Individual with type 2 diabetes who is planning a pregnancy€¦ · educational grant from...

Case study: Individual with type 2 diabetes who is planning a pregnancy

Authored by Anne-Marie Felton and Ramon Gomis on behalf of the Global Partnership for Effective Diabetes Management.

The Global Partnership for Effective Diabetes Management is supported by an unrestricted educational grant from Bristol-Myers Squibb, AstraZeneca LP.

• This case study outlines the treatment of an adult patient with type 2 diabetes who is planning to become pregnant

• The case reflects a full range of treatment and management tools available in the European/US context*

*The management of any patient is subject to social, economic, age, co-morbidity and ethnic variables, and is dependent on the range of treatment options available in specific regions or countries.

Individual with type 2 diabetes who is planning a pregnancy

• Alicia, 27, civil engineer with irregular eating patterns

• Non-smoker; drinks alcohol moderately

• Diagnosed with type 2 diabetes aged 22

• At diagnosis, blood pressure was normal but β-cell function was inadequate

• Her diabetes is now controlled with metformin and a DPP-4 inhibitor, and she also takes a statin to control elevated cholesterol levels

• Alicia is hoping to become pregnant, and is visiting her doctor for advice

Current medication

Metformin 750 mg b.i.d.

Linagliptin 5 mg o.d.

Atorvastatin 40 mg o.d.

b.i.d., twice daily; o.d, once daily.

Initial discussion with physician • The doctor explains that pre-existing type 2 diabetes is associated with a

greater risk of complications for both mother and child, during and after pregnancy1

• Occurrence of these complications is related to glycaemic control during pregnancy1

– Attaining glycaemic control before conception is, therefore, a priority

• Pregnancy can also exacerbate the effects of diabetes on renal function and retinopathy2

– Care for women with type 2 diabetes prior to conception should include a comprehensive assessment and treatment of diabetes-related complications3

• Medication use should be evaluated before conception: drugs used to treat diabetes and its complications may be contraindicated/not recommended in pregnancy, e.g. statins, ACE inhibitors, ARBs, and most non-insulin antihyperglycaemic agents3

1. Bailey CJ et al. Diab Vasc Dis Res 2013; DOI 10.1177/1479164113490765. 2. Leguizamon G et al. Obstet Gynecol Clin North Am 2007;34:225‒239. 3. American Diabetes Association. Diabetes Care 2013;36:S11‒66.

ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker.

Initial evaluation

• The doctor performs some tests and evaluates Alicia’s current medication

• She is also referred to an ophthalmologist for an eye exam

Current status FPG: 6.8 mmol/l HbA1c 6.7% LDL-cholesterol: 1.7 mmol/l HDL-cholesterol: 1.8 mmol/l Triglycerides: 1.5 mmol/l eGFR: 107 ml/min BP: 119/75 mmHg BMI: 23.2 kg/m2

Additional examination results: • Eye exam: no signs of

retinopathy • Foot exam: no signs of

neuropathy

Click here to change units Click here for normal range

BMI, body mass index; BP, blood pressure; eGFR, estimated glomerular filtration rate, FPG, fasting plasma glucose; HbA1c, glycosylated haemoglobin; HDL, high-density lipoprotein; LDL, low-density lipoprotein.

Initial evaluation



Current status Normal range FPG: 6.8 mmol/l 3.9–5.5 mmol/l HbA1c 6.7% 4.0–6.0%

LDL-cholesterol: 1.7 mmol/l <2.6 mmol/l HDL-cholesterol: 1.8 mmol/l >1.5 mmol/l Triglycerides: 1.5 mmol/l <1.7 mmol/l eGFR: 107 ml/min 90-120 ml/min BP: 119/75 mmHg 120/80 mmHg BMI: 23.2 kg/m2 18.5-24.9 kg/m2

Click here to change units Click here to hide normal range



neuropathy


Initial evaluation



Current status FPG: 123 mg/dl HbA1c 50 mmol/mol LDL-cholesterol: 66 mg/dl HDL-cholesterol: 69 mg/dl Triglycerides: 133 mg/dl eGFR: 107 ml/min BP: 119/75 mmHg BMI: 23.2 kg/m2

