Technology and Pregnancy
2024; Mary Ann Liebert, Inc.; Volume: 26; Issue: S1 Linguagem: Inglês
10.1089/dia.2024.2507
ISSN1557-8593
AutoresJennifer M. Yamamoto, Helen R. Murphy,
Tópico(s)Hyperglycemia and glycemic control in critically ill and hospitalized patients
ResumoDiabetes Technology & TherapeuticsVol. 26, No. S1 Original ArticlesFree AccessTechnology and PregnancyJennifer M. Yamamoto and Helen R. MurphyJennifer M. YamamotoDepartment of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada.Department of Medicine, University of Calgary, Calgary, Alberta, Canada.Search for more papers by this author and Helen R. MurphyNorwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom.Norwich Medical School, University of East Anglia, Norwich, United Kingdom.Search for more papers by this authorPublished Online:1 Mar 2024https://doi.org/10.1089/dia.2024.2507AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail IntroductionFrom over 5000 published articles on diabetes in pregnancy over the past year, this ATTD Yearbook article highlights nine manuscripts that address important physiologic, diagnostic, treatment, and health equity queries in diabetes in pregnancy. This includes two landmark trials that address areas of controversy for the diagnosis and treatment of gestational diabetes mellitus (GDM). The first of these evaluated a long-standing controversy in diagnostic thresholds for GDM. The Gestational Diabetes Mellitus Trial of Diagnostic Detection Thresholds (GEMS) study, which examined higher versus lower glucose cutoff levels, did not find lower rates of their primary outcome in large-for-gestational-age infants using lower glycemic criteria for GDM (1). Reassuringly, the pregnancy outcomes of women diagnosed with GDM by either criterion were good, with overall low rates of preterm birth, neonatal hypoglycemia, neonatal care unit admission, or serious adverse outcomes. The second was the Treatment of Gestational Diabetes Mellitus Diagnosed Early in Pregnancy (TOBOGM) study (2). This multicenter trial randomized participants with GDM diagnosed in early pregnancy to early treatment or no immediate treatment and rescreening at 24–28 weeks' gestation. It demonstrated some benefits in the composite of adverse neonatal outcomes, primarily driven by a difference in neonatal respiratory distress, which is not an established benefit of treating GDM. International guidelines will need to carefully consider the TOBOGM results and previous negative trials with the resource utilization required to screen and treat early GDM.Continuous glucose monitoring (CGM) measures fetal exposure to maternal glucose in daily life and is likely to provide a better estimate of fetal exposure to maternal glucose than the current oral glucose tolerance test (OGTT). A pilot study examining the potential of CGM to diagnosis GDM found that CGM was a more acceptable alternative for pregnant women than the current OGTT screening (3). Larger studies in different populations are required to further explore CGM metrics in the diagnosis of GDM and their relationship to obstetric and neonatal complications. A pilot study of intermittently scanned CGM in pregnant women with type 2 diabetes (T2D) found that it was acceptable, but they highlighted important systemic barriers that need to be addressed in the care of people with T2D who are pregnant (4). While CGM is becoming increasingly used in pregnancies with T2D and GDM, data demonstrating the ideal time in range in these pregnancies are limited. A retrospective cohort study of individuals with GDM or T2D found that in those with time in range of 70–140 mg/dL (3.9–7.8 mmol/L) ≤ 70% had more frequent maternal and neonatal complications (5). More data are needed to understand the pregnancy glucose targets in GDM and T2D.The type 1 diabetes (T1D) studies included this year explore the use of technology and therapeutics in pregnancy. Although CGM is generally recommended in T1D in pregnancy, a cohort study of women aged 15 to 45 years demonstrated a number of adverse social determinants of health were associated with lower odds of using CGM (6). Much more work needs to be done to ensure equitable access and use of CGM