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

Transcription

1 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.

2 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.

3 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.

4 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 pregnancy 1 Occurrence of these complications is related to glycaemic control during pregnancy 1 Attaining glycaemic control before conception is, therefore, a priority Pregnancy can also exacerbate the effects of diabetes on renal function and retinopathy 2 Care for women with type 2 diabetes prior to conception should include a comprehensive assessment and treatment of diabetes-related complications 3 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 agents 3 ACE, angiotensin-converting enzyme; ARB, angiotensin II receptor blocker. 1. Bailey CJ et al. Diab Vasc Dis Res 2013; DOI / Leguizamon G et al. Obstet Gynecol Clin North Am 2007;34: American Diabetes Association. Diabetes Care 2013;36:S11 66.

5 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 HbA 1c 6.7% LDL-cholesterol: 1.7 mmol/l HDL-cholesterol: 1.8 mmol/l Triglycerides: 1.5 mmol/l Additional examination results: Eye exam: no signs of retinopathy Foot exam: no signs of neuropathy egfr: 107 ml/min BP: 119/75 mmhg BMI: 23.2 kg/m 2 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; HbA 1c, glycosylated haemoglobin; HDL, high-density lipoprotein; LDL, low-density lipoprotein.

6 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 Normal range FPG: 6.8 mmol/l mmol/l HbA 1c 6.7% % 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 Additional examination results: Eye exam: no signs of retinopathy Foot exam: no signs of neuropathy egfr: 107 ml/min ml/min BP: 119/75 mmhg 120/80 mmhg BMI: 23.2 kg/m kg/m 2 Click here to change units Click here to hide normal range BMI, body mass index; BP, blood pressure; egfr, estimated glomerular filtration rate, FPG, fasting plasma glucose; HbA 1c, glycosylated haemoglobin; HDL, high-density lipoprotein; LDL, low-density lipoprotein.

7 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: HbA 1c LDL-cholesterol: HDL-cholesterol: Triglycerides: egfr: 123 mg/dl 50 mmol/mol 66 mg/dl 69 mg/dl 133 mg/dl 107 ml/min Additional examination results: Eye exam: no signs of retinopathy Foot exam: no signs of neuropathy BP: 119/75 mmhg BMI: 23.2 kg/m 2 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; HbA 1c, glycosylated haemoglobin; HDL, high-density lipoprotein; LDL, low-density lipoprotein.

8 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 Normal range FPG: 123 mg/dl mg/dl HbA 1c 50 mmol/mol 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 Additional examination results: Eye exam: no signs of retinopathy Foot exam: no signs of neuropathy egfr: 107 ml/min ml/min BP: 119/75 mmhg 120/80 mmhg BMI: 23.2 kg/m kg/m 2 Click here to change units Click here to hide normal range BMI, body mass index; BP, blood pressure; egfr, estimated glomerular filtration rate, FPG, fasting plasma glucose; HbA 1c, glycosylated haemoglobin; HDL, high-density lipoprotein; LDL, low-density lipoprotein.

9 Glycaemia and pregnancy outcomes Metabolic changes during pregnancy lower glucose tolerance increases BG levels and raises insulin production 1 Risk of adverse maternal, foetal and neonatal outcomes continuously increases as a function of maternal glycaemia even within ranges previously considered normal for pregnancy 2 a Incidence 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%) a Incidence 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%) *Category 1 FPG = <4.2 mmol/l, category 7 = >5.6 mmol/l. **Category 1 FPG = <5.8 mmol/l, category 7 = >11.8 mmol/l. Click here to change units a See slide 27 in deck for copyright acknowledgement. BG, blood glucose; FPG, fasting plasma glucose. 1. Alwan N, Tuffnell DJ & West J. Cochrane Database Syst Rev 2009;3:CD Metzger BE et al. N Engl J Med 2008;358:

10 Glycaemia and pregnancy outcomes Metabolic changes during pregnancy lower glucose tolerance increases BG levels and raises insulin production 1 Risk of adverse maternal, foetal and neonatal outcomes continuously increases as a function of maternal glycaemia even within ranges previously considered normal for pregnancy 2 a Incidence 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%) a Incidence 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. **Category 1 FPG = <105 mg/dl, category 7 = >213 mg/dl. Click here to change units a See slide 27 in deck for copyright acknowledgement. BG, blood glucose; FPG, fasting plasma glucose. 1. Alwan N, Tuffnell DJ & West J. Cochrane Database Syst Rev 2009;3:CD Metzger BE et al. N Engl J Med 2008;358:

11 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 pregnancy 1 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.

