Pharmacologic Management of Types 1 and 2 Diabetes Mellitus and Their Complications in Women of Childbearing Age

Abstract

The numbers of women of childbearing age with pregestational diabetes mellitus (diabetes existing before pregnancy) are increasing, primarily because more patients are developing type 2 diabetes at younger ages. The teratogenicity associated with hyperglycemia in early pregnancy is well documented, and tight glucose control minimizes the risk of congenital malformation. Preconception planning is essential; thus contraception that does not worsen complications of diabetes is desirable. In addition, because contraceptives are not 100% effective, the treatment of elevated blood glucose levels, hypertension, and dyslipidemia in these women requires consideration of unplanned pregnancy. We summarized the literature to aid clinicians in choosing individualized treatment that minimizes risk in case pregnancy occurs and maximizes benefit in preventing the complications of diabetes. In women with well-controlled diabetes without vascular disease, all contraceptive methods are safe. Intrauterine devices are recommended due to their minimal effects on risk factors for diabetic complications and their lack of reliance on patient adherence for efficacy. Among insulins, the insulin analogs-insulin lispro, insulin aspart, and insulin detemir-offer patients greater convenience than regular insulin and NPH insulin, and they are safe in case of unplanned pregnancy. Of the noninsulin agents, glyburide and metformin are the safest during pregnancy, but many of the other agents pose minimal risk as long as they are withdrawn during early pregnancy. The risks and benefits of angiotensin-converting enzyme inhibitors in women with compelling indications must be weighed individually. In hypertensive patients at a high risk for unplanned pregnancy, nifedipine should be considered due to literature supporting its safety during early pregnancy. Pravastatin is recommended for women with dyslipidemia who are using effective contraception because there have been no reports of birth defects with this statin when used during early pregnancy in humans and animals.

Berberine reduced blood pressure and improved vasodilation in diabetic rats

“…In addition, some antihypertensive agents, such as calcium channel blockers or angiotensin-converting enzyme inhibitors (ACEIs), are also effective to alleviate cardiovascular remodeling in diabetes (Tillin et al 2011, Ettehad et al 2016. However, few pharmacologic agents could provide a combinational therapy for controlling hyperglycemia and hypertension at the same time in diabetic patients at present (Mukherjee et al 2015).…”

The Influence of Age, Sex, and Socioeconomic Status on Glycemic Control Among People with Type 1 and Type 2 Diabetes in Canada: A Patient-Led Longitudinal Retrospective Cohort Study

“…[35,36] Age range 20-39 includes childbearing years for a large proportion of people who experience pregnancy. [37][38][39] Age range 40-59 includes perimenopause & menopause for a large proportion of people who experience these. [40][41][42][43] Age range 60-79 includes postmenopause for a large proportion of people who experience postmenopause.…”

Diabetes: how to manage gestational diabetes mellitus

“…In cell line studies, its low affinity to type 1 insulin growth factor (IGF1) receptors indicates that it has a low risk of adversely affecting embryonic transplantation; this finding was replicated in animal studies. 15 , 19 Additionally, in a prospective multicentre trial in 310 patients with T1DM during pregnancy, insulin detemir was statistically non-inferior to NPH insulin with respect to glycosylated HbA1c at 36 gestational weeks and hypoglycaemia. 19…”

“…Use of insulin lispro has been studied retrospectively, whereas insulin aspart has been studied prospectively in 322 pregnant women with T1DM. 15 Insulin aspart was shown to have equal efficacy and less hypoglycaemia in comparison to regular insulin. Despite a lack of prospective data, the combined retrospective trials for insulin lispro evaluated 1265 pregnancies and demonstrated its safety.…”

“… 7 Although insulin glargine does not reach the fetus, in vitro data indicate that insulin glargine has the potential to adversely affect embryonic implantation. 15 In general, this is more of a theoretical concern for women with pre-existing diabetes mellitus, and less so for individuals with GDM as a diagnosis of GDM is typically made after the first trimester. At present, there are no randomized controlled trials comparing insulin glargine to other basal insulins during pregnancy.…”