A provider toolkit with clinically relevant resources related to diagnosis and management of central precocious puberty.

CPP Provider Toolkit

A pair of experts in the management of diabetes review the role of insulin therapy and review the approval process for biosimilars, including the FDA's approval of the first interchangeable insulin biosimilar.

Interchangeable Insulin Biosimilars: A Game Changer in Diabetes Management

Podcast hosted by Diana Isaacs, PharmD, and Natalie Bellini, DNP aimed at providing real-world perspective on the latest advances in diabetes management.

Full data from the 13-week trial of the iLet insulin-only bionic pancreas details the improvements in glycemic control achieved with use of the bionic pancreas in adults and children with 

 aged from as young as 6 years old and up to 79 years of age.

With funding from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), results of the 13-week, randomized trial suggest use of BetaBionic’s iLet bionic pancreas was associated with greater reductions in HbA1c than standard care, with those using a bionic pancreas experience a greater percentage of time in range as well.

“Keeping tight control over blood glucose is important in managing diabetes and is the best way to prevent complications like eye, nerve, kidney, and cardiovascular disease down the road," said Guillermo Arreaza-Rubín, MD director of NIDDK’s diabetes technology program, in a statement. “The bionic pancreas technology introduces a new level of ease to the day-to-day management of type 1 diabetes, which may contribute to improved quality of life.”

Since initial data demonstrated feasibility of the system, the prospect of the iLet bionic pancreas has been looked upon by many as the next great advance in diabetes technology. The current trial was conducted with an interest in exploring the technology against usual care for improving glycemic control among patients with type 1 diabetes.

A 13-week, multicenter, parallel-group, unblinded, randomized trial, the trial people aged 6-79 years of age with type 1 diabetes to receive the bionic pancreas with insulin aspart or insulin lispro or to standard care, which was defined as any insulin-delivery method with unblinded, real-time continuous glucose monitoring. Conducted at 16 centers in the US, the trial had a primary outcome of interest of HbA1c at 13 weeks and a secondary outcome of interest of percentage of time in a target glucose range below 54 mg/dL.

A total of 326 individuals were identified for inclusion in the trial between January 4, 2021, and July 7, 2021, with 219 randomized to the bionic pancreas group and 107 randomized to standard care. This cohort had an observed range of HbA1c from 5.5-13.1% at baseline.

Upon analysis, results indicated the mean HbA1c decreased from 7.9% at baseline to 7.2% at week 13 in the bionic pancreas group and did not change in the standard-care group, which remained at 7.7% at both time points (adjusted between-group difference: -0.5 percentage points [95% CI, -0.6 to -0.3]; 

 <.001 for noninferiority). When assessing the secondary outcome of interest, results indicated the percentage of time in target glucose range below 54 mg/dL did not differ significantly between either group (adjusted difference, 0.0 percentage points [95% CI, −0.1 to 0.04]; 

In safety analyses, results indicated the rate of severe hypoglycemia was 17.7 events per 100 participant-years in the bionic pancreas group compared to 10.8 events per 100 participant-years (

=.39). Investigators highlighted there were also no episodes of diabetic ketoacidosis occurred in either arm of the trial.

“Our observation that this system can safely improve glucose control to the degree we found, and do so despite requiring much less input from users and their health care providers, has important implications for children and adults living with diabetes,” said Steven Russell, MD, study chair and associate professor of medicine at Harvard Medical School, in the aforementioned statement.

Multicenter, Randomized Trial of a Bionic Pancreas in Type 1 Diabetes

Articles

In data published in the New England Journal of Medicine, the iLet Bionic Pancreas was associated with improved glycemic control and time in target glucose range compared to standard care in a cohort of people with type 1 diabetes aged 6-79 years of age.

iLet Bionic Pancreas Improves Glycemic Control, Time in Target Range in Type 1 Diabetes

Natalie Bellini, DNP, FNP-BC, is a nurse practitioner specializing in diabetes management with the R&B Medical Group based out of Niagara Falls, NY. 

Diabetes technology represents a new realm of disease management that, for many, also represents a challenge. Whether it be people naive to the new technology or other members of the care team who are unfamiliar with optimal implementation strategies, optimizing diabetes technology, which has been shown to improve outcomes, can be viewed as a hurdle for many with diabetes.