in people living with diabetes. The results were published of the insulin degludec versus insulin detemir trial (EXPECT), both in combination with insulin aspart, in the treatment of pregnant women with T1D (7). This noninferiority trial demonstrated that insulin degludec is likely a suitable alternative to detemir, but degludec use was associated with potential trends for increased preeclampsia, preterm births, caesarean delivery, and large-for-gestational-age neonates.We continue to deepen our understanding of glucose physiology in pregnancy. A cohort of women with early, classic, and no GDM demonstrated that there is an increase in the insulin secretory response that is independent of insulin and describes a novel pregnancy insulin physiology (PIP) index that predicts GDM independent of clinical risk factors (8). Lastly, using CGM in early, middle, and late pregnancy and the postpartum period, a study including women with a previous Roux-en-Y gastric bypass and matched controls found that those with gastric bypass had different CGM profiles when compared with the matched controls (9). Future research is needed to examine whether these CGM measures are associated with pregnancy and neonatal outcomes.Key Articles ReviewedLower versus Higher Glycemic Criteria for Diagnosis of Gestational DiabetesCrowther CA, Samuel D, McCowan LME, Edlin R, Tran T, McKinlay CJ, for the GEMS Trial GroupN Engl J Med2022; 387:587–598Treatment of Gestational Diabetes Mellitus Diagnosed Early in PregnancySimmons D, Immanuel J, Hague WM, Teede H, Nolan CJ, Peek MJ, Flack JR, McLean M, Wong V, Hibbert E, Kautzky-Willer A, Harreiter J, Backman H, Gianatti E, Sweeting A, Mohan V, Enticott J, Cheung NW; TOBOGM Research GroupN Engl J Med2023; 388:2132–2144A New Continuous Glucose Monitor for the Diagnosis of Gestational Diabetes Mellitus: A Pilot StudyDi Filippo D, Henry A, Bell C, Haynes S, Chang MHY, Darling J, Welsh ABMC Pregnancy Childbirth2023; 23:186Feasibility and Acceptability of Intermittently Scanned Continuous Glucose Monitoring for Women with Type 2 Diabetes in PregnancyMcLean A, Sinha A, Barr E, Maple-Brown LJJ Diabetes Sci Technol2023; 17:256–258Continuous Glucose Monitoring and Time in Range: Association with Adverse Outcomes among People with Type 2 or Gestational Diabetes MellitusBitar G, Cornthwaite JA, Sadek S, Ghorayeb T, Daye N, Nazeer S, Ghafir D, Cornthwaite J, Chauhan SP, Sibai BM, Fishel Bartal MAm J Perinatol. Published online March 1, 2023. doi: 10.1055/s-0043-1764208Disparities in Continuous Glucose Monitoring Use among Women of Reproductive Age with Type 1 Diabetes in the T1D ExchangeVenkatesh KK, Powe CE, Buschur E, Wu J, Landon MB, Gabbe S, Gandhi K, Grobman WA, Fareed NDiabetes Technol Ther2023; 25:201–205Insulin Degludec versus Insulin Detemir, Both in Combination with Insulin Aspart, in the Treatment of Pregnant Women with Type 1 Diabetes (EXPECT): An Open Label, Multinational, Randomised, Controlled, Non-inferiority TrialMathiesen ER, Alibegovic AC, Corcoy R, Dunne F, Feig DS, Hod M, Jia T, Kalyanam B, Kar S, Kautzky-Willer A, Marchesini C, Rea RD, Damm P, on behalf of the EXPECT Study GroupLancet Diabetes Endocrinol2023; 11:86–95Distinct Insulin Physiology Trajectories in Euglycemic Pregnancy and Gestational Diabetes MellitusThaweethai T, Soetan Z, James K, Florez JC, Powe CEDiabetes Care. Published online May 1, 2023. doi: 10.2337/dc22-2226.Roux-en-Y Gastric Bypass Increases Glycemic Excursions during Pregnancy and Postpartum: A Prospective Cohort StudyStentebjerg LL, Madsen LR, Støving RK, Andersen LLT, Vinter CA, Juhl CB, Jensen DMDiabetes Care2023; 46:502–510Lower versus Higher Glycemic Criteria for Diagnosis of Gestational DiabetesCrowther CA1, Samuel D1, McCowan LME2, Edlin R3, Tran T4, McKinlay CJ1; for the GEMS Trial Group1The Liggins Institute, University of Auckland, Auckland, New Zealand; Garvan Institute of Medical Research, Sydney, Australia; 2Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand; Garvan Institute of Medical Research, Sydney, Australia; 3School of Population Health, University of Auckland, Auckland, New Zealand; Garvan Institute of Medical Research, Sydney, Australia; 4Osteoporosis and Bone