are grossly underweight, who have had extended periods of poor control or who have been grossly under-insulinised.
Allergic reaction usually takes the form of local swelling and reddening, but may be a systemic reaction. It may be due either to the preservatives or to the insulin itself.
Jacobson et al - Comparison of glyburide and insulin for the management of gestational diabetes in a large managed care organization, American Journal of Obstetrics and Gynecology 2005
Feig DS, Moses RG. Metformin during pregnancy. Diabetes Care. 2011;34:2329
Castillo WC. Association of Adverse Pregnancy Outcomes with Glyburide vs Insulin in Women with Gestational Diabetes. JAMA Pediatrics 2015
Balsells M, García-Patterson A, Sola I, Roque M, Gich I, Corcoy R. Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis. BMJ2015;350:h102.
The issue of weight gain needs to be addressed – in less resourced countries women may not gain enough weight and metformin might not be the right choice.
Metformin may not be the right choice for undernourished women or those who have not gained much weight.
Rowan JA, Hague WM, Gao W. et al. Metformin versus Insulin for the Treatment of Gestational Diabetes. NEJM 2008;358:2003-15
Feig DS, Moses RG. Metformin during pregnancy. Diabetes Care. 2011;34:2329