Insulin Management Strategies for Diabetes during Pregnancy

Recruiting at 3 trial locations

Overseen By Ashley Battarbee, MD

Age: < 65

Sex: Any

Trial Phase: Phase 2

Sponsor: University of Alabama at Birmingham

Must be taking: Insulin, Metformin

Disqualifiers: Major fetal anomaly, Triplet, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Prior Safety Data This treatment has passed at least one previous human trial

Approved in 3 Jurisdictions This treatment is already approved in other countries

Compensation: Varies

Number of Visits: Unknown

Duration: 5 days

120 Participants Needed

What You Need to Know Before You Apply

What is the purpose of this trial?

The trial aims to find the best way to manage blood sugar in pregnant women with diabetes who risk early delivery. Researchers will test three insulin treatments to determine which one best controls blood sugar after administering antenatal corticosteroids, which help the baby's lungs develop. This research is crucial because these steroids can spike blood sugar levels and may affect the baby if not managed properly. Women with type 2 or gestational diabetes who are currently taking insulin or certain diabetes pills might be suitable candidates if hospitalized for steroid treatment due to potential preterm birth. As a Phase 2 trial, this research measures the treatment's effectiveness in an initial, smaller group, offering participants a chance to contribute to important medical advancements.

Will I have to stop taking my current medications?

The trial does not specify if you need to stop your current medications. However, it involves testing different insulin strategies, so you may need to adjust your insulin treatment.

Is there any evidence suggesting that this trial's treatments are likely to be safe?

Research has shown that sliding scale insulin is generally safe for managing diabetes during pregnancy. This method stabilizes blood sugar levels, particularly when they become unpredictable. Studies suggest it is well-tolerated and helps prevent sudden blood sugar spikes.

For continuous insulin infusion, research indicates it can help pregnant women reach their blood sugar targets. However, this method slightly increases the likelihood of needing a C-section. Despite this, it remains a safe option for managing blood sugar.

Regarding home insulin dose adjustments, studies have shown that regularly changing the insulin amount can safely control blood sugar levels. This approach helps lower blood sugar and is linked to healthier birth weights for babies.

All three methods aim to maintain steady and safe blood sugar levels during pregnancy. Each has its pros and cons, but overall, they have been shown to be safe. ^{1 2 3 4 5}

Why are researchers excited about this trial's treatments?

Researchers are excited about these insulin management strategies for diabetes during pregnancy because they offer innovative ways to optimize insulin delivery after antenatal corticosteroids, addressing the unique challenges faced during this period. Unlike traditional insulin regimens, the sliding scale insulin approach allows for supplemental insulin adjustments based on immediate blood sugar levels, potentially enhancing control over short-term fluctuations. The continuous insulin infusion method replaces the conventional home regimen, providing a steady insulin delivery that might better stabilize blood sugar levels. Lastly, the up-titration strategy uses a standardized algorithm to adjust insulin doses, aiming for a more personalized and precise management that could improve both maternal and fetal outcomes during pregnancy.

What evidence suggests that this trial's treatments could be effective for managing diabetes during pregnancy?

This trial will compare different insulin management strategies for diabetes during pregnancy. Studies have shown that sliding scale insulin, one method tested in this trial, helps manage blood sugar by adjusting insulin doses based on regular blood sugar tests. This method is often used during pregnancy to maintain safe sugar levels. Another method under study is continuous insulin infusion, where a pump delivers insulin steadily. This approach has improved blood sugar control in pregnant women but may increase the likelihood of a cesarean section. The trial will also evaluate up-titration of home insulin, which involves gradually increasing the insulin dose at home. This method has been linked to better blood sugar control and lower birthweights in babies. Each method offers benefits for managing diabetes during pregnancy, and this trial explores the best approach after receiving antenatal corticosteroids. ^{1 2 6 7 8}

Who Is on the Research Team?

Ashley Battarbee, MD

Principal Investigator

University of Alabama at Birmingham

Are You a Good Fit for This Trial?