Biology, Garvan Institute of Medical Research, Sydney, AustraliaN Engl J Med2022; 387:587–598Controversy surrounding the diagnosis of gestational diabetes mellitus (GDM) has prevailed since the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study team evaluated 23,316 pregnant women from 2000 to 2006 and demonstrated continuous associations between maternal glucose and fetal hyperinsulinism (cord C-peptide) and neonatal birthweight, but no clear diagnostic threshold. The Gestational Diabetes Mellitus Trial of Diagnostic Detection Thresholds (GEMS) study group examined higher versus lower GDM cutoffs.MethodsParticipants were randomized to a higher or lower glycemic criteria after oral glucose tolerance test results at 24–32 weeks' gestation. Higher was defined as fasting plasma glucose (FPG) of ≥ 99 mg/dL (≥ 5.5 mmol/L) or 2-hour measure of ≥ 162 mg/dL (≥ 9.0 mmol/L). Lower was FPG of ≥ 92 mg/dL (≥ 5.1 mmol/L), 1-hour measure of ≥ 180 mg/dL (≥ 10.0 mmol/L), or a 2-hour measure of ≥ 153 mg/dL (≥ 8.5 mmol/L). The primary outcome was a large-for-gestational-age (LGA) birthweight. Secondary outcomes were obstetric and neonatal health measures.ResultsFrom 4061 randomized participants, 124 of 2039 (6.1%) had a diagnosis of GDM based on the higher criteria, and 310 of 2022 (15.3%) based on the lower criteria. Birthweights at 39 + 3 weeks' gestation (3402 vs 3389 g) and LGA rates (8.9% vs 8.8%) were similar using the higher versus lower criteria. Medical interventions (induced labor, health-care contacts, glucose-lowering therapy, and neonatal hypoglycemia) were more common using the lower criteria with no between-group differences in serious adverse pregnancy outcomes. Approximately 34% versus 30% of women had induced labor, and 35% versus 38% had caesarean deliveries.ConclusionsThe Gestational Diabetes Mellitus Trial of Diagnostic Detection Thresholds (GEMS) study did not find lower rates of LGA associated with use of lower glycemic criteria for GDM.CommentsThe pregnancy outcomes of women with a GDM diagnosis by either criterion were good, with overall low rates of preterm birth (5%), neonatal hypoglycemia (∼10%), neonatal care unit admission (5%), or serious adverse composite outcomes such as shoulder dystocia, birth injury, or perinatal death (2.5%). Women with GDM have good pregnancy outcomes, but more attention is needed on reducing T2D for both mother and child.Treatment of Gestational Diabetes Mellitus Diagnosed Early in PregnancySimmons D1, Immanuel J1, Hague WM2, Teede H3, Nolan CJ4, Peek MJ5, Flack JR6, McLean M7, Wong V8, Hibbert E9, Kautzky-Willer A10, Harreiter J10, Backman H11, Gianatti E12, Sweeting A13, Mohan V14, Enticott J3, Cheung NW15; TOBOGM Research Group1Western Sydney University, Campbelltown, NSW, Australia; Sydney, Australia; 2Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia; Sydney, Australia; 3Monash University, Melbourne, VIC, Australia; Sydney, Australia; 4Canberra Hospital and Australian National University, Canberra, ACT, Australia; Sydney, Australia; 5Australian National University, Canberra, ACT, Australia; Sydney, Australia; 6Bankstown-Lidcombe Hospital, Bankstown NSW, Australia; Sydney, Australia; 7Blacktown Hospital, Blacktown NSW, Australia; Sydney, Australia; 8Liverpool Hospital and University of New South Wales, Liverpool NSW, Australia; Sydney, Australia; 9Nepean Clinical School, University of Sydney and Nepean Hospital, Sydney, Australia; Sydney, Australia; 10Gender Medicine Unit, Division of Endocrinology and Metabolism, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Sydney, Australia; 11Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Orebro, Sweden; Sydney, Australia; 12Department of Endocrinology, Fiona Stanley Hospital, Murdoch, WA, Australia; Sydney, Australia; 13Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia; Sydney, Australia; 14Dr. Mohan's Diabetes Specialities Centre and Madras Diabetes Research Foundation, Chennai, India; Sydney, Australia; 15Westmead Hospital, Sydney, AustraliaN Engl J Med2023; 388:2132–2144There are limited data on the risks and benefits of treating gestational diabetes mellitus (GDM) when diagnosed early in pregnancy.MethodsThis randomized