Having experienced GDM herself while pregnant, perinatologist Jennie Duffy, MD, understands the challenges for both patients and doctors in the quest for better glycemic control. She lays out the risk factors – which shed light on why GDM is increasingly common – and discusses serious possible complications for both baby and birthing parent, such as significantly elevated risks of type 2 diabetes and heart disease. Learn pros and cons of the two screening tests and whether the evidence on those popular continuous glucose monitors supports their use in pregnancy. Duffy also shares her insights on metformin-versus-insulin and offers tips for safe and effective insulin dosing, including in special circumstances like food insecurity or religious fasting.
Yeah, of course. Thanks for having me. Um, so I'm hoping to talk about diagnosis and management. Um, my name is Jenny Duffy. I'm Assistant professors at UCSF, um, I will say just, uh, most of my clinical work actually is in the East Bay, so I'm predominantly at Highland Hospital. I work at the PDC out in, um, Berkeley. I'm actually, I don't do any prenatal care in San Francisco. Um, so I hope to bring a little bit of a different lens in That I work in predominantly resource constrained environments and often and help the CNMs and the MDs with, um, their gestational diabetics while they're waiting to get in with, you know, the next MD provider or the MFM provider or what have you. Um, and so some of what I'll present has a little bit more. More of like a, if you are in a more resource constrained environment, here are some like quick tips kind of thing. Um, in terms of disclosures, I have no financial disclosures. Um, and the only other disclosure is that I actually had GDM myself with my older son, and I bring that up only because, um, I've like had to like walk the walk a little bit and realized that when I had to Figure out how many carbs in a slice of bread that I like, as an MFM fellow at the time had like not a clue and so it's been nice to kind of Have that perspective as well, um, and so, anyway, that's just for what it's worth, full context. So, um, in terms of outline, I put in like a lot of slides. I'm happy to share them, um, with the hope of just going like a very brief overview of kind of why we care about diabetes, how sort of what's some of the data about how it should be diagnosed and what are some of the limitations of how it's diagnosed, um, some description of recommended monitoring, um, some overview of medications, and some of the more like hot off the presses kind of data, um. From there. So in terms of epidemiology, gestational diabetes, depending on your patient population can affect up to 25% of pregnancies. I think general average is kind of 8 to 10%, but if you're working um like where I work, um, Over at Highland, we have a much higher rate of gestational diabetes. Um, and of course, as um BMI's and just general health has kind of trended in a not favorable direction over time, so too has gestational diabetes. So there's many risk factors for gestational diabetes that includes things like advanced maternal age, increased BMI, uh, pre-pregnancy glucose intolerance, any kind of like predisposition to glucose intolerance, like a personal or family history of diabetes or gestational diabetes, um, non-white race, and then various social determinants of health as well. Um, in terms of like the underlying physiology, the precise way in which, um, There's an imbalance in hormones that leads to glucose intolerance is not entirely understood, but in general it's thought that the placenta creates hormones that leads to glucose intolerance, which leads to gestational diabetes. Um. We do know that because a lot of the processes of gestational diabetes are driven by placental hormones, that a lot of these um changes tend to be more pronounced in the beginning of the early 3rd trimester, which is why the typical screening time is in that 24 to 28 week period, because that's when those hormones start to ramp up and so it's a nice balance between being able to screen early enough to do something about it, but not screen so early that you miss kind of the diagnosis. Um, so we know that like pregnancy in general is a um promotes a diabetogenic state, um, in that there's many physiologic adaptations which are meant to actually support the growth of the fetus, and in gestational diabetes, they basically just go a little bit haywire. So we know there's an increase in glucose production. We know there's a decrease in insulin sensitivity. We know there's an increase in um insulin response, and all of these adaptations are necessary to help support and grow the baby, um, but in patients with gestational diabetes, those just go sort of to the extreme, um. And so, you know, this uh graphic basically just shows sort of some of these changes. And I bring this up because I think a lot of times patients, they get the diagnosis, they, um, hear, oh, you