This trial is for pregnant women aged 18-50 with gestational or pregestational type 2 diabetes, treated with insulin injections or medications like metformin. They must be hospitalized for corticosteroid administration due to the risk of premature birth between weeks 23 and almost 37 of pregnancy.

Inclusion Criteria

I am a woman aged between 18 and 50.

You are between 23 weeks and 36 weeks pregnant.

Hospitalized for antenatal corticosteroid administration in anticipation of preterm birth

Exclusion Criteria

You are planning to give birth within 72 hours after receiving the first dose of antenatal corticosteroids.

Triplet or higher order multiple gestation

The participant has a major abnormality in the unborn baby.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants receive one of three insulin treatment strategies for glycemic control after antenatal corticosteroids

5 days

Daily monitoring

Follow-up

Participants are monitored for safety and effectiveness after treatment, including completion of the Diabetes Treatment Satisfaction Questionnaire

1 week

Delivery and Neonatal Monitoring

Umbilical cord blood is collected at delivery, and neonates are monitored for glucose levels and respiratory morbidity

Birth to hospital discharge, assessed up to 28 days

What Are the Treatments Tested in This Trial?

Interventions

• Antenatal Corticosteroids
• Continuous Insulin Infusion
• Sliding Scale Insulin
• Up-Titration of Home Insulin

Trial Overview The study tests three strategies to control blood sugar after receiving corticosteroids: adding sliding scale insulin, increasing usual home insulin doses, and giving continuous insulin infusions. It also uses a Dexcom G6 monitor to track glucose levels.

How Is the Trial Designed?

Group I: Up-Titration of Home Insulin Experimental Treatment 2 Interventions

Increase in home insulin regimen based on standardized algorithm for maximum of 5 days after antenatal corticosteroids

Group II: Sliding Scale Insulin Experimental Treatment 2 Interventions

Addition of supplemental sliding scale insulin to home insulin regimen for maximum of 5 days after antenatal corticosteroids

Group III: Continuous Insulin Infusion Experimental Treatment 2 Interventions

Discontinuation of home insulin regimen and receipt of continuous insulin infusion for maximum of 5 days after antenatal corticosteroids

Antenatal Corticosteroids is already approved in European Union, United States, Canada for the following indications:

Approved in European Union as Betamethasone for:

• Antenatal corticosteroid therapy for fetal maturation
• Inflammatory conditions
• Allergic states
• Dermatologic disorders
• Gastrointestinal diseases
• Hematological disorders

Approved in United States as Betamethasone for:

• Antenatal corticosteroid therapy for fetal maturation
• Inflammatory conditions
• Allergic states
• Dermatologic disorders
• Gastrointestinal diseases
• Hematological disorders

Approved in Canada as Betamethasone for:

• Antenatal corticosteroid therapy for fetal maturation
• Inflammatory conditions
• Allergic states
• Dermatologic disorders
• Gastrointestinal diseases
• Hematological disorders

Who Is Running the Clinical Trial?

University of Alabama at Birmingham

Lead Sponsor

Trials

1,677

Recruited

2,458,000+

Published Research Related to This Trial

In a study of 59 pregnant women with diabetes receiving betamethasone for anticipated preterm delivery, the protocol for subcutaneous insulin showed preliminary safety, with no serious hypoglycemic incidents reported.

Most hyperglycemic episodes occurred within 48 hours post-betamethasone administration, particularly after meals, highlighting the need for enhanced monitoring of blood glucose levels for 72 hours following treatment.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Observations on Glucose Excursions With the Use of a Simple Protocol for Insulin, Following Antenatal Betamethasone Administration. Paulsen, C., Hall, DR., Mason, D., et al.[2021]

Antenatal corticosteroids (ACS) are effective in reducing risks for mothers at risk of preterm delivery before 34 weeks, but they can cause hyperglycemia, which is a significant side effect.

The review discusses management strategies for glycemic control in pregnant women, including those with pre-existing diabetes, gestational diabetes, and those with normal glucose levels after receiving ACS.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Glycemic management after antenatal corticosteroid therapy. Kalra, S., Kalra, B., Gupta, Y.[2021]

Antenatal corticosteroid therapy (ACS) has been widely used to promote fetal lung maturation, but current dosing practices may expose fetuses to higher levels of corticosteroids than necessary, which could pose risks.