controlled trial recruited women between 4 and 19 + 6 weeks' gestation with at least one risk factor for GDM. Participants completed a 75 g oral glucose tolerance test (OGTT) before 20 weeks' gestation, and GDM was diagnosed using the World Health Organization diagnostic criteria. Those who received a diagnosis of GDM were randomized to receive immediate treatment (intervention) or no immediate treatment (control). Participants assigned to the no immediate treatment group were rescreened with a 75 g OGTT at 24–28 weeks and treated if a diagnosis of GDM was made. The three prespecified outcomes included a composite of adverse neonatal outcomes, pregnancy-related hypertension, and neonatal lean body mass. A gatekeeping approach was used to examine the primary outcomes. The analyses were performed using a prespecified plan and an intention-to-treat analysis.ResultsA total of 802 women received a diagnosis of GDM in early pregnancy and were randomized to the early treatment group (n = 404) or control group (n = 396). The participants who were randomized to the immediate treatment group were less likely to have an adverse neonatal outcome event compared with the control group (24.9% vs 30.5%; P = 0.02) with an adjusted relative risk of 0.82 (95% CI, 0.68–0.98). This difference was mostly driven by neonatal respiratory distress, which occurred in 9.8% versus 17.0% in the invention and control arms, respectively. There was no difference in pregnancy-related hypertension between the treatment and control groups (10.6% and 9.9%, respectively), so the third primary outcome, neonatal lean body mass, was changed to a secondary outcome. Severe perineal injury was lower in the treatment group compared with the control group (0.8% vs 3.6%, respectively [95% CI, −4.1 to −1.5]). There were no significant differences in secondary neonatal outcomes.ConclusionsParticipants randomized to early treatment of GDM had fewer adverse neonatal outcomes compared with those who had deferred or no treatment of GDM.CommentsThis randomized controlled trial addresses an important clinical question in GDM management: should we screen and treat people for GDM early in pregnancy? This high-quality trial enrolled 802 women after screening a massive 43,721 women for possible inclusion, with 4537 providing consent and 3681 undergoing early GDM screening. It demonstrated some benefits in the composite of adverse neonatal outcomes, which was primarily driven by a difference in neonatal respiratory distress. International guidelines will need to balance the negative results of the Early Gestational Diabetes Screening in the Gravid Obese Women (EGGO) and the modest benefits seen in the Treatment of Booking Gestational Diabetes Mellitus (TOBOGM) study with the resource utilization required to screen and treat early GDM when they re-evaluate the recommendations on early screening for and treatment of GDM in women with risk factors. Importantly, TOBOGM excluded people with higher degrees of hyperglycemia (fasting > 6.1 mmol/L or 2-hour ≥ 11.1 mmol/L) because they were already considered to warrant treatment, so these results should not be applied to this likely higher risk group.A New Continuous Glucose Monitor for the Diagnosis of Gestational Diabetes Mellitus: A Pilot StudyDi Filippo D1, Henry A1,2, Bell C1, Haynes S1, Chang MHY1, Darling J3, Welsh A1,41Discipline of Women's Health, School of Clinical Medicine, University of New South Wales Sydney, Randwick, NSW, Australia; Royal Hospital for Women, Randwick, NSW, Australia; 2Department of Women's and Children's Health, St George Hospital, Kogarah, NSW, Australia; Royal Hospital for Women, Randwick, NSW, Australia; 3Diabetes Clinic Royal Hospital for Women, Randwick, NSW Australia; Royal Hospital for Women, Randwick, NSW, Australia; 4Department of Maternal-Fetal Medicine, Royal Hospital for Women, Randwick, NSW, AustraliaBMC Pregnancy Childbirth2023; 23:186The validity of the oral glucose tolerance test (OGTT) for gestational diabetes mellitus (GDM) diagnosis has long been questioned, and the OGTT is no longer commonly used outside of pregnancy. This study assessed the acceptability of continuous glucose monitoring (CGM) as