News Author: Alison Palkhivala
CME Author: Désirée Lie, MD, MSEd
October 26, 2009 — The International Diabetes Federation (IDF) announced the release of several new guidelines related to diabetes management here at the IDF 20th World Diabetes Congress. These include the first-ever international guidelines on the management of diabetes in pregnancy and guidelines on the use of self-monitoring of blood glucose (SMBG) among type 2 diabetic patients not being treated with insulin.
Pregnancy and Diabetes Guidelines Call for Universal Screening
Lois Jovanovi?, MD, CEO and chief scientific officer of Sansum Diabetes Research Institute in Santa Barbara, California, and clinical professor of medicine at the University of Southern California-Los Angeles Medical Center, is one of the authors of the IDF Global Guideline on Pregnancy and Diabetes. “The guidelines were created with evidence-based medicine. Then we asked an international group [of experts] to give us their opinion,” she told Medscape Diabetes & Endocrinology.
“There was no international standard [for the diagnosis and management of gestational diabetes], said Dr. Jovanovi?. “There was no consensus, there was a lot of confusion, women were suffering, and their pregnancy outcome was affected by having no standard by which to judge whether their diabetes was worth treating or not. This is the first time there is a worldwide consensus.”
A key message of the new guidelines, according to Dr. Jovanovi?, is the importance of universal screening. “Look for hyperglycemia in pregnancy,” she said. “Preconceptional counseling [also] has to be universal. . . . For a [primary care] physician who has a [patient] in child-bearing years, the first question should be: Are you interested in getting pregnant again?”
Self-Monitoring of Blood Glucose in Noninsulin-Treated Type 2 Diabetes
The IDF Guideline on Self-Monitoring of Blood Glucose in Non-Insulin Treated Type 2 Diabetes was developed in a manner similar to the IDF pregnancy guidelines. Their highlights include the following:
- SMBG should be considered at the time of diagnosis but should only be used when patients, their caregivers, and/or their healthcare providers have the knowledge and willingness to incorporate findings into the diabetes management plan.
- SMBG should be considered a part of ongoing diabetes self-management education.
- SMBG protocols should be individualized.
- Patients and their healthcare providers should agree on how to use SMBG data.
- Tools used to measure SMBG must be easy to use and accurate.
Unique Features of Guidelines
Both sets of guidelines have key features that differentiate them from guidelines on the same topics put out by other diabetes associations, such as the American Diabetes Association (ADA), said Dr. Jovanovi?.
“The ADA hopefully will change soon, but right now they don’t subscribe to the philosophy of universal screening [in pregnancy]. They talk about selective screening. Our guidelines not only talk about universal screening but almost assume that every woman has diabetes [and] doing the testing is to reassure her that she doesn’t. So, it’s a paradigm shift. The second major difference is the [IDF] recommendation that it be a 1-step [oral glucose tolerance] test, not a 2-step test [as currently recommended by the ADA]. The ADA also have the criteria for diagnosis [of gestational diabetes] very high to minimize the number of women identified. The strategies in the [IDF] guidelines actually increase the number of women that would be identified and therefore offer treatment worldwide with 1 standard of care.”
According to a coauthor of the SMBG guidelines, David Owens, MD, from the Cardiff University Diabetes Research Unit in the United Kingdom, a unique feature of the IDF SMBG guidelines is that they clarify the role of SMBG in diabetic patients who are not receiving insulin therapy. “For the noninsulin-treated individuals, [other guidelines] say that it’s a good idea to incorporate SMBG, . . . but there is no real clarity as to what to do about it. That’s where we’ve tried to extend the story more toward what the patient can do about it in their circumstances. . . . There are [other] guidelines that suggest that maybe there’s no reason to monitor blood glucose in the noninsulin-treated, and they say that . . . you need to look at the current evidence and see its limitations. Many of those publications are really not designed to ask [that] question.”
Dr. Jovanovi? has disclosed no relevant financial relationships. Dr. Owens reports being paid for lecturing by Roche Diagnostics, Sanofi-Aventis, Novo Nordisk, Merck Sharpe & Dohme, LifeScan, and Pfizer; being on advisory boards for Roche Diagnostics, Sanofi-Aventis, Novo Nordisk, Merck Sharpe & Dohme, LifeScan, and Pfizer; and receiving research funding from Sanofi-Aventis and Novo Nordisk.
International Diabetes Federation (IDF) 20th World Diabetes Congress: Abstracts 0498 and 0499. Presented October 22, 2009.
- Pregnancy and diabetes
- A 1-stage oral glucose tolerance test at 26 to 28 weeks’ gestation is recommended to screen all pregnant women for gestational diabetes vs the ADA recommendation for selective screening in at-risk women only.
- For women at high risk for diabetes because of previous gestational diabetes, screening should be performed as soon as practical and should be repeated at 26 to 28 weeks’ gestation.
- For women with preexisting diabetes, glycemic control should be optimized before planned pregnancy.
- Angiotensin-converting enzyme inhibitors and angiotensin-II receptor blockers should be stopped and substituted with appropriate medications in pregnant women.
- Statins, fibrates, and niacin should be stopped in pregnancy.
- In women with existing diabetes or gestational diabetes, risks for glucose-lowering agents should be discussed, and use of insulin and the type of insulin should be assessed and discussed.
- A hemoglobin A1c target of 6.0% or lower is desired in pregnant women with diabetes.
- If possible, SMBG should be done frequently in pregnant women with diabetes.
- Doses of glucose-lowering agents should be adjusted according to self-monitoring results, hemoglobin A1c level, and experience of hypoglycemia.
- Eyes should be examined at the first prenatal visit and at each trimester.
- Breast-feeding should be encouraged.
- SMBG should be performed to attain agreed-on treatment goals, and results should be acted on.
- Protocols (intensity and frequency) for SMBG should be individualized to specific behavioral and clinical requirements and meet the needs of therapeutic decision making.
- SMBG should be performed in patients with type 2 diabetes in conjunction with self-management and education of patients.
- An easy procedure should be available to patients who perform SMBG to monitor the performance and accuracy of their glucose meter.
- The IDF recommends screening all pregnant women for diabetes using a 1-stage testing process.
- SMBG should be performed to attain specific treatment goals.