Research using sheep and monkey models suggests that much lower doses of corticosteroids (around 1 ng/ml) are sufficient for fetal lung maturation, indicating a need for new clinical trials to explore safer dosing strategies, potentially including oral administration.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Antenatal corticosteroids: a reappraisal of the drug formulation and dose. Jobe, AH., Kemp, M., Schmidt, A., et al.[2021]

The pilot study involving 13 women and 9 clinicians found that both groups found participation acceptable, largely due to the perceived low risk of harm from corticosteroids and the high level of clinical support provided.

Women are more likely to participate in clinical trials when they feel well-informed and supported, while clinicians are more likely to support such trials if they believe it will benefit clinical practice and ensure patient safety.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Pregnant women with diabetes and their clinician's experience of participating in a pilot randomised controlled trial of corticosteroid administration in late pregnancy: A qualitative study. Sweet, L., Vasilevski, V., Lynch, LA., et al.[2023]

In a study involving 98 newborn infants whose mothers received either Celestona or Celeston during pregnancy, there was no significant difference in occipitofrontal circumference compared to a control group of 1012 untreated infants, suggesting that these treatments do not adversely affect brain development in terms of head size.

The findings indicate that administering betamethasone to pregnant women to prevent respiratory distress syndrome does not lead to negative outcomes in newborn head circumference, particularly when given more than 7 days before delivery and without placental dysfunction.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Occipitofrontal circumference in newborns of betamethasone treated mothers. Verder, H., Kjer, JJ., Hess, J., et al.[2019]

The direct medical costs associated with diabetes mellitus have increased over five times from $44 billion to $176 billion annually between 1997 and 2012, primarily due to rising prevalence and care costs.

Despite stable treatment rates for diabetes, there has been a shift towards increased use of oral medications and a stagnation in insulin usage, highlighting challenges in medication management and the need for better patient engagement in diabetes care.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Economic implications of type 2 diabetes management. McAdam Marx, C.[2013]

Flexible, intensive insulin management using new insulin analogues significantly improves glycemic control and allows for greater dietary freedom in individuals with type 1 diabetes, particularly benefiting children and adolescents.

Effective implementation of this management approach relies on individualized patient education and collaboration between patients and clinicians, which is crucial for addressing the specific needs and preferences of adolescents with diabetes.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A fairy tale of modern insulin therapy in type 1 diabetes. Papanas, N., Demetriou, M., Maltezos, E.[2021]

Approximately six million people with diabetes rely on insulin for their treatment, but many face significant barriers that lead to poor adherence to their insulin regimens.

There is a lack of effective interventions to improve insulin adherence, highlighting the need for patient involvement in shared decision-making until better insulin options are developed.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Adherence to Insulin Therapy. Sarbacker, GB., Urteaga, EM.[2022]

A pharmacist-led diabetes medication management program (MMP) significantly reduced A1c levels in type 2 diabetic patients over 2 years, with a mean reduction of -1.24 compared to -0.59 in standard care patients (P = 0.009).

The MMP patients had a lower A1c level after 2 years (8.06) compared to control patients (8.67), demonstrating the program's effectiveness in managing diabetes when combined with a copay waiver for medications.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Analysis of Glycemic Control of a Pharmacist-Led Medication Management Program in Patients with Type 2 Diabetes. Ko, JJ., Lu, J., Rascati, K., et al.[2023]

In a study of 347 women with diabetes in pregnancy, an intravenous insulin protocol effectively maintained maternal glucose levels within the target range after administration of betamethasone, with a high time-in-range of 83%.

Factors such as type of diabetes and late-pregnancy complications were linked to increased insulin requirements, suggesting that personalized glycaemic control strategies could improve outcomes for mothers and their infants.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Factors associated with maternal hyperglycaemia and neonatal hypoglycaemia after antenatal betamethasone administration in women with diabetes in pregnancy. Rowe, CW., Rosee, P., Sathiakumar, A., et al.[2023]

Primary care physicians are now primarily responsible for managing diabetes and insulin therapy, highlighting the need for clear, evidence-based guidelines to assist in treatment.