a diagnostic test to replace the OGTT for pregnant women undergoing screening for GDM.MethodsThe participants wore a masked CGM device (FreeStyle Libre Pro 2) for 7 days while undergoing the OGTT at 24–28 weeks' gestation. CGM metrics and acceptability were examined in comparison with the OGTT results, a GDM risk factor score (total risk score), and a subgroup who provided antenatal ultrasound data (modified ultrasound GDM score).ResultsParticipation rates were high (81%) and included 74 women (85%) with normal glucose tolerance and 13 (15%) with GDM. Pregnant women found CGM far more acceptable than the OGTT (81% vs 27% rating 5/5 for CGM, P < 0.001). Fifty-five participants with normal glucose tolerance had simultaneous CGM data, showing 28 true negatives (no GDM on OGTT or CGM), and most of those (four of five) had normal ultrasound features. Five participants had false-negative results (no GDM on OGTT but CGM glucose values that were consistent with GDM), and six were false positive (positive OGTT but normal CGM glucose values and low GDM total risk score).ConclusionsFor GDM diagnosis, CGM is a more acceptable alternative for pregnant women than the current OGTT screening test, which resulted in both false-positive and false-negative results.CommentsCGM can measure fetal exposure to maternal glucose in daily life, and it is likely to provide a better estimate of fetal exposure to maternal glucose than the current OGTT screening test. Larger studies in representative patient samples are needed to better understand the relationship between CGM and OGTT metrics, and to relate CGM glucose profiles to obstetric and neonatal complications.Feasibility and Acceptability of Intermittently Scanned Continuous Glucose Monitoring for Women with Type 2 Diabetes in PregnancyMcLean A1,2, Sinha A2, Barr E1, Maple-Brown LJ1,31Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia; Royal Darwin Hospital, Darwin, NT, Australia; 2Endocrinology Department, Cairns Hospital, North Cairns, QLD, Australia; Royal Darwin Hospital, Darwin, NT, Australia; 3Endocrinology Department, Royal Darwin Hospital, Darwin, NT, AustraliaJ Diabetes Sci Technol2023; 17:256–258Intermittently scanned continuous glucose monitoring (isCGM) has not been widely studied in women with type 2 diabetes (T2D) and pregnancy, who have high rates of obstetric and neonatal morbidity and mortality. This study assessed the feasibility and acceptability of isCGM in pregnancy for women with T2D.MethodsIn a single-arm prospective pilot study between 2019 and 2021, pregnant women before 30 weeks' gestation were given the option to use isCGM (flash monitoring) for the remaining duration of their T2D pregnancy. Participants' characteristics, enrollment, and retention rates, sensor usage, and satisfaction were evaluated.ResultsFifty-seven participants were enrolled (75% Aboriginal and Torres Strait Islander, and 30% from remote areas), of whom 88% completed the satisfaction questionnaire, 79% used isCGM for ≥ 2 weeks, and 21% discontinued. Mean sensor use was 12 weeks (range: 0–32), and mean sensor activity time was 60% (range: 12%–98%); the proportion of participants with sensor activity of > 75% was 27%. Only 40% commenced isCGM use at < 14 weeks' gestation. The self-reported frequency of capillary blood glucose testing four times per day increased from 36% to 68% (P = 0.001) compared with before isCGM use. Diabetes educators (nurses/dietitians) gave the most useful user support and training (compared with physicians). The majority of participants reported isCGM was worthwhile, and 94% would recommend isCGM use to others.ConclusionsThe use of isCGM was acceptable for pregnant women with T2D, but late referrals, discontinuation, and variable use meant that very few participants used isCGM throughout their pregnancy. Ensuring culturally appropriate education and T2D pregnancy care pathways are needed to support optimal use.CommentsThis study suggests that CGM could be a useful and well-received tool for improving maternal glucose levels during T2D pregnancy. However, it identifies important barriers among women from minority ethnic groups, including the need for culturally appropriate