Treating Women of Childbearing Age

Case Study

Lucille is 37 years old and has had type 2 diabetes for 7 years. Her A1C has been creeping up for several years. Her BMI has been fluctuating around 38 kg/m2. She is presently taking the maximum doses of metformin and a sulfonylurea (SU). DPP-4 inhibitors, GLP-1 receptor agonists and SGLT2 inhibitors have been avoided as she may desire another pregnancy. She is attending a local weight support group sessions. She has been encouraged to do 150 minutes of weekly aerobic exercise. Her A1C is now at 8.2% and her fasting blood glucose, on home monitoring, averages 12 mmol/L. She is frightened as several family members have had diabetes complications. She is now ready for insulin.

Question 1: What would you recommend for Lucille?

A.  Stop her metformin and SU and begin a bedtime intermediate or long-acting insulin.
B.  Continue her metformin and SU but add a fixed dose of 10 units of bedtime intermediate or long acting-insulin.
C.  Continue her metformin and SU, begin a bedtime intermediate or long-acting insulin, teaching Lucille how to titrate the insulin based on her pre-breakfast BG.
D.  Stop metformin and SU and begin a premixed insulin before breakfast and supper.
Stop her metformin and SU and begin a bedtime intermediate or long-acting insulin. Incorrect. With this pattern in her SMBG it is unlikely that Lucille will meet her A1C target. Don’t wait. Act now.
Continue her metformin and SU but add a fixed dose of 10 units of bedtime intermediate or long acting-insulin. CORRECT. This is sometimes called a basal-plus program and is a good way to introduce short-acting (bolus) insulin to a patient with type 2 diabetes. For more, see Example B: Examples of Insulin Initiation and Titration Regimens in People with Type 2 Diabetes.
Continue her metformin and SU, begin a bedtime intermediate or long-acting insulin, teaching Lucille how to titrate the insulin based on her pre-breakfast BG. Incorrect. Try Again. Lucille has already had lifestyle teaching. It’s unlikely that another round of teaching will help get her blood glucose to target.
Stop metformin and SU and begin a premixed insulin before breakfast and supper. Incorrect. Bariatric surgery is an option for people with type 2 diabetes and a BMI > 35 kg/m2 but it’s not going to happen quickly as an extensive pre-operative work-up is required. For more on weight loss surgery see: Chapter 17: Weight Management.
Reveal Answer

Incorrect. Try Again.

Lucille has been referred to a local diabetes clinic where she learns to inject insulin, do appropriate self-monitoring of blood glucose (SMBG), prevent and manage hypoglycemia, do sick day plans and she had a dietary and exercise review. She has increased her dose of bedtime insulin to 42 units. Her pre-breakfast BG is now averaging 6.5 mmol/L but 2 hours after supper her BG is often 16 mmol/L.

Question 2: What would you recommend now?

A.  Do nothing and wait for the next scheduled A1C test.
B.  Add a rapid acting insulin analogue before supper, titrating the dose until her 2 hour post-supper BG is 5 – 8 mmol/L.
C.  Advise life-style changes.
D.  Discuss bariatric surgery.
Do nothing and wait for the next scheduled A1C test. Incorrect. With this pattern in her SMBG it is unlikely that Lucille will meet her A1C target. Don’t wait. Act now.
Add a rapid acting insulin analogue before supper, titrating the dose until her 2 hour post-supper BG is 5 – 8 mmol/L. CORRECT. This is sometimes called a basal-plus program and is a good way to introduce short-acting (bolus) insulin to a patient with type 2 diabetes. For more, see Example B: Examples of Insulin Initiation and Titration Regimens in People with Type 2 Diabetes.
Advise life-style changes. Incorrect. Lucille has already had lifestyle teaching. It’s unlikely that another round of teaching will help get her blood glucose to target.
Discuss bariatric surgery. Incorrect. Bariatric surgery is an option for people with type 2 diabetes and a BMI > 35 kg/m2 but it’s not going to happen quickly as an extensive pre-operative work-up is required. For more on weight loss surgery see: Chapter 17: Weight Management.
Reveal Answer

Incorrect. Try Again.

Lucille has worked hard and obtained an A1C of 6.8% with minimal hypoglycemia. She is taking 42 units of NPH at bedtime and 14 units of a rapid-acting insulin analogue before supper. She remains on metformin 1000 mg BID. She is also on an ACE inhibitor and a statin. She wants to talk about have a (safe) pregnancy. She has previously been told that she has polycystic ovarian syndrome (PCOS) and she has read that women with PCOS may have diminished fertility.

Question 3: Which of the following is NOT a CDA CPG recommendation for Lucille?

A.  Maintain excellent glycemic control (A1C < 7.0%) while trying to conceive.
B.  Stop metformin.
C.  Stop ACE inhibitor and statin.
D.  Start folic acid at 5 mg / day for 3 months prior to conception.
E.  Screen for complications: retinopathy and nephropathy.
Maintain excellent glycemic control (A1C < 7.0%) while trying to conceive. Incorrect. Attaining a preconception A1C ≤ 7.0% (or A1C as close to normal as can safely be achieved) can decrease the risk of: spontaneous abortion, congenital anomalies and preeclampsia; and can slow the progression of retinopathy in pregnancy.
Stop metformin. CORRECT. Women with pre-gestational diabetes who also have PCOS may continue metformin for ovulation induction. For a full check list of how to prepare a women with diabetes for pregnancy, see: Quick Reference Guide - Diabetes In Women of Childbearing Age.
Stop ACE inhibitor and statin. Incorrect. Both of these classes of drugs are potentially embryopathic and should be stopped prior to conception.
Start folic acid at 5 mg / day for 3 months prior to conception. Incorrect. 5 mg daily intake of folic acid is considered to be most effective in reducing the risk of neural tube defects in the offspring of mothers with diabetes.
Screen for complications: retinopathy and nephropathy. Incorrect. Women with pre-existing vascular complications are more likely to have poor pregnancy outcomes, and there may be progression in the degree of vascular damage. Women with type 1 or type 2 diabetes should have ophthalmological assessments before conception. Prior to conception, women should be screened for chronic kidney disease. Microalbuminuria and overt nephropathy are associated with increased risk of maternal and fetal complications.
Reveal Answer

Incorrect. Try Again.

Reveal All Answers
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References for Lucille:

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