Individualized settings can maximize benefits of automated insulin delivery in pregnancy
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Key takeaways:
- Automated insulin delivery systems may improve time in range during pregnancy.
- Providers should individualize care for each person.
- Manual settings may be needed to achieve glycemic control.
Pregnant women with diabetes can use automated insulin delivery systems with settings optimized to achieve tight glycemic targets, according to two speakers at the Association of Diabetes Care and Education Specialists annual meeting.
Kevin Malloy, PharmD, BCPS, BC-ADM, CDCES, an endocrinology clinical pharmacist at Cleveland Clinic, said pregnant women have a difficult time meeting glycemic targets, especially during the second and third trimesters. The target goal for pregnant women with type 1 diabetes is an HbA1c of less than 6.5% and at least 70% of time in range with a glucose of 63 mg/dL to 140 mg/dL.
“The glucose targets utilized by available automated insulin delivery system algorithms are higher than those recommended for pregnancy,” Malloy told Healio. “However, with adequate knowledge of these systems, clinicians and patients are often able to achieve glucose control near or above targets during pregnancy, with a lower risk of hypoglycemia. The ability to differentiate adjustable variables in each system, along with patient involvement and education throughout the process, is critical.”
Benefits of automated insulin delivery
Two randomized controlled trials have found automated insulin delivery can lead to glycemic benefits for pregnant women with diabetes. As Healio previously reported, in the AiDAPT trial, pregnant women with type 1 diabetes who used a hybrid closed-loop insulin delivery system that included the CamAPS FX (CamDiab) closed-loop algorithm achieved a 68.2% time in range with a glucose of 63 mg/dL to 140 mg/dL compared with a 55.6% time in range for those receiving standard care.
During the presentation, Malloy discussed findings from the CRISTAL trial, in which 95 pregnant women with type 1 diabetes for at least 1 year were randomly assigned to use the MiniMed 780G (Medtronic) with a Guardian 3 or Guardian 4 continuous glucose monitor (Medtronic) or CGM only with standard insulin therapy. Women using the MiniMed 780G had lower incidence of hypoglycemia than the standard insulin therapy group, though time in range did not differ between the two arms.
Malloy said the benefits observed with automated insulin delivery went beyond glycemic control and reductions in hypoglycemia.
“Both of these trials used validated diabetes treatment satisfaction scales with greater treatment satisfaction in the automated insulin delivery arms,” Malloy told Healio.
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, FADCES, FCCP, an endocrine clinical pharmacy specialist and co-director of endocrine disorders in pregnancy at the Cleveland Clinic Endocrinology & Metabolism Institute and a Healio | Endocrine Today Editorial Board Member, said more randomized controlled trials on automated insulin delivery’s efficacy during pregnancy are needed. However, she said, trials are challenging to perform due to the length of time they take to conduct compared with the frequent updates made to insulin dosing algorithms.
Limitations with target glucose
As Healio previously reported, the FDA authorized the CamAPS FX algorithm for pregnant women with type 1 diabetes in May. Additionally, the FDA cleared the twiist automated insulin delivery system (Sequel Med Tech) that uses Tidepool Loop technology for people aged 6 years and older with type 1 diabetes in March. Both algorithms allow the user to set lower glucose targets than other available automated insulin delivery systems, according to Isaacs. She said the CamAPS FX system allows a target glucose as low as 80 mg/dL and the Tidepool Loop algorithm can set a minimum target glucose of 87 mg/dL. However, both algorithms are not yet available for commercial use.
Of the available automated insulin delivery systems in the U.S., Isaacs said the MiniMed 780G allows the lowest target glucose at 100 mg/dL. She added the t:slim X2 with control-IQ (Tandem) is good to use during pregnancy because it includes modifiable factors allowing more basal insulin adjustments, which can help the user maintain a tighter time in range.
Regardless of which system a pregnant woman may use, Isaacs said it is important for them and their provider to understand its features and settings.
“Insulin requirements increase each week of pregnancy in second and third trimester, so frequent adjustments are needed even with an automated insulin delivery system,” Isaacs told Healio. “[It is] usually intensifying carb ratios and increasing basals, or intensifying the correction factor for systems that use that information.”
Tips for using automated insulin delivery
Isaacs said it is crucial for providers to individualize diabetes management during pregnancy by considering the person’s glycemic control before pregnancy and if they used an insulin pump or automated insulin delivery system during any past pregnancies. Providers should also set realistic expectations.
“Even with CamAPS, the mean time in range was still not at 70%,” Isaacs said during the presentation. “Even with these systems as great as they are, it’s still a lot of work and it’s still very hard to meet those recommended targets.”
Providers should also reassess the use of automated insulin delivery systems throughout pregnancy by considering a switch to manual basals overnight or using a suspend-on-low or suspend-before-low glucose feature that is available with some systems.
Isaacs said pregnant women using an automated insulin delivery system should use the lowest target glucose available. Hyperglycemia should be frequently corrected by intensifying correction factors, shortening active insulin time and potentially using manual boluses or adding “fake carbohydrates” to the system.
“I know that seems against what we usually teach, but in [hyperglycemia] it can help,” Isaacs said during the presentation. “If someone is doing that, maybe you give them a suggested amount, or they can mark a [hyperglycemia] event in some way, so you know that they weren’t actually eating.”
Pregnant women should also avoid overtreating hypoglycemia due to the prospective suspension of basal insulin, and to avoid more than 1 hour of prolonged suspension of basal insulin to prevent rebound hyperglycemia.
References:
- Benhalima K, et al. Lancet Diabetes Endocrinol. 2024;doi:10.1016/S2213-8587(24)00089-5.
- Lee TTM, et al. N Engl J Med. 2023;doi:10.1056/NEJMoa2303911.
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Isaacs D, et al. Presentation D25. Presented at: ADCES24; Aug, 9-12, 2024; New Orleans.
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