know, you have to make these changes, they make those changes and things still get worse as they progress throughout the pregnancy, and it's very discouraging and very disheartening. And so I bring this up just to say like one of The things that I really, really, really counsel patients about is that I want to make sure that patients understand that worsening glycemic control throughout pregnancy is actually a reflection of this very normal placenta mediated process and not like a personal failing on their part to like do what we're asking them. Um, and I think like having that understanding. Has help it seems like patients are then like, oh, you're asking me to go up on my insulin, not because I'm doing anything wrong, but because this is what's going to happen, and I think that anticipatory guidance really helps. Um, there are many associated complications with gestational diabetes, um, growth abnormalities in the fetus, either too big or too small, preterm delivery, shoulder dystopia, um, related birth injury, neonatal hypoglycemia, and then also, um, considerations for the, for the, um. The mom, uh, hypertensive disorders, operative delivery, cesarean delivery, uh, increased risk later in life of type 2 diabetes, and then also long-term cardiovascular risk just from having, um, Gestational diabetes alone. Um, and so I just wanna kind of put this out there that, you know, gestational diabetes, we definitely know it predisposes to type 2 diabetes and this risk is actually fairly significant depending on like the source you cite, it's um estimated that 30 to 50% of patients with gestational diabetes will be diagnosed with type 2 diabetes um within kind of a 3 to 5 year time period. Um, and so it's not insignificant, and it's so much so that um there's a A large body of literature that suggests that we should be adjusting how we're screening postpartum patients for gestational diabetes, uh, or sorry, for type 2 diabetes when they have this history. The other thing that I think is an area of evolving research that's very interesting is that we know that for people with gestational diabetes, even those that never developed type 2 diabetes, just having the diagnosis of gestational diabetes confers an increased cardio metabolic risk. And so you have gestational diabetes, you never get type 2 diabetes, you still are at higher cardiovascular risk. And I think this comes up importantly because I think traditional models of that, OK, you have your, you know, gestational diabetes, it's gone when the placenta is out, and then you can just carry on with your life until your next pregnancy and I think that You know, especially as patients are coming into pregnancy, maybe a little bit older, maybe a little bit higher BMIs, etc. just keeping in mind that this is an important opportunity to kind of get ahead of cardio metabolic health is, is a good thing to keep in mind. So in terms of diagnosis, there's many points for discussion regarding GDM screening, including when to screen, how to screen, who to screen. Um, typical practice historically has been um to screen all pregnancies at 24 to 28 weeks with either a one step or two-step glucose tolerance test. I will say that at Highland for many, many years they were doing the um one step, um, which we'll get into, and we've recently changed recently to the two step. Um, But this is definitely A source of of conversation. Um, so the one step glucose tolerance test involves a 75 g glucose load. It is a fasting test where you get a fasting, a 1 hour and a 2 hour blood draw. A single elevated value is required for the diagnosis. Um, and there are many, uh, organizations that recommend this is sort of your primary screen for, um, diabetes. The benefit of this test and often why we used it, um, at Highland initially was because it's kind of one and done. If you get a patient out to the lab, you get your answer that same day. There are a lot of benefits to that, um, especially in a resource constrained environment, resource limited, um, more marginalized patients. The two step in contrast is a 50 g glucose load. It has a single non-fasting blood draw at 1 hour. If you're above the threshold, which is another source of conversation, um, then you need to do a second step, which is a 3 hour glucose tolerance test. Um, that 3 hour is a 100 g glucose load and requires a fasting 12, and 3 hour blood draw. You need 2 elevated values to be diagnosed with gestational diabetes with this test. This is what's currently recommended essentially by ACOG. Um, In terms of what percentage of people getting the 1 hour need the 3 hour, it's estimated to be about 20%. Um, obviously that value would be very different depending on your patient population, and they're kind of a priority risk for gestational diabetes, but on average it's about 20%. So, um, there have been a fair number of head to head trials looking at the one step versus the two step for diabetes, um. There's some older data