Click here to change units Click here for normal range



neuropathy


Initial evaluation



Current status Normal range FPG: 123 mg/dl 70-100 mg/dl HbA1c 50 mmol/mol 20–42 mmol/mol LDL-cholesterol: 66 mg/dl <100 mg/dl HDL-cholesterol: 69 mg/dl >60 mg/dl Triglycerides: 133 mg/dl <150 mg/dl eGFR: 107 ml/min 90-120 ml/min BP: 119/75 mmHg 120/80 mmHg BMI: 23.2 kg/m2 18.5-24.9 kg/m2

Click here to change units Click here to hide normal range



neuropathy


Glycaemia and pregnancy outcomes • Metabolic changes during pregnancy lower glucose tolerance – increases BG levels and

raises insulin production1

• Risk of adverse maternal, foetal and neonatal outcomes continuously increases as a function of maternal glycaemia – even within ranges previously considered normal for pregnancy2

1. Alwan N, Tuffnell DJ & West J. Cochrane Database Syst Rev 2009;3:CD003395. 2. Metzger BE et al. N Engl J Med 2008;358:1991–2002.

*Category 1 FPG = <4.2 mmol/l, category 7 = >5.6 mmol/l.

aIncidence of birth weight >90 percentile* was ~5 times higher in women with FPG >5.6 mmol/l (26.3%) compared with those whose FPG was <4.2 mmol/l (5.3%)

aIncidence of primary caesarean section** was was more than doubled in women with 1 hour BG >11.8 mmol/l (32%) compared with those whose 1 hour BG was <5.8 mmol/l (12%)

Click here to change units

aSee slide 27 in deck for copyright acknowledgement. BG, blood glucose; FPG, fasting plasma glucose.

**Category 1 FPG = <5.8 mmol/l, category 7 = >11.8 mmol/l.

Glycaemia and pregnancy outcomes • Metabolic changes during pregnancy lower glucose tolerance – increases BG levels and raises

insulin production1

• Risk of adverse maternal, foetal and neonatal outcomes continuously increases as a function of maternal glycaemia – even within ranges previously considered normal for pregnancy2

aIncidence of birth weight >90 percentile* was ~5 times higher in women with FPG >101 mg/dl (26.3%) compared with those whose FPG was <76 mg/dl (5.3%)

aIncidence of primary caesarean section** was was more than doubled in women with 1 hour BG >213 mg/dl (32%) compared with those whose 1 hour BG was <105 mg/dl (12%)

*Category 1 FPG = <76 mg/dl, category 7 = >101 mg/dl.

Click here to change units

1. Alwan N, Tuffnell DJ & West J. Cochrane Database Syst Rev 2009;3:CD003395. 2. Metzger BE et al. N Engl J Med 2008;358:1991–2002.

aSee slide 27 in deck for copyright acknowledgement. BG, blood glucose; FPG, fasting plasma glucose.

**Category 1 FPG = <105 mg/dl, category 7 = >213 mg/dl.

Glycaemic control during pregnancy • Alicia’s diabetes is well controlled and she has no signs of complications

• However, it will be necessary for Alicia to stop statin therapy before she conceives, as statins are contraindicated in pregnancy1

• The doctor advises Alicia that she will be supported by a multidisciplinary team that may include a diabetologist, specialist diabetes nurse/educator and dietitian

• Education on maternal complications, foetal risks and the importance of glycaemic control during pregnancy will form an important part of her obstetric care

Question In addition to lifestyle interventions, which of the following is appropriate antihyperglycaemic medication for Alicia during pregnancy?