12 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 pregnancy 1 In general, women planning or continuing pregnancy are recommended to substitute insulin for oral antihyperglycaemic medication 2 Drawbacks of insulin include hypoglycaemia, weight gain and daily injections 2 If an alternative option to insulin is preferred, metformin may be considered on an individual basis 2 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 Metformin use in pregnancy Reported outcomes for the use of metformin in pregnancy have generally been favourable 3 However, metformin crosses the placenta 4 and could affect foetal physiology directly 3 Trial results have suggested metformin is sometimes preferred to insulin by patients 3 However, insulin (plus MNT or lifestyle measures) is generally recommended for glycaemic control in pregnancy 2 Tieu J et al. Cochrane Database Syst Rev 2010;10:CD Bailey CJ et al. Diab Vasc Dis Res 2013;DOI / Rowan JA et al. N Engl J Med 2008;358: Metzger BE et al. Diabetes Care 2007;30:S251 S260. BG, blood glucose; MNT, medical nutritional therapy; SMBG, self-monitoring of blood glucose.

13 Treatment selected in addition to lifestyle measures: Insulin There is little information on the effects of oral antihyperglycaemic agents in the early stages of pregnancy 1 In general, women planning or continuing pregnancy are recommended to substitute insulin for oral antihyperglycaemic medication 2 Drawbacks of insulin include hypoglycaemia, weight gain and daily injections 2 If an alternative option to insulin is preferred, metformin may be considered on an individual basis 2 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 Use of insulin analogues in pregnancy Human insulin is the least immunogenic; however, analogues lispro and aspart have similar profile 3 Lispro and aspart: effective, minimal placental transfer, no teratogenesis 3 (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 doses 5 1. Tieu J et al. Cochrane Database Syst Rev 2010;10:CD Bailey CJ et al. Diab Vasc Dis Res 2013;DOI / Metzger BE et al. Diabetes Care 2007;30:S251 S Singh SR et al. CMAJ 2009;180: Pollex EK et al. Diabetes Care 2010;33: BG, blood glucose; SMBG, self-monitoring of blood glucose.

14 Treatment selected in addition to lifestyle measures: Metformin There is little information on the effects of oral antihyperglycaemic agents in the early stages of pregnancy 1 In general, women planning or continuing pregnancy are recommended to substitute insulin for oral antihyperglycaemic medication 2 Drawbacks of insulin include hypoglycaemia, weight gain and daily injections 2 If an alternative option to insulin is preferred, metformin may be considered on an individual basis 2 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 Metformin use in pregnancy Reported outcomes for the use of metformin in pregnancy have generally been favourable 3 However, metformin crosses the placenta 4 and could affect foetal physiology directly 3 Trial results have suggested metformin is sometimes preferred to insulin by patients 3 However, insulin (plus MNT or lifestyle measures) is generally recommended for glycaemic control in pregnancy 2 Tieu J et al. Cochrane Database Syst Rev 2010;10:CD Bailey CJ et al. Diab Vasc Dis Res 2013;DOI / Rowan JA et al. N Engl J Med 2008;358: Metzger BE et al. Diabetes Care 2007;30:S251 S260. BG, blood glucose; MNT, medical nutritional therapy; SMBG, self-monitoring of blood glucose.

15 Glycaemic target during pregnancy The doctor and Alicia have decided to switch to insulin to control her diabetes during pregnancy Alicia currently maintains her HbA 1c between 6.5 and 7.0% Question What is the most appropriate HbA 1c * target for Alicia during pregnancy? <6.0% % % % % HbA 1c, glycosylated haemoglobin. *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.