that suggests that the one-step approach, so that's the 2 hour, um, might be more sensitive than the two step, meaning more likely to identify someone as gestational diabetic. Um, that said, it was unclear if capturing this like extra group of people actually made any difference in pregnancy outcomes. So back in a few years ago, there was a randomized control trial um based out of Kaiser, so, um, you know, uh, Kaiser tends to have a very uh demographically. Uh Certain kind of patient population and so, but they did a randomized controlled trial. It was about 24,000 patients, um, and they basically looked at a primary outcome of primary cesarean. And so it, it randomized to the one step versus the two-step. Um, you can see here that just to um put this out there, only about a quarter of their patients were obese, 50% were white, um, in their patient population, you know, and their average age was 30. Um, and in this, what they found was that for the two steps, so again that's the non-fasting followed by the fasting test, the 1 hour followed by the 3 hour. So for the two step, their adherence rate was 92%, for the fasting one step, it was 66%. They found that the um they had about double the number of um Cases of diagnosis of gestational diabetes and that they had no difference in cesarean delivery rate, no difference in LGA, no difference in a neonatal composite or um hypertension. And so they basically their conclusion was that using the one step approach had lower compliance was more sens more likely to diagnose you as GDM but with no difference in pregnancy outcomes. And so this really raised the question of You know, what is the benefit of telling more people they have GDM if it's not gonna make a difference in your outcomes. Um, but like I mentioned before, at least for where I work, um, the demographics of this initial RCT didn't really reflect our patient population, so it was hard to really like apply it to them. Um, so there was this other admittedly smaller, um, study that looked retrospectively, so take it with a grain of salt at the two step versus the one step in a higher um. You know, in a higher risk patient population where they had 60% obesity and only 7% um white patients, and they found that um of those that, you know, underwent the two-step screening, they had like pretty decent adherence, still higher with the two step than the one step but not quite as desperate in the Kaiser population. Um, they found that about 16% required that second step and again found that there was like about a double um. The twice as many cases of GDM diagnosed with the one step. Mhm. Yeah. Um, and so then, you know, there have been additional meta-analysis and Many, many clinical trials and observational studies and essentially they found that with the um the one step uh glucose tolerance test that you typically have a higher rate of GDM diagnosis, higher rate of treatment, um, but no difference in outcomes. And so this I will um put up here. This is what we typically use at UCSF um we do the two-step, um, and then They, you know, you start with your kind of non-fasting 50 g, um, one hour glucose tolerance test. Um, if you are less than 130, you can considered normal. If you're 130, um, and I will say this 130 is a little bit institution specific. Some places use 140, some places use 130, um, when we at Highland made the jump from the, um, the one step to the two-step. We used a lower threshold as like a compromise, right? Like now we're gonna do the maybe less sensitive test but maybe use a lower threshold because there was a concern that gosh are we missing an opportunity to counsel people and so this was sort of like, well, we use a lower threshold, but with the two step, maybe that's like a good middle ground. Um, if someone has a 1 hour and they have a greater than 200, just diagnose them as gestational diabetes. They don't need the, the 3 hour. Um, this part here with what to do with the fasting is a little bit, um, Institution specific, um, in terms of whether, uh, you know, depending on your access and your availability of your registered dietitians, are you going to be sending people that have like glucose intolerance to see them or not? Um And that's something that's even at UCSF is always kind of evolving. Um, the other question is, you know, can you screen for gestational diabetes with a hemoglobin A1C? Um, you know, the A1C is a measurement of average glucosylation of hemoglobin over about a 3 month period, um, but there are many things that can, uh, impact, uh, A1C, including he uh hemodilution, especially as it's seen in, you know, the later stages of pregnancy, um, any condition with a high RBC turnover, so like for instance, sickle cell anemia, sickle cell disease, um. And yes, of course, pregnancy. There have been some limited studies looking at whether or not um hemoglobin A1C in early pregnancy is a good predictor, and the punch line is that if you have a hemoglobin A1C greater