Continue with metformin + DPP-4 inhibitor

Switch to insulin

Continue with metformin alone

1. American Diabetes Association. Diabetes Care 2013;36:S11‒66.

Treatment selected in addition to lifestyle measures: Metformin + DPP-4 inhibitor

• There is little information on the effects of oral antihyperglycaemic agents in the early stages of pregnancy1

• In general, women planning or continuing pregnancy are recommended to substitute insulin for oral antihyperglycaemic medication2

– Drawbacks of insulin include hypoglycaemia, weight gain and daily injections2

• If an alternative option to insulin is preferred, metformin may be considered on an individual basis2

– However, the doctor is concerned that metformin alone will not adequately control Alicia’s BG levels

• Together, Alicia and the doctor decide to begin an immediate trial of insulin with careful SMBG, so that glycaemic targets can be established before conception

Tieu J et al. Cochrane Database Syst Rev 2010;10:CD007724. Bailey CJ et al. Diab Vasc Dis Res 2013;DOI 10.1177/1479164113490765. Rowan JA et al. N Engl J Med 2008;358:2003–2015. Metzger BE et al. Diabetes Care 2007;30:S251–S260.

Metformin use in pregnancy

• Reported outcomes for the use of metformin in pregnancy have generally been favourable3

– However, metformin crosses the placenta4 and could affect foetal physiology directly3

• Trial results have suggested metformin is sometimes preferred to insulin by patients3

– However, insulin (plus MNT or lifestyle measures) is generally recommended for glycaemic control in pregnancy2

BG, blood glucose; MNT, medical nutritional therapy; SMBG, self-monitoring of blood glucose.

Treatment selected in addition to lifestyle measures: Insulin

1. Tieu J et al. Cochrane Database Syst Rev 2010;10:CD007724. 2. Bailey CJ et al. Diab Vasc Dis Res 2013;DOI 10.1177/1479164113490765. 3. Metzger BE et al. Diabetes Care 2007;30:S251–S260. 4. Singh SR et al. CMAJ 2009;180:385–397. 5. Pollex EK et al. Diabetes Care 2010;33:29–33.

Use of insulin analogues in pregnancy

• Human insulin is the least immunogenic; however, analogues lispro and aspart have similar profile3

• Lispro and aspart: effective, minimal placental transfer, no teratogenesis3 (no data on glulisine)

• Safety data on long-acting analogues is lacking (glargine, detemir)3,4 – glargine not likely to cross the placenta at therapeutic doses5







BG, blood glucose; SMBG, self-monitoring of blood glucose.

Treatment selected in addition to lifestyle measures: Metformin

Metformin use in pregnancy

• Reported outcomes for the use of metformin in pregnancy have generally been favourable3

– However, metformin crosses the placenta4 and could affect foetal physiology directly3

• Trial results have suggested metformin is sometimes preferred to insulin by patients3

– However, insulin (plus MNT or lifestyle measures) is generally recommended for glycaemic control in pregnancy2







Tieu J et al. Cochrane Database Syst Rev 2010;10:CD007724. Bailey CJ et al. Diab Vasc Dis Res 2013;DOI 10.1177/1479164113490765. Rowan JA et al. N Engl J Med 2008;358:2003–2015. Metzger BE et al. Diabetes Care 2007;30:S251–S260.

BG, blood glucose; MNT, medical nutritional therapy; SMBG, self-monitoring of blood glucose.

Glycaemic target during pregnancy • The doctor and Alicia have decided to switch to insulin to control her diabetes

during pregnancy

• Alicia currently maintains her HbA1c between 6.5 and 7.0%

Question What is the most appropriate HbA1c* target for Alicia during pregnancy?

<6.0% 6.0–6.5% 6.5–7.0%

7.0–7.5% 7.5–8.0%

*Equivalent values: 6.0% = 42 mmol/mol; 6.5% = 48 mmol/mol; 7.0% = 53 mmol/mol; 7.5% = 58 mmol/mol; 8.0% = 64 mmol/mol.

HbA1c, glycosylated haemoglobin.

Glycaemic target during pregnancy

• Glycaemic targets should always be individualized, based on a range of factors1

– During pregnancy, management of maternal glucose concentrations remains a priority1

• Individuals should aim for normal glycaemia (HbA1c 6.5–7.0% or FPG <7 mmol/l) to minimize risk of perinatal complications1

– An HbA1c of <5.5% (37 mmol/mol) or FPG <5.3 mmol/l can also be targeted, while being careful to avoid episodes of hypoglycaemia

• Dietary and lifestyle advice plus insulin is generally required/recommended1

– Individual needs/preferences may necessitate an alternative to insulin, e.g. metformin

• Dietary regulation, home BG monitoring and insulin/oral anti-hyperglycaemic drugs reduce the risk of serious perinatal morbidity in the infant2

What is the most appropriate HbA1c* target for Alicia during pregnancy?

