Transcript For glucose <50 mg/dL

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SH.ARBABI, M.D
Endocrinology Center
18-OCT-2007
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Approximately 15 percent of women with
GDM are placed on insulin therapy
With diet , 75 - 80 percent of women with
GDM will achieve normoglycemia
main purpose of drug intervention at these
levels is to minimize the incidence of
macrosomia
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
Goals of medical nutritional therapy :
 Achieve
normoglycemia
 Prevent ketosis
 Provide adequate weight gain
contribute to fetal well-being
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
BMI < 22
40 KCAL/Kg

BMI(22-27)
3O
“

BMI(27-29)
24
“

BMI > 30
(12-15)
“
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 Carbohydrate
40%
 Protein
20%
 Fat
40%
 75-80%
will achieve
normoglycemia
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Tissue sensitivity to insulin
both fasting and postprandial

BG
 Three times a week
(20-30) minutes per session
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 FBS
>95mg/dL
 1hpp>130 to 140 mg/dL
 2hpp>120 mg/dL
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 FBS
>1O5mg/dl
 1hpp>155 mg/dl
 2hpp>130 mg/dl
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Varies in different populations
(obesity, ethnic, demographic
criteria)
but the majority of studies have
reported a total insulin dose
ranging from 50 to 90 units to
achieve glucose control
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 If
insulin is required because the
FBS is high, an intermediateacting insulin, such as NPH
insulin, is given bedtime
 initial dose : 0.2 U/kg
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 If
postprandial BS are high:
regular insulin or insulin lispro
before meals
 1.5 U per 10 gr CHO in the breakfast
meal
 1 U per 10 gr CHO in the lunch and
dinner meals
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If both preprandial and postprandial
blood glucose are high
four injection per day regimen
 0.7 U/kg up to week 18
 0.8 U/kg for weeks 18 to 26
 0.9 U/kg for weeks 26 to 36
 1.0 U/kg for weeks 36 to term
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 In
a morbidly obese woman, the
initial doses of insulin may need
to be increased to 1.5 to 2.0
units/kg to overcome the
combined insulin resistance of
pregnancy and obesity
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insulin is divided :
 45% as NPH insulin (30% before
breakfast and 15% bedtime)
 55% as preprandial regular insulin
(22% before breakfast, 16.5% before
lunch, and 16.5% before dinner)
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A four-times daily regimen improved
glycemic control and perinatal
outcome compared to a twicedaily regimen
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Based upon frequent SMBG
4 or more glucose measurements each day
are needed to optimize therapy and ensure
a smooth increase of insulin as insulin
requirements increase with pregnancy
progression.
Twin gestations have an approximate
doubling of the insulin requirement
throughout pregnancy
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 ADA
recommendations
FPG
<95 mg/dl
 1hr pp < 140 mg/dl
 2hr pp < 120 mg/dl
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Acute hypoglycemia remote from meal
or snack time

treated by 10 to 20 gr of carbohydrate
immediately
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also use a correction factor of one unit
of rapid-acting insulin lowers blood
glucose by 25 mg/dL
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For glucose <50 mg/dL, subtract two
units of regular insulin from the dose
of insulin given before the meal
for glucose 50 to 75 mg/dL, we
subtract one unit from the dose of
insulin given before the meal
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for glucose 75 to 100 mg/dL do not change
insulin dose
for glucose 100 to 125 mg/dL add one unit
regular insulin to the dose of insulin given
before the meal
for glucose 100 to 150 mg/dL, add two units
regular insulin to the dose of insulin given
before the meal
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insulin pumps are expensive and
 Do not clearly provide a benefit in the
setting of GDM
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The three rapid acting insulin analogs
(lispro, aspart, glulisine) are
comparable in immunogenicity to
human Regular insulin, but only lispro
and aspart have been investigated in
pregnancy and shown to have
acceptable safety profiles, minimal
transfer across the placenta, and no
evidence of teratogenesis
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lispro and aspart insulin analogs both
improve postprandial excursions
compared to human Regular insulin
and are associated with lower risk of
delayed postprandial hypoglycemia
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Long-acting insulin analogs
(insulin glargine, insulin detemir)
have not been studied extensively in
pregnancy
 use human NPH insulin as part of a
multiple injection regimen in pregnant
women
 Lente insulins are not recommended
due to variability of effect
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Insulin is required during the latent
phase of labor
 SQ or IV insulin infusion with a goal :
blood glucose 70 - 90 mg/dL
 One method :1-3 U/h
 N/S may be sufficient to maintain
euglycemia when labor is anticipated
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active labor : insulin resistance rapidly
decreases and insulin requirements fall
rapidly
Thus, continuing insulin therapy is likely to
lead to hypoglycemia
To prevent this, glucose should be infused
at a rate of 2.55 mg/kg per min
Capillary blood glucose : q1h
glucose infusion should be doubled for the
next hour if the blood glucose value is < 60
mg/dL
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 bedtime
NPH insulin dose
may be given safely at the
night of C/S
 Dw10 % if PG < 60 mg / dl
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 If
induction procedure is judged
likely to be lengthy , 25 – 30 % of
morning insulin as NPH may be
administered especially if the
mother will be allowed meals
during early labor
 If BG >110 mg / dl :use insulin
drip
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 BG
should be measured on the
day after delivery to ensure that
the mother no longer has
hyperglycemia, using criteria
established for nonpregnant
individuals
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The ADA and ACOG do not approve
the use of oral anti-hyperglycemic
agents during pregnancy
 Not been approved by the Unites
States FDA
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No tolbutamide or chlorpropamide
(older sulfonylureas) as therapy of
GDM because these drugs cross the
placenta and
 can cause fetal hyperinsulinemia,
which can lead to macrosomia and
prolonged neonatal hypoglycemia
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In contrast to older sulfonylureas,
transplacental passage of glyburide
appears to be minimal and is not
associated with an excess of neonatal
hypoglycemia. Several reports have
suggested that glyburide is a safe and
effective treatment of GDM, and its
use is becoming more prevalent
 The fifth International Workshop
cautioned its use until there is more
research
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The only large, randomized study of
glyburide therapy in pregnancy included
404 women with mild GDM who were
randomly assigned to receive glyburide or
insulin
The mean blood glucose concentration
during treatment was 105 mg/dL in both
groups, and there were no differences in
the frequency of macrosomia, neonatal
hypoglycemia, and other neonatal morbidity
or cord serum insulin concentrations
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Glyburide
Achieved N BG
LGA infants
Macrosomia
C Section
Hypoglycemia
Preeclampsia
Anomalies
82%
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7
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9
6
2
Insulin
88%
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4
24
6
6
2
Langer NEJM 2000
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 Glyburide
is not recommended as
Rx of women with GDM until its
safety and efficacy have been
more firmly established
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no randomized trials evaluating the use of
metformin in women with GDM
Several observational series have reported
generally good outcomes with use of
metformin in pregestational diabetics
A meta-analysis of pregnancy outcome
after first trimester metformin did not find
risk of major malformations
Until then, metformin should not be used
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an alpha glucosidase inhibitor,
is poorly absorbed from the gastrointestinal
tract.
studies have suggested efficacy in reducing
postprandial glucose excursions in GDM,but
with the expected frequency of abdominal
cramping
Since a small proportion of this drug may
be absorbed systemically, further study
should evaluate potential transplacental
passage
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 There
are no controlled data
available in pregnancy
 One
study reported that
rosiglitazone crossed the human
placenta at 10 to 12 weeks
gestation, fetal tissue levels were
about half of maternal serum
levels
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THANKS
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