than 5.7%, it has like, you know, reasonable predictive value saying like you may be headed towards a GDM diagnosis, but like as a diagnostic tool that the false positive rate was also very high. Um, and so it's like if you see someone and they have an A1C of 6.3%. You know, there, I think it's fair to say, gosh, we really should be, you know, just inspiratory guidance, you may end up with gestational diabetes, but I don't think you can just say like you have it. Um, All right, so in terms of monitoring, So standard um in terms of monitoring is to use the glucometer um to uh check the blood sugars. Typically, uh, fasting and 1 hour after meals or 2 hour after meals, that tends to be pretty um institutions specific, um, is, so it's 4 times a day. In terms of the timing, um, we know that peak glucose levels occur roughly 90 minutes after the start of the meal. Um, there's not really been any head to head studies looking at whether 1 hour postprandial or 2 hour postprandial glucose is better in terms of pregnancy outcomes. Um, and there's not any data to really guide, you know, 90 minute postprandial, um, blood sugar checks, um, and so I think, you know, as a matter of kind of institutional practice, we tend to do 1 hour postprandials, um, that being said, if I've had patients that are like, hey, at 1 hour post perennial, I have to go pick my kid up and I can't do it until 2 hours postial, that's fine. Uh, In terms of the threshold that is utilized, um, Sweet success I believe was less than 90 for fasting and less than 130. Um, most like uh ACOG and ADA use fasting less than 95 and postprandial less than 140. Um, The reason I believe when I looked into this, that Sweetes use the lower threshold is because there were some like earlier studies of You know, diabetic pregnant women that suggested that was like the normal range, um, but in terms of there's small studies that suggest that you really don't have worsening pregnancy outcomes if you use 95 or 140. So I personally use 95 and 140 cause it gives a little bit of grace, um, to the, to the patient and just, you know. Kind of meets them a little, it's a little bit of an easier target and as long as I if they're doing all the right stuff and then it's endorsed by ACOG and ADA, that's the threshold I use. Um, there was 1 2020, um, RCT that did try to address this question of like should we use 130 or 140. Um, it was among 616 individuals. They defined their tight and lose control. Um, it wasn't exactly the tight control was 92 and the posterial is 126. The loose control was 96 and post, so it wasn't exactly 130 versus 140, but close, um, and their primary outcome was uh LGA infant, and they basically found no difference in perinatal outcomes, but it is worth noting that um in the tight control group, 45% of them went on to require medications, not surprisingly compared to 26%. Um, and so I just think that this is like just highlights that like being stricter might just require kind of more resources for patients and more stress for patients without necessarily a proven benefit. But I will say that um there are many ongoing trials, so in the coming years, this question may have additional information. Um, the other thing that has that this is very recent, I will say if anyone has access to ACOG, they just came out with an entire diabetes, um, journal like. Um, I don't know, volume, like the entire, um, it's all about GDM uh in November of this year, so last month, and every single article in that um in that volume is dedicated to GDM and this came out with that and so this is a study that was a randomized controlled trial of about 200 participants, and they actually randomized people to checking their blood sugars daily versus every other day. And they essentially found that similar amounts of insulin were used in both groups, and there's no difference in like birth weight, insulin start, time to insulin start, or like average glycemia in each group. And so I think this is also something um in this trial they the participants had to have, I believe a week of regular um You know, regular documentation of blood sugar levels before they could be randomized, but I just think it's something to kind of keep in mind, um, especially if you have a patient that is like very hesitant to do the Accu checks that it's OK to like consider, especially if they're pretty well controlled, going with every other day checking. Um, so in terms of continuous glucose monitoring, there's this really, really nice, I highly recommend if some if um pulling this article, um, because it really outlines a lot of the issues really nicely. This was also in the um Green Journal from last month. Um, so continuous glucose monitoring is something that is like getting like very popular and and is being used a lot and is covered by payers and patients are like, I want the thing in my arm, so I don't have to poke my fingers. That sounds great. Um, but it is different than the Accuexx, so the