<6.0% 6.0–6.5% 6.5–7.0%

7.0–7.5% 7.5–8.0%

1. Bailey CJ et al. Diab Vasc Dis Res 2013;DOI 10.1177/1479164113490765. 2. Rowan JA et al. N Engl J Med 2008;358:2003–2015.

*Equivalent values: 6.5% = 48 mmol/mol; 7.0% = 53 mmol/mol.

BG, blood glucose; FPG, fasting plasma glucose; HbA1c, glycosylated haemoglobin.

Self-monitoring of blood glucose • Avoiding hypoglycaemia during pregnancy is integral to the safety of both mother

and foetus

• For those using insulin for glycaemic control during pregnancy, SMBG is essential

• Alicia is referred to a perinatal diabetes nurse to learn about SMBG and how to adjust insulin dose(s) in response to fluctuations in BG levels

Question What BG concentrations should Alicia aim for during pregnancy?1

3.8–5.2 mmol/l

5.5–7.7 mmol/l

5.0–6.6 mmol/l

Pre-prandial

1h post-prandial

2h post-prandial

5.0–6.6 mmol/l

6.9–8.5 mmol/l

6.4–7.5 mmol/l

3.2–4.6 mmol/l

4.9–7.0 mmol/l

4.4–6.0 mmol/l

1. Canadian Diabetes Association. Can J Diabet 2008;32:S1‒S201.

Click to change units


Question What BG concentrations should Alicia aim for during pregnancy?1

Self-monitoring of blood glucose

68–94 mg/dl

99–139 mg/dl

90–119 mg/dl

90–119 mg/dl

124–153 mg/dl

115–135 mg/dl

58–83 mg/dl

88–126 mg/dl

79–108 mg/dl

Pre-prandial

1h post-prandial

2h post-prandial

• Avoiding hypoglycaemia during pregnancy is integral to the safety of both mother and foetus

• For those using insulin for glycaemic control during pregnancy, SMBG is essential

• Alicia is referred to a specialist diabetes nurse to learn about SMBG and how to adjust insulin dose(s) in response to fluctuations in BG levels


1. Canadian Diabetes Association. Can J Diabet 2008;32:S1‒S201.



• In order to safely maintain glycaemic control during pregnancy, Alicia should measure her BG before and after meals, ≥4 times per day if necessary1

• Due to the increased risk of nocturnal hypoglycaemia during pregnancy, measurements before bedtime and during the night may also be required1,2

What BG concentrations should Alicia aim for during pregnancy?1

3.8 to 5.2 mmol/l

5.5 to 7.7 mmol/l

5.0 to 6.6 mmol/l

Pre-prandial

1h post-prandial

2h post-prandial

5.0–6.6 mmol/l

6.9–8.5 mmol/l

6.4–7.5 mmol/l

3.2–4.6 mmol/l

4.9–7.0 mmol/l

4.4–6.0 mmol/l

1. Canadian Diabetes Association. Can J Diabet 2008;32:S1‒S201. 2. Hellmuth E et al. Acta Obstet Gynecol Scand 2000;79:958‒962.


BG, blood glucose.

What BG concentrations should Alicia aim for during pregnancy?1


68–94 mg/dl

99–139 mg/dl

90–119 mg/dl

Pre-prandial

1h post-prandial

2h post-prandial

5.0–6.6 mmol/l

6.9–8.5 mmol/l

6.4–7.5 mmol/l

3.2–4.6 mmol/l

4.9–7.0 mmol/l

4.4–6.0 mmol/l

• In order to safely maintain glycaemic control during pregnancy, Alicia should measure her BG before and after meals, ≥4 times per day if necessary1

• Due to the increased risk of nocturnal hypoglycaemia during pregnancy, measurements before bedtime and during the night may also be required1,2

1. Canadian Diabetes Association. Can J Diabet 2008;32:S1‒S201. 2. Hellmuth E et al. Acta Obstet Gynecol Scand 2000;79:958‒962.