16 Glycaemic target during pregnancy What is the most appropriate HbA 1c * target for Alicia during pregnancy? <6.0% % % % % Glycaemic targets should always be individualized, based on a range of factors 1 During pregnancy, management of maternal glucose concentrations remains a priority 1 Individuals should aim for normal glycaemia (HbA 1c % or FPG <7 mmol/l) to minimize risk of perinatal complications 1 An HbA 1c 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/recommended 1 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 infant 2 BG, blood glucose; FPG, fasting plasma glucose; HbA 1c, glycosylated haemoglobin. 1. Bailey CJ et al. Diab Vasc Dis Res 2013;DOI / Rowan JA et al. N Engl J Med 2008;358: *Equivalent values: 6.5% = 48 mmol/mol; 7.0% = 53 mmol/mol.

17 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 Pre-prandial mmol/l mmol/l mmol/l 1h post-prandial mmol/l mmol/l mmol/l 2h post-prandial mmol/l mmol/l mmol/l Click to change units BG, blood glucose; SMBG, self-monitoring of blood glucose. 1. Canadian Diabetes Association. Can J Diabet 2008;32:S1 S201.

18 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 specialist 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 Pre-prandial mg/dl mg/dl mg/dl 1h post-prandial mg/dl mg/dl mg/dl 2h post-prandial mg/dl mg/dl mg/dl Click to change units BG, blood glucose; SMBG, self-monitoring of blood glucose. 1. Canadian Diabetes Association. Can J Diabet 2008;32:S1 S201.

19 Self-monitoring of blood glucose What BG concentrations should Alicia aim for during pregnancy? 1 Pre-prandial 3.8 to 5.2 mmol/l mmol/l mmol/l 1h post-prandial 5.5 to 7.7 mmol/l mmol/l mmol/l 2h post-prandial 5.0 to 6.6 mmol/l mmol/l 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 necessary 1 Due to the increased risk of nocturnal hypoglycaemia during pregnancy, measurements before bedtime and during the night may also be required 1,2 Click to change units BG, blood glucose. 1. Canadian Diabetes Association. Can J Diabet 2008;32:S1 S Hellmuth E et al. Acta Obstet Gynecol Scand 2000;79:

20 Self-monitoring of blood glucose What BG concentrations should Alicia aim for during pregnancy? 1 Pre-prandial mg/dl mmol/l mmol/l 1h post-prandial mg/dl mmol/l mmol/l 2h post-prandial mg/dl mmol/l 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 necessary 1 Due to the increased risk of nocturnal hypoglycaemia during pregnancy, measurements before bedtime and during the night may also be required 1,2 Click to change units BG, blood glucose. 1. Canadian Diabetes Association. Can J Diabet 2008;32:S1 S Hellmuth E et al. Acta Obstet Gynecol Scand 2000;79:

21 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.

22 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 (112 mg/dl) 5.3 (95 mg/dl) Week (108 mg/dl) 5.2 (94 mg/dl) Week (142 mg/dl) 6.9 (124 mg/dl) Week (124 mg/dl) 6.1 (110 mg/dl) Week (144 mg/dl) 6.8 (123 mg/dl) Week (130 mg/dl) 6.0 (108 mg/dl) Week (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.

23 Glycaemic control during the second and third trimester Period Mean 1 hour post-prandial (mmol/l) Mean 2 hour post-prandial (mmol/l) Week (112 mg/dl) 5.3 (95 mg/dl) Week (108 mg/dl) 5.2 (94 mg/dl) Week (142 mg/dl) 6.9 (124 mg/dl) Week (124 mg/dl) 6.1 (110 mg/dl) Week (144 mg/dl) 6.8 (123 mg/dl) Week (130 mg/dl) 6.0 (108 mg/dl) Week (141 mg/dl) 7.1 (128 mg/dl) 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 SMBG, self-monitoring of blood glucose; BG, blood glucose.

24 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.

25 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? 3 6 mmol/l ( mg/dl) 4 7 mmol/l ( mg/dl) 6 9 mmol/l ( mg/dl) BG, blood glucose.

