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GLUCOSE CONTROL DURING LABOR - MADE EASY(Continued from page 1)dissipates and not require any more insulin duringlabor. Some may actually require extra glucose iftheir insulin peaks while they are NPO during activelabor.2. With long inductions and cervical ripening, mealcoverage becomes an issue. Adjustments inan insulin infusion for the duration of the mealand the following hour can cover a meal, as willsubcutaneous injections. Most clear liquids havecalories, as well, that are quickly absorbed and causea spike in the glucose level if not covered. Thinkingahead and common sense are the best allies in theseatypical situations. ●REFERENCESReferences available on request.ABOUT THE AUTHORDr. Dorothea Mostello is a Saint Louis University Professor of Obstetrics andGynecology, Department of Obstetrics, Gynecology and Women’s Health; aMaternal-Fetal Medicine specialist in the Maternal-Fetal Medicine Division andDirector of the Diabetes-in-Pregnancy Program at SSM St. Mary’s Health Center,St. Louis, MO.FORMULARY FACTSBY AREZO NOORMOHAMMADI, PHARM.D.AND ALICIA B. FORINASH, PHARM.D., BCPS, BCACPNPH insulin, with or without rapid-acting insulin, had beenconsidered standard of care in pregnancy when patientsrequired insulin. Two basal insulins (glargine, Lantus® anddetemir, Levemir®) are widely used in non-pregnant patientsas an alternative for NPH. Studies have shown that detemirdoes not differ significantly from regular human insulin withregard to activation of insulin-like growth factor-I (IGF-I).1Stimulation of IGF-1 receptors increases the risk for excessivefetal growth. However, glargine has higher affinity to bind toIGF-I receptors than detemir thus decreasing the potential forglargine’s use in pregnancy. (1,2)Detemir is a peakless, long-acting insulin with a durationof 24 hours, administered once or twice daily. Because ofits peakless effects, fasting blood sugar (FBS) should be theprimary target for adjustments. Detemir should not be mixedwith other insulin and is stable at room temperature for 42days after opening. (3) In contrast, NPH has a peak that canvary but occurs approximately around 4-12 hours and isgenerally split into two doses per day. (4)Until recently, safety data was lacking for detemir duringpregnancy; however, a recent randomized, open-label,controlled, multicenter trial published in October 2012demonstrated similar effects of detemir and NPH duringpregnancy. (5) This trial evaluated the efficacy and safety ofinsulin detemir compared to NPH in 310 pregnant women withType 1 diabetes.Mathiesen and colleagues randomized patients to eitherdetemir or NPH plus insulin aspart with meals. Patients wereincluded if they had a singleton gestation between 8 and 12weeks or if they intended to become pregnant, were on insulinfor at least 12 months prior to enrollment, and had A1c
LEVEMIR IN PREGNANCYneonatal outcomes were not presented in this manuscript butshould be published later.The study was open-labeled, therefore it could have beeninfluenced by possible confounding factors. It is alsoimportant to note that the study was performed includingpatients with Type 1 diabetes, limiting its external validity inextrapolating to patients with gestational diabetes or type2. However, it is likely that similar results would be seen inpatients with gestational diabetes.Unfortunately, initial dosing strategies for detemir have notbeen published. However, in non-pregnant patients, detemircan be initiated at bedtime doses of 0.1-0.2 units/kg/day.When used in non-pregnant patients, the total daily insulindose is divided into 50% detemir and 50% rapid-acting insulin.The rapid-acting insulin is further divided to give 1/3 witheach meal.Detemir can now be considered an effective option formanagement of diabetes in pregnancy. Based on thesefindings, the FDA has changed detemir to pregnancy categoryB. (1) This is a major step forward in the management ofdiabetes in pregnancy. ●EFFICACY RESULTSREFERENCES1. Porcellati F, Rosetti P, Candeloro P, et al. Short-term effects of the long actinginsulin analog detemir and human insulin on plasma levels of insulin-likegrowth factor-I (IGF-I) and its binding proteins in humans. J ClinEndocrinMetab2009;94:3017-24.2. Varewijik AJ, Goudzwaard JA, Brugts MP, et al. Insulin glargine is more potentin activating the human IGF-I receptor than human insulin and insulin demetir.Growth Horm IFG Res 2010;20:429-41.3. Levemir [package insert]. Princeton, NJ: Novo Nordisk Inc; May 2012.4. Insulin pharmacokinetics. Facts and Comparison St. Louis, MO. Website http://online.factsandcomparisons.com/MonoDisp.aspx?monoID=fandc-hcp11093&quick=8274%7c24&search=8274%7c24&isstemmed=True&fromTop=true#InsulinPharmacokinetics. Accessed January 15, 2013.5. Mathiesen ER, Hod M, Ivanisevic M et al. Maternal efficacy and safety outcomesin a randomized, controlled trial comparing insulin detemir with NPH insulin in310 pregnant women with Type 1 diabetes. Diabetes Care 2012;35:2012-17.ABOUT THE AUTHORSAlicia B. Forinash, Pharm.D., BCPS, BCACP is an Associate Professor of PharmacyPractice at the Saint Louis College of Pharmacy and an OB-Gyn/Maternal-Fetal ClinicalPharmacy Specialist at SSM St. Mary’s Health Center, St. Louis, MO.Arezo Noormohammadi, Pharm.D. is a PGY2 Ambulatory Care Resident at the SaintLouis College of Pharmacy at SSM St. Mary’s Health Center.THE PERINATAL TIMES | 3
Page 2 and 3: THE PERINATAL OUTREACH PROGRAMThe P
Page 6 and 7: INFANT OF A DIABETIC MOTHERBY JEFFR
Page 8 and 9: MONITOR CORNERA CASE STUDY BY SHARO
Page 10 and 11: NUTRITIONAL MANAGEMENT OF DIABETES
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