In this regularly scheduled September 2022 episode of 

Diabetes Dialogue: Therapeutics, Technology, & Real-World Perspectives

, hosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, provide their own perspective on DIY looping based on the results of a recent study published in the 

 and also break down a new set of consensus recommendations for the use of automated insulin delivery (AID) systems in clinical practice published in 

which Isaacs helped compose as a member of the writing committee.

Diabetes Dialogue: Therapeutics, Technology, and Real-World Perspectives

 is available in an audio-only format on 

In this regularly scheduled September 2022 episode of Diabetes Dialogue: Therapeutics, Technology, & Real-World Perspectives, hosts Diana Isaacs, PharmD, and Natalie Bellini, DNP, provide their own perspective on DIY looping based on the results of a recent study published in the New England Journal of Medicine and also break down a new set of consensus recommendations for the use of automated insulin delivery (AID) systems in clinical practice published in Endocrine Reviews, which Isaacs helped compose as a member of the writing committee.

Diabetes Dialogue: September 2022

The American Academy of Clinical Endocrinology (AACE) has released a new clinical practice guideline for the 

Announced on September 27, the new guideline, which represents the organization’s first update to the guideline recommendations for diabetes management since 2015, includes 170 updated and new evidence-based recommendations aimed at optimal management of diabetes at every stage, including prevention, diagnosis, and treatment.

“The updated diabetes guideline—created by clinicians, for clinicians—can be used by the multi-disciplinary care teams that are involved in the care and management of diabetes,” said S. Sethu K. Reddy, MD, MBA, FRCPC, FACP, MACE, president of AACE and an author of the guideline, in 

. “The guideline is framed to support person-centered, team-based clinical decision-making, which importantly puts the patient at the center to improve care for people with prediabetes and diabetes.”

At pages in length and citing more than reference documents, the AACE’s updated guideline for management of diabetes was composed by Reddy and a team of more than 2 dozen leading experts in endocrinology and cardiometabolic health, including co-chairs Lawrence Blonde, MD, and Guillermo Umpierrez, MD. A reflection of the changing landscape of diabetes management, the guideline includes evidence-based recommendations on multiple new topics related to diabetes management, including COVID-19 vaccination, telehealth, infertility, secondary diabetes, nutritional supplements, and social determinants of health.

Leveraging data from the literature searches used to back recommendations in the 2015 guidelines on diabetes management and data from a more recent literature search, the new guideline’s recommendations were divided in 4 distinct sections:

Screening, diagnosis, glycemic targets, and glycemic monitoring

Management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy

Specific portions of the new guideline highlighted with the AACE’s aforementioned statement included information on the latest cardiovascular outcomes trial, perspective on FDA-approved weight loss medications and trends in management of obesity, and recommendations for management of comorbidites, including obesity, dyslipidemia, chronic kidney disease, and more. Additionally, throughout the guideline is an emphasis on the importance of a team-based approach for clinical decision-making in the management of diabetes, with the person with diabetes at the center of this team.

The AACE also pointed out the guideline will be discussed during in-person sessions at the organization's Cardiometabolic Conference, which is slated to occur from September 30-October 2, 2022 in San Antonio, TX.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan—2022 Update,

Announced on September 27, the latest guideline recommendations on diabetes management from the American Academy of Clinical Endocrinology represent their first update on the topic since 2015 and contains 170 new or updated evidence-based recommendations. 

AACE Releases New 2022 Diabetes Management Guidelines

A patient in their mid-70s with a history of obesity, hypertension, osteoporosis, and prior ankle surgery presents to the urgent care with right lateral foot pain ongoing for about 10 days. She denies any injury, fever, redness, or other complaints. Pain does not involve her ankle and is minimal at rest but moderate to severe with walking.

Vital signs are normal. A physical exam is also normal except for tenderness to the 5th metatarsal base. There is no appreciable swelling or warmth and pulses are symmetric.

Our latest endocrine case report from Brady Pregerson, MD, features a person in their mid-70s with a history of obesity, hypertension, osteoporosis, and prior ankle surgery presenting to urgent care with right lateral foot pain ongoing for about 10 days. Can you determine the correct diagnosis?

Endocrine Case Report: Foot Pain

Our endocrinology month in review spotlights the most popular content from the past month. Our top content from September 2022 includes new guideline recommendations from the ADA/EASD, new data on semaglutide 2.4 mg and tirzepatide, a label update for finerenone, & more!