education and care. It is interesting that the women found their consultations with diabetes educators (nurses/dietitians) more supportive than those with physicians.Continuous Glucose Monitoring and Time in Range: Association with Adverse Outcomes among People with Type 2 or Gestational Diabetes MellitusBitar G1, Cornthwaite JA1, Sadek S1, Ghorayeb T1, Daye N1, Nazeer S1, Ghafir D1, Cornthwaite J2, Chauhan SP1, Sibai BM1, Fishel Bartal M1,31Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center, Houston, TX; Sheba Medical Center at Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; 2Department of Earth, Environmental and Planetary Science, Rice University, Houston, TX; Sheba Medical Center at Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; 3Department of Obstetrics and Gynecology, Sheba Medical Center at Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, IsraelAm J Perinatol. Published online March 1, 2023. doi: 10.1055/s-0043-1764208Continuous glucose monitoring (CGM) is increasingly used in pregnancies complicated by gestational diabetes mellitus (GDM) and type 2 diabetes (T2D), but the recommended CGM time-in-range (TIR) targets and their associations with obstetric and neonatal outcomes are unclear in this population.MethodsThis retrospective cohort study of CGM use with GDM and T2D pregnancies compared maternal and neonatal outcomes in the patients with TIR of > 70% and ≤ 70%: 70–140 mg/dL (3.9–7.8 mmol/L). The neonatal composite outcome included large-for-gestational-age neonates, neonatal intensive care unit admission, hypoglycemia with intravenous glucose, neonatal respiratory support, or neonatal death.ResultsA total of 65 of 114 pregnant women (46%) were included. In this cohort, 37 women (57%) had a TIR of ≤ 70%, and 28 (43%) had a TIR of > 70%. The neonatal composite outcome occurred more frequently in those with a TIR of ≤ 70% (71.4% vs 37.8%; adjusted odds ratio, 4.8 [95% CI, 1.6–15.7]). Those with a TIR ≤ 70% were more likely to have hypertensive disorders of pregnancy (43% vs 16%), preterm births (54% vs 27%), and caesarean delivery (96% vs 51%).ConclusionsIn pregnancies complicated by T2D and GDM, women with TIR ≤ 70% had more frequent maternal and neonatal complications.CommentsAiming for at least 70% time in range of 70–140 mg/dL seems sensible for those with GDM and T2D, although a time in range of 80%–90% may be optimal. Tighter time-in-range targets, such as 63–120 mg/dL, may be more applicable for GDM. However, more data are needed to understand the pregnancy glucose targets in GDM and T2D pregnancy.Disparities in Continuous Glucose Monitoring Use among Women of Reproductive Age with Type 1 Diabetes in the T1D ExchangeVenkatesh KK1, Powe CE2, Buschur E3, Wu J1, Landon MB1, Gabbe S1, Gandhi K4, Grobman WA1, Fareed N51Department of Obstetrics and Gynecology, The Ohio State University, Columbus, OH; The Ohio State University, Columbus, OH; 2Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA; The Ohio State University, Columbus, OH; 3Department of Medicine, The Ohio State University, Columbus, OH; The Ohio State University, Columbus, OH; 4Department of Pediatrics, The Ohio State University, Columbus, OH; The Ohio State University, Columbus, OH; 5Department of Biomedical Informatics, The Ohio State University, Columbus, OHDiabetes Technol Ther2023; 25:201–205When used during pregnancy, continuous glucose monitoring (CGM) has been shown to improve outcomes for women with type 1 diabetes (T1D) and their babies, but little is known about whether these disparities exist in women of reproductive age.MethodsThis was a secondary analysis of the T1D Exchange Registry, which is a prospective cohort of people with T1D that includes over 80 clinics in the United States. Girls and women aged 14–45 years in the T1D Exchange from 2015–2018 were included. Logistic regression was used to examine the association of CGM use and a number of sociodemographic and clinical characteristics.ResultsA total of 6478 women and girls aged 15–45 were included in this analysis, of whom 1702 (26.3%) were using CGM. They had a median age of 20.0 years, median duration of diabetes of 11.5 years, and 67.3% were using insulin pump