For patients with type 2 diabetes who have not achieved target blood glucose levels after using two oral medications, initiating insulin therapy with a basal insulin analog is recommended, along with simplified regimens for insulin titration and follow-up.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Insulin therapy in type 2 diabetes mellitus: a practical approach for primary care physicians and other health care professionals. LaSalle, JR., Berria, R.[2022]

In a study of 647 women with diabetes who received antenatal corticosteroids, 92% experienced elevated blood glucose levels after treatment, with hyperglycaemia lasting about 72 hours.

Maternal hyperglycaemia within 24 hours of delivery significantly increased the risk of neonatal hypoglycaemia, indicating the need for careful monitoring of blood sugar levels in pregnant women receiving corticosteroids.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Maternal and neonatal glycaemic control after antenatal corticosteroid administration in women with diabetes in pregnancy: A retrospective cohort study. Tuohy, JF., Bloomfield, FH., Crowther, CA., et al.[2021]

Antenatal betamethasone treatment in pregnant women with severe diabetes can lead to severe acute complications for both the mother and fetus, raising concerns about its safety in this high-risk group.

While corticosteroids are typically used to prevent complications from prematurity, this study questions their overall benefit in diabetic pregnancies due to potential disturbances in metabolic and blood pressure balance.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

[Antenatal betamethasone during pregnancy with severe diabetes: is better worse than good?]. Barondiot, C., Morel, O., Vieux, R., et al.[2013]

Citations

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Insulin pump therapy with and without continuous glucose ... This observational study shows that CSII therapy helped women with T1D who were pregnant or planning pregnancy achieve glycemic targets ...

2. sciencedirect.com sciencedirect.com/science/article/pii/S3050915725000748

Continuous Subcutaneous Insulin Infusion Versus Multiple ... Continuous subcutaneous insulin infusion improves glycemic control in pregnant women with type 1 diabetes but may increase the risks of cesarean ...

3. nejm.org nejm.org/doi/full/10.1056/NEJMe2310798

Technology Use and Glycemic Outcomes during ... These results provide confidence that closed-loop use in persons with type 1 diabetes can improve maternal glycemic control and perhaps positively affect ...

4. onlinelibrary.wiley.com onlinelibrary.wiley.com/doi/full/10.1111/1753-0407.13558

Continuous subcutaneous insulin infusion versus multiple ... The study aimed to compare glycemic control and pregnancy outcomes in women with type 1 diabetes mellitus (T1DM) using multiple daily injection therapy (MDI)

5. mdpi.com mdpi.com/2673-3897/6/4/26

Treatment of Type 1 Diabetes Mellitus During Pregnancy ... The study concluded that AHCL insulin delivery is safe and enhances glycaemic control during pregnancy, particularly in the overnight period, underscoring its ...

6. diabetesjournals.org diabetesjournals.org/care/article/48/Supplement_1/S306/157565/15-Management-of-Diabetes-in-Pregnancy-Standards

15. Management of Diabetes in Pregnancy: Standards of Care ... Both multiple daily insulin injections and continuous subcutaneous insulin infusion are reasonable delivery strategies in pregnancy, with ...

7. academic.oup.com academic.oup.com/jcem/article/110/7/e2317/7944771

Approach to the Patient Using Diabetes Technology in ... Recent randomized controlled trials have demonstrated improved glycemic outcomes with use of HCL insulin pumps in pregnancy with T1D, though the results vary ...

8. dom-pubs.onlinelibrary.wiley.com dom-pubs.onlinelibrary.wiley.com/doi/10.1111/dom.15999

Use of continuous glucose monitoring and hybrid closed‐loop ... Continuous glucose monitoring (CGM) has led to a paradigm shift in the management of pregnant women with type 1 diabetes (T1D), with improved glycaemic control.