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e-Letters: Comments and Responses

Response to Comment on Law et al. Suboptimal Nocturnal Glucose Control Is Associated With Large for Gestational Age in Treated Gestational Diabetes Mellitus. Diabetes Care 2019;42:810–815

  1. Graham R. Law1,
  2. Alia Alnaji2,
  3. Lina Alrefaii2,
  4. Del Endersby3,
  5. Sarah J. Cartland2,3,
  6. Stephen G. Gilbey3,
  7. Paul E. Jennings4,
  8. Helen R. Murphy5 and
  9. Eleanor M. Scott2,3⇑
  1. 1School of Health and Social Care, University of Lincoln, Lincoln, U.K.
  2. 2Division of Clinical and Population Sciences, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, U.K.
  3. 3Leeds Teaching Hospitals NHS Trust, Leeds, U.K.
  4. 4York NHS Foundation Trust, York, U.K.
  5. 5Division of Maternal Health, St Thomas’ Hospital, King's College London, London, U.K.
  1. Corresponding author: Eleanor M. Scott, e.m.scott{at}leeds.ac.uk
Diabetes Care 2019 Jul; 42(7): e123-e124. https://doi.org/10.2337/dci19-0018
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We thank Foussard et al. (1) for their insightful comments on our recent article (2). We demonstrated that women with gestational diabetes mellitus who subsequently have a large for gestational age (LGA) infant run significantly higher glucose overnight, detectable by continuous glucose monitoring (CGM), at 32 weeks’ gestation than those women who do not go on to have an LGA infant (2). We speculate that there may be several reasons why this is observed.

Foussard et al. (1) suggest that, irrespective of the cause, NPH insulin administered in the evening should be considered the treatment of choice because its peak action coincides with the relative nocturnal hyperglycemia we demonstrated. Our own clinical practice has been to use a long-acting insulin analog (e.g., detemir or glargine) overnight to target a raised fasting self-monitored blood glucose (SMBG) and quick-acting analog insulin with meals to specifically target 1-h postprandial SMBG.

None of the women in the present study were therefore treated with NPH insulin, so we are unable to evaluate Foussard’s valid hypothesis regarding the potential efficacy of NPH in targeting nocturnal hyperglycemia. It is worth noting that in our study, fewer women in the LGA group were being treated with insulin (n = 1 [7%]) at the time of CGM, compared with the women who subsequently did not have an LGA infant (n = 20 [14%]). There were similar numbers of women with and without an LGA infant on metformin (57% vs. 54%). Although we are clearly underpowered to draw definitive conclusions, this perhaps suggests that long-acting analog insulin was effective at preventing a higher glucose overnight.

The effects of different insulins on glucose control and outcomes have been studied in pregnancies affected by diabetes. It is interesting that when NPH and detemir were compared in pregnant women with gestational diabetes mellitus and type 2 diabetes, NPH was associated with more hypoglycemia (3). In pregnant women with type 1 diabetes, detemir was shown to be more effective at lowering fasting SMBG than NPH (4), and when detemir and glargine were compared, glargine was associated with a lower prevalence of LGA in type 1 diabetes, with no difference observed in glucose control (5). None of these studies included CGM, and while their impact on nocturnal glucose control alone cannot be specifically addressed, they illustrate that the effect of any insulin needs to be considered in the context of managing the whole pregnancy.

We believe the real challenge lies not in which treatment to choose but in detecting the need for additional treatment in the first place. Only then can we personalize therapy to the glucose profile in the right woman at the right time.

Article Information

Funding. E.M.S. and G.R.L. were funded by the Higher Education Funding Council for England. A.A. was funded by the Saudi Arabian Government. L.A. was funded by a University of Leeds International Studentship. H.R.M. was funded by the National Institute for Health Research (CDF-2013-06-035).

Duality of Interest. E.M.S. serves on the Abbott Diabetes Care Global Advisory Panel and has received honoraria. H.R.M. serves on the Medtronic European Scientific Advisory Board. No other potential conflicts of interest relevant to this article were reported.

  • © 2019 by the American Diabetes Association.
http://www.diabetesjournals.org/content/license

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. More information is available at http://www.diabetesjournals.org/content/license.

References

  1. ↵
    1. Foussard N,
    2. Cambos S,
    3. Poupon P, et al
    . Comment on Law et al. Suboptimal nocturnal glucose control is associated with large for gestational age in treated gestational diabetes mellitus. Diabetes Care 2019;42:810–815(Letter). Diabetes Care 2019;42:e122. DOI: 10.2337/dc19-0446
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Law GR,
    2. Alnaji A,
    3. Alrefaii L, et al
    . Suboptimal nocturnal glucose control is associated with large for gestational age in treated gestational diabetes. Diabetes Care 2019;42:810–815
    OpenUrlAbstract/FREE Full Text
  3. ↵
    1. Herrera KM,
    2. Rosenn BM,
    3. Foroutan J, et al
    . Randomized controlled trial of insulin detemir versus NPH for the treatment of pregnant women with diabetes. Am J Obstet Gynecol 2015;213:426.e1–426.e7
    OpenUrlCrossRef
  4. ↵
    1. Mathiesen ER,
    2. Hod M,
    3. Ivanisevic M, et al.; Detemir in Pregnancy Study Group
    . Maternal efficacy and safety outcomes in a randomized, controlled trial comparing insulin detemir with NPH insulin in 310 pregnant women with type 1 diabetes. Diabetes Care 2012;35:2012–2017
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Callesen NF,
    2. Damm J,
    3. Mathiesen JM,
    4. Ringholm L,
    5. Damm P,
    6. Mathiesen ER
    . Treatment with the long-acting insulin analogues detemir or glargine during pregnancy in women with type 1 diabetes: comparison of glycaemic control and pregnancy outcome. J Matern Fetal Neonatal Med 2013;26:588–592
    OpenUrlCrossRefPubMed
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Diabetes Care: 42 (7)

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Response to Comment on Law et al. Suboptimal Nocturnal Glucose Control Is Associated With Large for Gestational Age in Treated Gestational Diabetes Mellitus. Diabetes Care 2019;42:810–815
Graham R. Law, Alia Alnaji, Lina Alrefaii, Del Endersby, Sarah J. Cartland, Stephen G. Gilbey, Paul E. Jennings, Helen R. Murphy, Eleanor M. Scott
Diabetes Care Jul 2019, 42 (7) e123-e124; DOI: 10.2337/dci19-0018

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Response to Comment on Law et al. Suboptimal Nocturnal Glucose Control Is Associated With Large for Gestational Age in Treated Gestational Diabetes Mellitus. Diabetes Care 2019;42:810–815
Graham R. Law, Alia Alnaji, Lina Alrefaii, Del Endersby, Sarah J. Cartland, Stephen G. Gilbey, Paul E. Jennings, Helen R. Murphy, Eleanor M. Scott
Diabetes Care Jul 2019, 42 (7) e123-e124; DOI: 10.2337/dci19-0018
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