therapy. Of this cohort, 19.6% had Medicaid, and 5.9% and 9.3% self-identified as non-Hispanic Black and Hispanic, respectively. CGM use was associated with achieving target glycemia (adjusted odds ratio [aOR], 1.95 [95% CI, 1.57–2.44]). Several social determinants of health were associated with CGM use; specifically, self-identifying as non-Hispanic Black or Hispanic was associated with lower odds of using CGM (aOR 0.40 [95% CI, 0.28–0.56] and aOR 0.73 [95% CI, 0.57–0.92], respectively) compared with people who self-identified as non-Hispanic White. Lower income, lower levels of education, and enrollment in Medicaid were also associated with lower odds of CGM use.ConclusionsIn this cohort of women aged 15–45 years, CGM use was associated with achieving target hemoglobin A1c levels. Concerningly, a number of adverse social determinants of health were associated with lower odds of using CGM.CommentsAlthough a number of international guidelines now recommend CGM for people with T1D both during and outside of pregnancy, there is a growing body of evidence demonstrating that people who are experiencing higher levels of social deprivation are less likely to use diabetes technologies. The findings in this study are consistent with those in the larger T1D population and suggest that, despite the benefits of CGM, people with adverse social determinants of health are less likely to be using these devices (10,11). Given that the period covered by this cohort included a number of years before the publication of landmark studies and trials demonstrating the benefits of CGM use in pregnancy and would be based on older CGM technology, additional research is needed to examine whether these trends persist.Insulin Degludec versus Insulin Detemir, Both in Combination with Insulin Aspart, in the Treatment of Pregnant Women with Type 1 Diabetes (EXPECT): An Open Label, Multinational, Randomised, Controlled, Non-inferiority TrialMathiesen ER1,2, Alibegovic AC3, Corcoy R4,5,6, Dunne F7, Feig DS8, Hod M9, Jia T3, Kalyanam B10, Kar S10, Kautzky-Willer A11, Marchesini C3, Rea RD12, Damm P1,2, on behalf of the EXPECT Study Group1Center for Pregnant Women with Diabetes, Departments of Endocrinology and Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; Oxford, UK; 2Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Oxford, UK; 3Novo Nordisk A/S, Søborg, Denmark; Oxford, UK; 4Servei d'Endocrinologia i Nutrició, Hospital de la Santa Creu i Sant Pau-Dos de Maig, Barcelona, Spain; Oxford, UK; 5CIBER-Bioengineering Biomaterials and Nanomedicine, (CIBER-BBN, ISCIII), Madrid, Spain; Oxford, UK; 6Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; Oxford, UK; 7Clinical Research Facility (CRF), College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland; Oxford, UK; 8Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto and the Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada; Oxford, UK; 9Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Oxford, UK; 10Novo Nordisk Service Centre India Private Ltd, Bangalore, India; Oxford, UK; 11Division of Endocrinology & Metabolism, Medical University of Vienna, Vienna, Austria; Oxford, UK; 12Oxford Centre for Diabetes Endocrinology and Metabolism and NIHR Oxford Biomedical Research Centre, Oxford, UKLancet Diabetes Endocrinol2023; 11:86–95The EXPECT study group compared the safety and efficacy of two long-acting basal insulin analogues: first-generation insulin detemir and second-generation insulin degludec. Degludec has a longer half-life (∼24 vs 12 hours) and longer duration of action (42 vs 24 hours) than detemir, which means that degludec is taken once daily whereas detemir is usually taken twice daily.MethodsIn this open-label, multicenter, randomized controlled trial at 56 sites from across 14 countries, women with type 1 diabetes (T1D) and glycated hemoglobin (HbA1c) levels of ≤ 8.0% (≤ 64 mmol/mol) were randomized to receive degludec or detemir, both in combination with insulin aspart. Randomization was stratified according to pregnancy status (pregnant or planning pregnancy) and CGM use. The primary outcome measure was the last HbA1c measure before delivery, based on a noninferio
Referência(s)