Management of hyperglycemia during pregnancy, as the new CDS guidelines say

*Only for medical professionals to read and refer to Islets of Dete, the only recommended basal insulin analogue for hyperglycemia during pregnancy.

Hyperglycemia during pregnancy is a huge global problem that people are currently facing.
The 2020 edition of the "Guidelines for the Prevention and Treatment of Type 2 Diabetes in China" (hereinafter referred to as the "CDS Guidelines") released on April 19, 2021 [1] pointed out: The world is 20 years old The prevalence of hyperglycemia in pregnant women above is 15.
8%, and the average prevalence rate in various regions of our country is 17.
5%, which is a severe form.

Poor blood glucose control in pregnant women will increase the adverse outcomes of mothers and babies.
It is urgent to control blood sugar strictly to ensure the safety of mothers and babies and the health of offspring.

01 Harm of poor blood glucose control during pregnancy.
Hyperglycemia during pregnancy can be divided into three types: gestational diabetes (GDM), overt diabetes (ODM) and pre-pregnancy diabetes (PGDM), which account for 83.
6% of the percentage of hyperglycemia during pregnancy.
, 8.
5%, 7.
9%, mainly GDM.

Poor blood glucose control during pregnancy (hyperglycemia and hypoglycemia) has many hazards, and can increase the risk of preeclampsia, premature delivery, hyperamniotic fluid, and postpartum hemorrhage.
The fetus and newborn can develop respiratory distress syndrome, jaundice, and hypocalcemia.
Disease and other risks.

In the long run, the risk of diabetes mellitus when the mother is pregnant again is significantly increased, and the risk of metabolic-related diseases such as obesity and type 2 diabetes (T2DM) in the offspring is significantly increased.

Therefore, in order to reduce the harm caused by poor blood glucose control during pregnancy, early and timely intervention and standardized treatment should be carried out for women with hyperglycemia during pregnancy.

02What is the control objective? ▎The 2020 version of the "CDS Guidelines" pointed out: all types of pregnancy hyperglycemia blood glucose targets during pregnancy are fasting blood glucose <5.
3mmol/L, 1h blood glucose after meal <7.
8mmol/L, 2h blood glucose after meal <6.
7mmol/L, for The blood glucose target of ordinary adult T2DM patients is fasting blood glucose of 4.
4-7.
0mmol/L, non-fasting <10.
0mmol/L, it can be seen that the control target of hyperglycemia during pregnancy is more stringent than that of ordinary diabetic patients [1].

In addition, the "CDS Guidelines" newly included time within the glucose target range (TIR) ​​as an important target for blood sugar control, and also proposed TIR control targets for special patients such as hyperglycemia during pregnancy.
TIR of type 1 diabetes during pregnancy is >70%.
TIR >90% in patients with T2DM and GDM.

Hypoglycemia should be avoided while reducing blood sugar during pregnancy.

When blood sugar is less than 3.
3 mmol/L, the treatment plan needs to be adjusted, immediate treatment is given, and glucose or sugary foods are added.

Generally conscious people take 15-20g carbohydrate food orally, blood sugar is still ≤3.
9 mmol/L, and then give glucose orally or intravenously; people with impaired consciousness receive intravenous injection of 50% glucose solution 20-40ml or intramuscular injection of glucagon 0.
5 -1.
0mg, blood sugar is still ≤3.
0mmol/L, continue to give intravenous injection of 50% glucose 60ml.

03What are the sugar control methods + therapeutic drugs? Medications for hyperglycemia during pregnancy have certain particularities.
The 2020 version of the "CDS Guidelines" also gives specific medication opinions, which can prompt us to choose appropriate hypoglycemic drugs.

Metformin is the first-line drug of choice for the treatment of T2DM, and the "CDS Guidelines" clearly stated that if there are no contraindications, metformin should always be kept in the drug treatment plan for diabetes.
However, for hyperglycemia during pregnancy, there is no application of metformin during pregnancy in my country.
Indications should be applied with the patient’s informed consent.
Metformin alone during pregnancy is not recommended, and combined application on the basis of insulin is required.

Except for metformin, other oral hypoglycemic drugs are not recommended for use during pregnancy.

Insulin is an important hypoglycemic drug for the treatment of all types of diabetes.
For hyperglycemia during pregnancy, the "CDS Guidelines" clearly states that the safe use of insulin includes all human insulins (short-acting, medium-acting and premixed human insulin), Insulin analogs (insulin aspart, insulin lispro, insulin detemir).

For both fasting and postprandial blood glucose increases, short-acting/rapid-acting insulin combined with intermediate/detemir pre-meal therapy is recommended.
The application of premixed insulin has limitations and is not recommended as a routine recommendation.

