perinatal-times_2013-03_print_and_read - SSM Cardinal Glennon ...
perinatal-times_2013-03_print_and_read - SSM Cardinal Glennon ...
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GLUCOSE CONTROL DURING LABOR - MADE EASY(Continued from page 1)dissipates <strong>and</strong> 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 <strong>and</strong> cervical ripening, mealcoverage becomes an issue. Adjustments inan insulin infusion for the duration of the meal<strong>and</strong> the following hour can cover a meal, as willsubcutaneous injections. Most clear liquids havecalories, as well, that are quickly absorbed <strong>and</strong> causea spike in the glucose level if not covered. Thinkingahead <strong>and</strong> 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 <strong>and</strong>Gynecology, Department of Obstetrics, Gynecology <strong>and</strong> Women’s Health; aMaternal-Fetal Medicine specialist in the Maternal-Fetal Medicine Division <strong>and</strong>Director of the Diabetes-in-Pregnancy Program at <strong>SSM</strong> 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 st<strong>and</strong>ard of care in pregnancy when patientsrequired insulin. Two basal insulins (glargine, Lantus® <strong>and</strong>detemir, 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 <strong>and</strong> 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 <strong>and</strong> isgenerally split into two doses per day. (4)Until recently, safety data was lacking for detemir duringpregnancy; however, a recent r<strong>and</strong>omized, open-label,controlled, multicenter trial published in October 2012demonstrated similar effects of detemir <strong>and</strong> NPH duringpregnancy. (5) This trial evaluated the efficacy <strong>and</strong> safety ofinsulin detemir compared to NPH in 310 pregnant women withType 1 diabetes.Mathiesen <strong>and</strong> colleagues r<strong>and</strong>omized patients to eitherdetemir or NPH plus insulin aspart with meals. Patients wereincluded if they had a singleton gestation between 8 <strong>and</strong> 12weeks or if they intended to become pregnant, were on insulinfor at least 12 months prior to enrollment, <strong>and</strong> had A1c