BG, blood glucose.

Pre-pregnancy and antenatal care • As recommended, Alicia replaced her diabetes

medications with insulin and began SMBG before becoming pregnant

• She took immediate measures to address her irregular eating habits and increase her activity levels

• Alicia’s pregnancy was confirmed at 5 weeks

– She was prescribed folic acid 5 mg/day, to be taken until week 12 of pregnancy

• Alicia was referred to a joint diabetes-antenatal clinic immediately, where contact with a specialist diabetes multidisciplinary team was established

• The diabetes nurse advised Alicia’s partner how to recognize, manage and treat hypoglycaemia

• Alicia and her partner were advised to attend the clinic every 2 weeks throughout the pregnancy

– Glycaemic control and general health assessed

– Preparations for the birth/postnatal period discussed and questions answered

Specialist diabetes multidisciplinary team may include: • Diabetologist • Diabetes obstetrician • Diabetes dietitian • Diabetes nurse/educator • Specialist diabetes midwife

SMBG, self-monitoring of blood glucose.

Glycaemic control during the second and third trimester

• Throughout Alicia’s pregnancy her glycaemic control is monitored by the midwife who reviews the SMBG diary every 2 weeks

• Any necessary adjustments are discussed with the wider diabetes care team

Period Mean 1 hour post-prandial (mmol/l) Mean 2 hour post-prandial (mmol/l)

Week 22‒24 6.2 (112 mg/dl) 5.3 (95 mg/dl)

Week 24‒26 6.0 (108 mg/dl) 5.2 (94 mg/dl)

Week 26‒28 7.9 (142 mg/dl) 6.9 (124 mg/dl)

Week 28‒30 6.9 (124 mg/dl) 6.1 (110 mg/dl)

Week 30‒32 8.0 (144 mg/dl) 6.8 (123 mg/dl)

Week 32‒34 7.2 (130 mg/dl) 6.0 (108 mg/dl)

Week 34‒36 7.8 (141 mg/dl) 7.1 (128 mg/dl)

Question According to Alicia’s BG readings, at which of the above points should her insulin dose be adjusted? Click to reveal

SMBG, self-monitoring of blood glucose.

Glycaemic control during the second and third trimester

• At week 28, 32, and 36, Alicia’s SMBG diary revealed some elevations in 1 and 2 hour post-prandial BG levels in the preceding 2 weeks

– Insulin resistance becomes increasingly common during the third trimester

• At each of these points, Alicia’s insulin dose was titrated upwards and split into three daily injections before meals

Period Mean 1 hour post-prandial (mmol/l) Mean 2 hour post-prandial (mmol/l)

Week 22‒24 6.2 (112 mg/dl) 5.3 (95 mg/dl)

Week 24‒26 6.0 (108 mg/dl) 5.2 (94 mg/dl)

Week 26‒28 7.9 (142 mg/dl) 6.9 (124 mg/dl)

Week 28‒30 6.9 (124 mg/dl) 6.1 (110 mg/dl)

Week 30‒32 8.0 (144 mg/dl) 6.8 (123 mg/dl)

Week 32‒34 7.2 (130 mg/dl) 6.0 (108 mg/dl)

Week 34‒36 7.8 (141 mg/dl) 7.1 (128 mg/dl)

SMBG, self-monitoring of blood glucose; BG, blood glucose.

Preparations for birth • During the pregnancy, the midwife provides Alicia and her partner

with information and advice about the birth

– Induction of labour and Caesarean section are more common in women with type 2 diabetes

• In association with the obstetrician and diabetes care team, arrangements are made about the timing, mode and management of delivery

For pregnant women with pre-existing diabetes:1 • Offer elective birth after 38 completed weeks (induction of labour or, if

indicated, elective Caesarean section) – Inform women who have a macrosomic foetus – diagnosed with

ultrasound – about the risks and benefits of vaginal birth, induction of labour and Caesarean section

• At 39, 40, and 41 weeks, offer tests of foetal wellbeing for women who are awaiting spontaneous labour

1. National Institute of Clinical Excellence. Clinical Guideline 2008;CG63.

Intrapartum glycaemic control • No evidence of foetal overgrowth was apparent and it was agreed that

Alicia would deliver her baby naturally

– At week 38 of gestation, Alicia underwent induction of labour

• During labour and the birth, Alicia’s BG levels were monitored on an hourly basis

Question Within what range should Alicia’s BG levels be maintained during labour and birth?