CGM provides a continuous assessment of interstitial glucose every 1 to 5 minutes for basically 10 to 14 days at a time. Um. This graphic just shows like how it differs. So you get a lot more detailed data, right? Like if these black circles are your finger sticks. Uh, you will get all of the information in between as well, and so it gives you a lot more information, and the question is, what do you do with this information, and is it the same as doing the finger sticks? Um, and so this is just a picture from the same article that basically shows you have your transmitter and then your sensor, and you, when you're doing the finger stick, it's the, you know, capillary glucose here versus the CGM is actually getting that interstitial glucose. And you know, the, in theory it makes a lot of sense, right? So, This is kind of three different scenarios where you could imagine with CGM rereadings, where if you figure that this is kind of your target range, this patient's 100% in range, this patient is like mostly in range, little teensy bit low, couple of times high, this patient is kind of all over the place. They could theoretically all have the same um You know, depending on when you're checking, right? Like you could check here, here, here and here, and they would seem very similar, but they and they would all have the same A1C, but you could tell like the glycemic exposure in the pregnancy would be very different. So in theory it makes a lot of sense that if you have more data you could control more data and therefore make a big difference. Um, but it doesn't, uh, that is an area that's kind of a hot topic right now in terms of, um, ongoing studies. Um, generally speaking for type one diabetes, definitely significant improvements. There's less microsomia, less neonatal hypoglycemia, better overall control, less NICU stage. So for a type one diabetic, they should be offered CGM and there's a lot of data, um, being gathered in terms of using it like in labor and like really being like pro CGM. For type 2 diabetes, most of the studies to date have been fairly underpowered, but generally speaking are not thought to lead to improvement in OB outcomes. And then in gestational diabetes, um, couple of mixed reviews, couple of mixed studies, maybe a slight decrease in the A1C, maybe a, uh, improved detection of hyperglycemia and hypoglycemia. But like overall pretty limited evidence in terms of improved obstetric outcomes. Um, this study came out last month and basically this is interesting, they put, um, as a prospective cohort study, they put a CGM on GDM patients as well as non-GDM patients and then looked at the differences between the glycaemic patterns, um, for patients with adverse outcomes. So they said, OK, we have these patterns, how many had preeclampsia, how many had preterm delivery, how many had um growth abnormalities, and they did see. There were differences in the patterns, um, just kind of supporting this idea that like maybe if we look at the data correctly and well designed studies, maybe there will be an improvement in outcomes, but we just haven't shown it yet because of the studies that have been available. But again, this included non gestational diabetic and gestational diabetic pregnancies. Um, so right now the data says good for type 1 diabetes, maybe for type 2 diabetes, maybe not for GDM, hard to say, um, but patients still wear them and they come into pregnancy having used them, and so the question is what do we do with that? So this, this, um, same article from last month basically suggests kind of a stepwise approach to evaluating and it's basically like step one. Do we have data? Like how often are there readings. Step 2 is how often are they in range, high, very high or low, and then step 3 is like, How does, how do the time and ranges in the various ranges um relate to like food consumption and sleeping and insulin administration and things like that, and then what do you do about it? Um, and so kind of taking that because the CGM provides so much data in 1000 different charts that you can look at and so like how do you distill it down to like what do you need to do for a patient. Um, in terms of nutrition, cause, you know, once you figured out your monitoring, um, the next question is what do you do in terms of nutrition, um, You know, generally speaking, the, the tenets of how to handle the nutrition is that there should be 3 meals and 3 snacks a day, that the carb portion should not be restricted per se, but they should just be like. Kept in mind. Um, this is general kind of carb intake recommendations um throughout the day, um, definitely promote eating fiber. Um, this is a big one. Avoid fasting for more than 8 to 10 hours because once you do that, your body goes into somewhat starvation mode and it'll actually jack your sugars up. Um, you know, try to avoid kind of Lots of fruit, lots of dairy, um, try to avoid added sugars, that kind of stuff. So it's not carb