perinatal-times_2013-03_print_and_read - SSM Cardinal Glennon ...

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