4–7 mmol/l (72–126 mg/dl)

3–6 mmol/l (54–108 mg/dl)

6–9 mmol/l (108–162 mg/dl)

BG, blood glucose.

Intrapartum glycaemic control

• During labour and birth, it is essential to maintain good glycaemic control

– Maternal hyperglycaemia during labour is associated with increased risk of neonatal hypoglycaemia1

• Intravenous dextrose and insulin infusion is recommended during labour and birth for women with diabetes whose BG is not maintained between 4 and 7 mmol/l (72–126 mg/dl)2

Within what range should Alicia’s BG levels be maintained during labour and birth?

1. Jovanovic L. Endocr Pract 2004;10:S40‒S45. 2. National Institute for Clinical Excellence. Clinical Guideline 2008;CG63.

4–7 mmol/l (72–126 mg/dl)

3–6 mmol/l (54–108 mg/dl)

6–9 mmol/l (108–162 mg/dl)

BG, blood glucose.

Postnatal diabetes medication • Alicia gave birth with no complications to a healthy baby weighing 3.0 kg

(6.7 lbs)

• While pregnant, Alicia and her partner had discussed with a specialist diabetes midwife the advantages and disadvantages of breastfeeding

– Following discussion, Alicia and her partner agreed that Alicia would breastfeed her baby

Anti-diabetic medication before pregnancy:

• Metformin 750 mg b.i.d.

• Linagliptin 5 mg o.d.

• Atorvastatin 40 mg o.d.

Anti-diabetic medication during pregnancy:

• Insulin (aspart; adjusted as necessary)

Postnatal diabetes medication

Question Which of the following medications may be taken while breastfeeding?

Metformin

DPP-4 inhibitor

Statin

Insulin

Click to reveal

Click to reveal

Click to reveal

Click to reveal

DPP, dipeptidyl peptidase.



Metformin

DPP-4 inhibitor

Statin

Insulin

Click to hide

Click to reveal

Click to reveal

Click to reveal

• Although small amounts of metformin are transferred into breast milk, the risk of neonatal hypoglycaemia is thought to be low

– Studies suggest that infants receive less than 0.5% of their mother's weight-adjusted dosage1‒3

• Available data suggest no adverse effects for neonates exposed to metformin through breast milk1,3,4

• However, no long-term safety data on the effects of neonatal metformin exposure are available

1. Hale T et al. Adv Exp Med Biol 2004;554:435‒436. 2. Gardiner SJ et al. Clin Pharmacol Ther 2003;73:71‒77. 3. Eyal S et al. Drug Metab Dispos 2010;38:833‒840. 4. Glueck CJ et al. Pediatr 2006;148:628‒32.e2.



Statin

Insulin

Click to reveal

Click to reveal

Metformin

DPP-4 inhibitor

Click to hide

Click to hide

• There are currently no data on the transfer of DPP-4 inhibitors into human milk

• As such, DPP-4 inhibitors should not be taken while breastfeeding

DPP, dipeptidyl peptidase.



Insulin Click to reveal

Metformin Click to hide

DPP-4 inhibitor

Statin Click to hide

• While breastfeeding, women should continue to avoid any medications that are contraindicated during pregnancy

• Statins are not, therefore, appropriate for women who are breastfeeding1

1. American Diabetes Association. Diabetes Care 2013;36:S11‒66. 2. National Institute for Clinical Excellence. Clinical Guideline 2008;CG63.