restriction per se, although for the average American diet, it probably would feel like that. I know it felt like that when I was like, what do you mean I can't have a latte in the morning, um. There's a lot of carbs and lattes. Um, so, but the main things in terms of like counting patients is like you have to have adequate glucose intake, like severe carb restriction is not. Like safe or healthy. Um, you have to keep in mind the distribution and the type of intake. So patients specifically uh with gestational diabetes tend to have more glucose intolerance in the morning, um, and then also consistent intake, don't go long periods of fasting. So once you've kind of given the general kind of um discussion about diet, the question is at what point is medication oriented. Generally speaking, if you have greater than 30 to 50% elevation despite dietary modifications, that's when you should consider medications. Delaying medication for more than 1 to 2 weeks is not likely to be beneficial. I know I've gotten into that place where the patients like one more week to try this one more week and you're like, OK, at some point. We got to move on to the next thing. Um And then you kind of decide on insulin regimen. I'll kind of go, I won't go into great detail with this because it sounds like that's maybe more detail than was needed, but I do want to talk a little bit about some of the oral agents because I think when you're Talking to a patient about insulin, they're kind of like, oh, sometimes, um. So the typically used oral agent is metformin. Um, it suppresses gluconiogenesis, it increases insulin sensitivity, it does cross the placenta, um. You know, the dose is 500 to 1000 mg Q day to BID. You know, historically insulin is thought to be the first line kind of agent, and metformin was like, if you have to, um, and so I wanted to just present a little bit as to like why that is, um, there was this randomized control trial back. I forget when it was, um, I think it was many, like many years ago, um, and it included 751 participants which were randomized either to metformin or insulin, and they basically found there was no difference in outcomes, um, except for about 50% of the participants in the Metformin group ultimately needed insulin as well. There's been, like, many, many smaller trials, randomized control trials, meta-analysis, and basically the thought is that metformin has very similar obstetric outcomes with no identified short term um adverse effects, but there are unknown long-term effects, and I think that is the reason that insulin is typically promoted as first line for two reasons. Number one is many of the people that start on metformin probably are ultimately going to need insulin anyway. And number 2, it crosses the placenta. And so while we don't have any reason to think it's a problem, longer term data is a little bit lacking. And so if you have a, my, my personal approach is, if I have a patient, I say, hey, listen, I would like to put you on insulin because I can titrate it better. But if I have a patient who didn't get their screening until 35 weeks, and it's gonna take 3 weeks to get in to see someone who can manage the insulin or what have you, Metformin is not a terrible idea. Um, this, uh, kind of the same stuff here like another RCT randomized metformin or insulin. Metformin has some benefits maybe, but, you know, not, not a slam dunk, um, benefit. Um, I'll skip this cause it's kind of the same thing, and I know we're short on time. So the one thing I will bring up is there's this question of long term effects of metformin and so when I'm talking to patients about metformin, um, the question is, well, is metformin bad for my baby? Um, you know, the, even the long term follow up data is like 9 years of follow-up, 10 years, so it's not necessarily up until the baby becomes an adult, but there's some follow-up study that suggests there might be an increased BMI among offspring who were exposed to metformin. But, um, again, it's like short follow up, obviously it's more multifactorial, so it's a little bit kind of hand wavy in terms of how strongly that um that relationship exists. Um, there's also, there was a prior concern of whether or not Metformin would impact the neurodevelopment of the offspring, and that has, um, there's no real convincing data um that that's the case. And so right now ACOG essentially says like, Do, uh, insulin as first line therapy. However, like in patients who decline insulin therapy, um, insulin therapy, like you could consider metformin, but recognize the limitations in the follow-up data. Um, I will kind of go through this very quickly, but there's a lot, basically with insulin, there's basal options which are longer acting, bolus options which are shorter acting. Um, this is just a thing to show kind of how, um, Kind of the timeline to peak effective insulins, um, The type of insulin I bring up as important. And I'm happy to send these slides and go through