Compared with the 2017 version of the "CDS Guidelines", the 2020 version of the CDS Guidelines adds insulin detemir on the basis of previous medications.

The U.
S.
Food and Drug Administration (FDA) recommends it as level B.
The International Diabetes Federation (IDF), the American Association of Obstetricians and Gynecologists (ACOG), and the American Association of Endocrinologists (AACE) all recommend the use of insulin detemir during pregnancy (other Long-acting insulin analogs are not recommended).

04Can all insulin be used in patients with gestational diabetes? Although insulin cannot pass through the placenta, not all insulin can be used during pregnancy.
In order to help lower blood sugar during pregnancy, insulin needs to meet two conditions.

 First of all, there needs to be a large number of randomized controlled clinical trials (RCT) evidence to support the effectiveness and safety of blood sugar reduction during pregnancy.

A domestic review summarized randomized controlled trials of insulin detemir used in pregnancy, confirming the efficacy and tolerance of insulin detemir in blood glucose control during pregnancy [2].

Relevant studies have shown that [3, 4] insulin detemir and neutral protamine zinc insulin (NPH) group improve the level of glycosylated hemoglobin, but the fasting blood glucose level is lower in the insulin detemir group at 24 weeks of gestation and 36 weeks of gestation; and There was no significant difference in the incidence of overall, daytime, and nighttime hypoglycemia and severe hypoglycemia in the NPH group, and the pregnancy outcomes of the two groups were similar.

In addition, in terms of combination drugs, studies have shown that [4] Insulin detemir + insulin aspart has a higher blood glucose compliance rate (41% vs 32%) and better fasting blood glucose levels than NPH + insulin aspart.
Other safety data are two.
The groups are similar. Secondly, when choosing insulin to treat hyperglycemia during pregnancy, it is also necessary to pay attention to a growth factor closely related to the growth and development of the fetus-insulin-like growth factor-1 (IGF-1), which not only promotes the formation and growth of the fetus under the physiological state of pregnancy Development, and is closely related to the occurrence and development of perinatal diseases such as pre-eclampsia, diabetes with pregnancy, GDM, and fetal growth restriction [5].

The structure of IGF-1 is very similar to that of insulin, which has the function of insulin-like and mitosis promotion [6, 7].

Insulin receptor (IR) has 70% homology with IGF-1 receptor and can bind a small amount of each other's ligand.

The mitogenic effect of insulin analogues is mainly mediated by the IGF-1 receptor, so an increase in affinity with the IGF-1 receptor can enhance its mitogenic effect.

In terms of the difference in IGF-1 affinity, some foreign studies have shown [8] that the affinity of insulin glargine and IGF-1 receptor is about 6.
5 times that of human insulin, while the affinity of insulin detemir and IGF-1 receptor is that of human insulin.
1/6.

Insulin detemir, which has a lower affinity for IGF-1 receptors, has weaker mitogenic effects, so it has higher safety and is more advantageous in the treatment of hyperglycemia during pregnancy.

 It is precisely because of these two points that insulin detemir has become the only basal insulin analog recommended for gestational diabetes in the 2020 edition of the "CDS Guidelines", and it has been clinically "favored".

Summary Women during pregnancy should control their blood sugar within a normal range to ensure the safety of mothers and babies.

In terms of medication selection, according to the 2020 version of the "CDS Guidelines" and recommendations from foreign guidelines, select hypoglycemic drugs that take into account both safety and effectiveness.

Among them, insulin detemir is the only basal insulin analog recommended in the new version of the "CDS Guidelines".
It has obvious advantages over other insulins in terms of safety, effectiveness, and weight impact.
It is a long-acting insulin that is given priority for high blood sugar during pregnancy. References [1] Diabetes Branch of Chinese Medical Association.
Chinese Journal of Diabetes.
2021;13(4):315-409.
[2] Yang Huixia.
Chinese Journal of Diabetes.
2015;23(4):381-384.
[3] Mathiesen ER, et al.
Diabetes Metab Res Rev.
2011;27(6):543-551.
[4] Mathiesen ER, et al.
Diabet Care.
2012;35(10):2012-2017.
[5] Niu Haiying.
Foreign Medical Obstetrics and Gynecology.
2004;31(4):238-240.
[6] Ann Hellström, et al.
Acta Paediatrica.
2016;105(6):576-86.
[7] Dupont J, et al.
Endocrinology.
2001;142(11):4969-4975.
[8] Kurtzhals P, et al.
Diabetes.
2000;49(6):999-1005.
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