Statin


Metformin Click to hide

DPP-4 inhibitor

Insulin Click to hide

• Insulin may be continued while breastfeeding1 • Due to the lactose in breast milk, maternal

blood glucose levels are typically reduced during breastfeeding, leading to reduced insulin requirements

– Insulin dose should be adjusted immediately postpartum to reflect this1

1. National Institute for Clinical Excellence. Clinical Guideline 2008;CG63.

Postnatal glycaemic control

• The doctor and Alicia decide to continue using insulin to maintain glycaemic control

• Alicia’s insulin dose was reduced immediately postpartum

• BG levels were monitored closely to establish an appropriate dose

– The doctor explained to Alicia and her partner the increased risk of hypoglycaemia associated with breastfeeding

• As well as careful SMBG, Alicia was advised to always have a snack available during feeds


Metformin

DPP-4 inhibitor

Statin

Insulin

x

x

BG, blood glucose; DPP, dipeptidyl peptidase; SMBG, self-monitoring of blood glucose.

Long term follow-up • It is now 1 year since Alicia gave birth to a healthy baby

• When the baby began bottle feeding:

– Alicia’s pre-pregnancy antihyperglycaemic medication was gradually reinstated, alongside gradual tapering off insulin therapy

– Statin therapy was resumed

• Alicia has regularly attended a diabetes clinic specializing in postpartum care

– After following a tailored diet and exercise plan, Alicia lost her pregnancy weight

• Partnership with the multidisciplinary team, where possible, helped Alicia to receive optimal care during her pregnancy

• Planned pregnancies help to ensure appropriate preconception diabetes care: however, the majority of pregnancies in women with diabetes are unplanned, leading to an excess of malformations in infants1

• To minimize the occurrence of these malformations, standard care for all women with diabetes who have childbearing potential should include:1

– Education about the risk of malformations associated with unplanned pregnancies and poor metabolic control

– Use of effective contraception at all times unless the patient has good metabolic control and is actively trying to conceive

1. American Diabetes Association. Diabetes Care 2013;36:S11‒66.

Permission statements/copyright acknowledgement

aSlides 9 and 10

From New England Journal of Medicine, Metzger BE et al. Hyperglycemia and adverse pregnancy outcomes 358, 1991‒2002. Copyright © 2008 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

10 Steps to get more type 2 diabetes patients

to goal

10 Steps to get more people with type 2 diabetes to goal: • Aim for an appropriate individualized glycaemic target, e.g. HbA1c 6.5–7% (48–53 mmol/mol)

(or fasting/preprandial plasma glucose 110–130 mg/dl [6.0–7.2 mmol/l] where assessment of HbA1c is not possible) when safe and appropriate.

• Monitor HbA1c every 3 months in addition to appropriate glucose self-monitoring.

• Appropriately manage all cardiovascular risk factors.

• Refer all newly diagnosed patients to a unit specializing in diabetes care where possible.

• Address the underlying pathophysiology of diabetes, including the treatment of β-cell dysfunction and insulin resistance.

• Treat to achieve appropriate target HbA1c within 6 months of diagnosis.

• After 3 months, if patients are not at the desired target HbA1c, consider combination therapy.

• Consider initiating combination therapy or insulin for patients with HbA1c ≥9% (≥75 mmol/mol).

• Use combinations of antihyperglycaemic agents with complementary mechanisms of action.

• Implement a multidisciplinary team approach that encourages patient self-management, education and self-care, with shared responsibilities to achieve goals.

The Global Partnership for Effective Diabetes Management recommends:1

1. Bailey CJ et al. Diab Vasc Dis Res 2013;DOI 10.1177/1479164113490765.

HbA1c, glycosylated haemoglobin.

For more case studies visit www.effectivediabetesmanagement.com

© 2013 International Medical Press. All rights reserved. No responsibility is assumed by the Global Partnership for Effective Diabetes Management or International Medical Press for any injury and/or damage to persons or property through negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Due to rapid advances in the medical sciences, the Global Partnership and International Medical Press recommend that independent verification of diagnoses and drug dosages should be made. Neither the Global Partnership for Effective Diabetes Management or International Medical Press assume liability for any material contained herein.

http://www.effectivediabetesmanagement.com/

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