26 Intrapartum glycaemic control Within what range should Alicia s BG levels be maintained during labour and birth? 3 6 mmol/l ( mg/dl) 4 7 mmol/l ( mg/dl) 6 9 mmol/l ( mg/dl) During labour and birth, it is essential to maintain good glycaemic control Maternal hyperglycaemia during labour is associated with increased risk of neonatal hypoglycaemia 1 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 ( mg/dl) 2 BG, blood glucose. 1. Jovanovic L. Endocr Pract 2004;10:S40 S National Institute for Clinical Excellence. Clinical Guideline 2008;CG63.

27 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)

28 Postnatal diabetes medication Question Which of the following medications may be taken while breastfeeding? Metformin Click to reveal DPP-4 inhibitor Click to reveal Statin Click to reveal Insulin Click to reveal DPP, dipeptidyl peptidase.

29 Postnatal diabetes medication Question Which of the following medications may be taken while breastfeeding? Metformin Click to hide Although small amounts of metformin are transferred into DPP-4 inhibitor Click to reveal breast milk, the risk of neonatal hypoglycaemia is thought to be low Statin Studies suggest Click to that reveal infants receive less than 0.5% of their mother's weight-adjusted dosage 1 3 Available data suggest no adverse effects for neonates Insulin exposed to metformin Click to reveal through breast milk 1,3,4 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: Gardiner SJ et al. Clin Pharmacol Ther 2003;73: Eyal S et al. Drug Metab Dispos 2010;38: Glueck CJ et al. Pediatr 2006;148: e2.

30 Postnatal diabetes medication Question Which of the following medications may be taken while breastfeeding? Metformin Click to hide DPP-4 inhibitor Click to hide Statin Insulin There are currently no data on the transfer of Click to reveal DPP-4 inhibitors into human milk As such, DPP-4 inhibitors should not be taken while breastfeeding Click to reveal DPP, dipeptidyl peptidase.

31 Postnatal diabetes medication Question Which of the following medications may be taken while breastfeeding? While breastfeeding, women should continue to Metformin avoid any medications Click to hide that are contraindicated during pregnancy Statins are not, therefore, appropriate for women DPP-4 inhibitor who are breastfeeding 1 Statin Click to hide Insulin Click to reveal 1. American Diabetes Association. Diabetes Care 2013;36:S National Institute for Clinical Excellence. Clinical Guideline 2008;CG63.

32 Postnatal diabetes medication Question Which of the following medications may be taken while breastfeeding? Metformin Insulin may be continued Click to hide while breastfeeding 1 Due to the lactose in breast milk, maternal blood glucose levels are typically reduced DPP-4 inhibitor during breastfeeding, leading to reduced insulin requirements Insulin dose should be adjusted Statin immediately postpartum to reflect this 1 Insulin Click to hide 1. National Institute for Clinical Excellence. Clinical Guideline 2008;CG63.

33 Postnatal glycaemic control Question Which of the following medications may be taken while breastfeeding? Metformin DPP-4 inhibitor Statin Insulin x x 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 BG, blood glucose; DPP, dipeptidyl peptidase; SMBG, self-monitoring of blood glucose.

34 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 infants 1 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.

35 Permission statements/copyright acknowledgement a Slides 9 and 10 From New England Journal of Medicine, Metzger BE et al. Hyperglycemia and adverse pregnancy outcomes 358, Copyright 2008 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.

36 10 Steps to get more type 2 diabetes patients to goal The Global Partnership for Effective Diabetes Management recommends: 1 10 Steps to get more people with type 2 diabetes to goal: Aim for an appropriate individualized glycaemic target, e.g. HbA 1c 6.5 7% (48 53 mmol/mol) (or fasting/preprandial plasma glucose mg/dl [ mmol/l] where assessment of HbA 1c is not possible) when safe and appropriate. Monitor HbA 1c 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 HbA 1c within 6 months of diagnosis. After 3 months, if patients are not at the desired target HbA 1c, consider combination therapy. Consider initiating combination therapy or insulin for patients with HbA 1c 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. HbA 1c, glycosylated haemoglobin. 1. Bailey CJ et al. Diab Vasc Dis Res 2013;DOI /

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