Building Competency in Diabetes Education THE ESSENTIALS

TREATMENT MODALITIES: PHARMACOLOGICAL THERAPIES | 6-50

ANTIHYPERGLYCEMIC AGENTS IN SPECIAL POPULATIONS

Type 2 diabetes in pregnancy The 2018 Guidelines recommend women with type 2 diabetes planning pregnancy should be started on insulin therapy to achieve glycemic targets and oral antihyperglycemic agents should be stopped. Metformin is safe to use in women with polycystic ovary syndrome (PCOS) to increase fertility and lower miscarriage rates. Metformin and glyburide can be used preconception as both agents are not associated with an increased risk of congenital abnormalities in the first trimester. All other antihyperglycemic agents should be discontinued prior to conception and insulin initiated (115). While intermediate-acting NPH insulin is firmly established for use in pregnancy with long-term safety data, the guidelines state insulin detemir and glargine may be used in women with type 1 and type 2 diabetes planning and during pregnancy as an alternative to intermediate insulin and are associated with similar perinatal outcomes. (115). Gestational diabetes Insulin therapy may be used as first-line therapy (basal-bolus therapy). Metformin can be used in pregnancy as it does not increase perinatal complications; however, metformin does cross the placenta. Glyburide can be used as third-line therapy in women who refuse insulin therapy, and/or are unable to achieve glycemic targets with metformin monotherapy (116). Refer to Chapter 10: Gestational Diabetes Mellitus, for more details. Diabetes in older people Care of the older person with diabetes should be individualized based on the presence of comorbid conditions, functional, cognitive or self-care status, duration of diabetes and life expectancy, ability to recognize and treat hypoglycemia and individual preference (23). Through shared-decision making and in consideration of the aforementioned factors, individualized glycemic targets are agreed upon. • An A1C target of <7.0% is appropriate for healthy older adults with a life-expectancy of greater than 10 years. • An A1C target of 7.1 to 8.0% is appropriate for functionally dependent people • An A1C of 7.1 to 8.5% is appropriate for: • an individual experiencing recurrent severe hypoglycemia and/or hypoglycemia unawareness