Optimal metabolic control is the goal in pregnancies complicated by diabetes. Studies of the glucose metabolism in physiological pregnancy indicate that the concept of "normality" in pregnancy is definitely different from what is "normal" outside pregnancy. Knowledge of the pathophysiology of the carbohydrate metabolism in pregnancy and changes in the glycemic profile and the patients' characteristics should guide the choice of insulin therapy and mode of delivery. Prospective trials with the insulin analogs aspart and detemir showed that in the preconceptional period these reduced the risk of nocturnal hypoglycemia and improved glycemic profiles. Although insulin analogs did not appear to show any particular superiority over human insulin the women enrolled from preconception had better outcomes. Meta-analysis on insulin lispro and on glargine showed no worsening of fetal malformations compared with human insulin. Even today, unfortunately, the objectives of the Saint Vincent's Declaration for pregnancy have not been fully achieved. Insulin analogs should be favored as early as possible in preconception counseling to stabilize metabolic control better and obtain more favorable maternal and fetal outcomes. Despite the paucity of clinical trials in pregnancy, some experts still consider the insulin pump (CSII) the first choice in the treatment of type 1 diabetes and it can be an effective tool in highly selected pregnant women. Women using an insulin pump during pregnancy maintain better glycemic control in the postpartum period too. In addition their metabolic control improves faster, they have a lower insulin requirement and fewer episodes of hypoglycemia, with better metabolic control at term. This therapy must take account of the overall burden, indications to treatment and selection of patients by an experienced team. Continuous glucose monitoring (CGM) can be useful in carefully selected pregnant women. Integrated CSII-CGM systems are attracting increasing attention, above all from the perspective of "closing the loop".
Insulin therapy in pregnancy today - Is there a "gold standard"? [L'approccio attuale alla terapia insulinica in gravidanza: Esiste un "gold standard"?]
VITACOLONNA, Ester
2013-01-01
Abstract
Optimal metabolic control is the goal in pregnancies complicated by diabetes. Studies of the glucose metabolism in physiological pregnancy indicate that the concept of "normality" in pregnancy is definitely different from what is "normal" outside pregnancy. Knowledge of the pathophysiology of the carbohydrate metabolism in pregnancy and changes in the glycemic profile and the patients' characteristics should guide the choice of insulin therapy and mode of delivery. Prospective trials with the insulin analogs aspart and detemir showed that in the preconceptional period these reduced the risk of nocturnal hypoglycemia and improved glycemic profiles. Although insulin analogs did not appear to show any particular superiority over human insulin the women enrolled from preconception had better outcomes. Meta-analysis on insulin lispro and on glargine showed no worsening of fetal malformations compared with human insulin. Even today, unfortunately, the objectives of the Saint Vincent's Declaration for pregnancy have not been fully achieved. Insulin analogs should be favored as early as possible in preconception counseling to stabilize metabolic control better and obtain more favorable maternal and fetal outcomes. Despite the paucity of clinical trials in pregnancy, some experts still consider the insulin pump (CSII) the first choice in the treatment of type 1 diabetes and it can be an effective tool in highly selected pregnant women. Women using an insulin pump during pregnancy maintain better glycemic control in the postpartum period too. In addition their metabolic control improves faster, they have a lower insulin requirement and fewer episodes of hypoglycemia, with better metabolic control at term. This therapy must take account of the overall burden, indications to treatment and selection of patients by an experienced team. Continuous glucose monitoring (CGM) can be useful in carefully selected pregnant women. Integrated CSII-CGM systems are attracting increasing attention, above all from the perspective of "closing the loop".I documenti in IRIS sono protetti da copyright e tutti i diritti sono riservati, salvo diversa indicazione.