it more, but basically like NPH because it's intermediate acting will affect the meal that's like very much closer to when you administer the insulin, and then the lispro affects the meals as you give it, versus Lantus or glargine, that's much longer acting and so it is much more of a kind of a gentle um. A gentle kind of effect throughout the day. Um, this, if you ever are in a pinch and you just need to calculate something while you're waiting for someone to get in with a provider, there's a couple of kind of quick calculations. I like this one a lot. It's just 0.165 times the kilograms, and you can do it as MPH or Lantus, um, and it's just like it's, you're not likely to run someone into hypoglycemia. It tends to be lower than the weight the weight-based dose and so it's kind of a nice. Quick on the fly calculation. Um, the other way to do it is the weight-based dose where you basically take your kilograms, you multiply it by your, um correction factor for your um trimester. And then you split it into half basil, half bolus, and then do half and half for your basil, and then mealtime for your bolus. Um, usually if I'm like getting a curbside, it says, hey, I need a quick calculation, um, I'll just do kind of both of those calculations and then probably settle out with something in the middle. Um, in terms of some insulin practical tips, I would say that if you ever are getting to a point where you need more than 40 units required at one time, probably better to use multiple injection sites because there's better absorption and better response. If a meal is missed, you need to skip the bowl of insulin as well. So if someone's like, I never eat lunch, don't give them lunchtime, let's bro. Um, the other thing that I bring up, and this comes up a lot, um, with my patients at Highland, is I have a lot of um food insecurity in that patient population, and so historically there's been a lot of like, oh we should put them on NPH, which is fine, but if you use NPH you have to eat lunch 4 to 6 hours after the morning dose because that the way that NPH works is that it takes effect midday. So if someone's on NPH and then they're not gonna eat lunch because they don't have food security, um, then they're gonna bottom out. And so the other thing with NPH is that it's actually a mix of a shorter and a long acting and so like with the pens, you can, if they aren't like mixing appropriately, you can get some in um consistent administration and so. I trained in a place that was like Team NPH and then I came up to UCSF and they were Team Latis and I will say that over the last several years I've sort of moved over to Team Lantus or Garin because of the patients I take care of um. Frozen insulin does not work, and then, um, you know, the other thing that that I think is easy to forget about is like alternate eating schedules, Ramadan, night shift workers, like someone will come and say my fasting is this, and then it's like, well, it's they're calling it their fasting cause we've told them that 6 a.m. is fasting, but they ate breakfast at 4 a.m. or whatever. And so just being mindful of that. Um, this, um, this article isn't the same. I feel like, I feel like I'm promoting this journal article, but, um, so this is really nice. This basically is like if you're ever in a pinch and you have a patient that's like, oh, I have, sorry, just time check, it's 1:15. Yeah, totally. I don't think I have that much more left actually, um. So this is like if you're ever in a pinch and you have a patient who's like maybe already on insulin and they don't have their next follow up and they're like, I don't know why my blood sugar is so high all of a sudden, it's just a couple of things to kind of check in about, um, and kind of some suggested solutions. So again, I'm happy to send this out, um, but it's like, it's nice to kind of, it's almost like a troubleshooting. Uh, table. So my personal practice having gone from team NPH to teamlantis is basically like when in doubt, I honestly err on the side of Lantus and Lispro, um, only because, especially for the Highland patients like it's less dependent on Kind of the precise time of eating. Um, the only exception is that if someone has just elevated blood glucosis, then I feel like the nighttime NPH is helpful, but even in those cases, nighttime glargine is fine. I've been, I have yet to You know, bottom someone out that way, knock on wood. Um, so in summary, gestational diabetes has significant pregnancy implications. Um, there's some data that suggests the two-step diagnosis would be preferred to one step. Um, of course, nutrition and diet changes are first line interventions. Probably the CGM does not improve outcomes in GDM based on available data, but I think that's a definite area where we may find that have a different answer to years. If medical therapy is warranted, insulin is considered first line, but Um, is probably not inferior and probably doesn't cause any issues.