1. American Diabetes Association, EASD Update Recommendations on Hyperglycemia Management in Type 2 Diabetes

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) have announced the release of a new consensus update on the management of hyperglycemia in type 2 diabetes.

Released on September 23, the 42-page document has a target audience described as the “full spectrum of professional healthcare team providing diabetes care” and provides updates to recommendations made in previous consensus reports from the organizations released in 2018 and 2019.

2. Studies Debate Link Between COVID-19 and Increased Type 1 Diabetes Diagnoses

A pair of studies released within days of one another have produced conflicting reports related to the apparent increase in type 1 diabetes diagnoses following a COVID-19 infection in younger patients.

Although one of the studies suggests a COVID-19 infection was associated with up to a 72% increase in new diagnoses of type 1 diabetes, the second, which was presented at the European Association for the Study of Diabetes 2022 annual meeting, purports that while overall rates of diagnoses may be elevated, COVID-19 may not be the cause of increased prevalence.

3. Real-World Data Backs 2.4 mg Semaglutide (Wegovy) for Weight Management in Obesity

A retrospective analysis of EMR data from Mayo Clinic referral centers provides an overview of the effects of 2.4 mg semaglutide on weight loss in populations outside of clinical trial settings.

With data from more than 150 patients treated at a referral center for weight management prescribed semaglutide for 3 months or more between January 1, 2021-March 15, 2022, results of the study suggest the mean weight loss achieved at 3 months was 5.9% of body weight, with this improving to 10.9% at 6 months and further analysis indicating more than 50% of semaglutide users achieving weight loss of 10% or more at 6 months.

4. Declining Mental Health During COVID-19 Pandemic Linked to Worsening Obesity

In his most recent column, Gregory Weiss, MD, provides perspective on new research from a team at University of Texas Southwestern describes the impact of the COVID-19 pandemic on mental health and subsequent increases in body weight among people with obesity.

5. High HbA1c Linked to Increased Risk of Trigger Finger in Both Type 1 & Type 2 Diabetes

New research from an analysis of a national diabetes register in Europe suggests inadequate glycemic control was linked to an increased risk of developing stenosing tenosynovitis, more commonly known as trigger finger, for people with either type 1 or type 2 diabetes.

An analysis of data from more than 95,000 individuals with diabetes from the Swedish National Diabetes Register, results of the study suggest elevated HbA1c levels were associated with an increase in risk of trigger finger of 26% or more in type 1 diabetes and 12% or more in type 2 diabetes in analyses adjusting for sex, age, duration of diabetes, and other clinical factors.

6. Tirzepatide Cuts Time to Glycemic Targets by 4-12 Weeks vs Other Diabetes Therapies

A new analysis of data from the SURPASS program suggests use of tirzepatide (Mounjaro) could help people with diabetes reach glycemic targets in a fraction of the time as other medications.

Results of the analysis, which were presented at the European Association for the Study of Diabetes (EASD) Annual Meeting, indicate a weekly injection of tirzepatide helped adults with type 2 diabetes reach glycemic targets 4-12 weeks sooner than those receiving semaglutide 1 mg and long-acting insulin degludec.

7. FDA Updates Finerenone Label to Reflect Cardiovascular Outcomes Data

On September 1, Bayer announced the US FDA had approved a label update for finerenone (Kerendia), which received initial approval in July 2021 for chronic kidney disease associated with type 2 diabetes, to include cardiovascular outcomes data from the FIGARO-DKD trial.

Endocrine Month in Review: September 2022

A new study from investigators at Queen Mary University of London and King’s College London suggests children and young adults with Down syndrome were 3.6 times more likely to be 

 than their counterparts without Down syndrome.

A retrospective cohort analysis matching children and young adults with Down syndrome in a 1:4 ratio to those without Down syndrome from the UK Clinical Practice Research Datalink, results of the study found that the overall risk of developing diabetes for individuals aged 5-24 years was 3.6 times greater among those with Down syndrome than their counterparts without Down syndrome, with investigators noting the risk among children aged 5-14 years with Down syndrome was 10 times greater than that of their counterparts without Down syndrome.

“This is the largest study ever conducted in Down Syndrome patients to show that they have unique needs with regards to diabetes and obesity, and that screening and intervention- including a healthy diet and physical activity - at younger ages is required compared to the general population,” said study investigator Andre Strydom, MSc, PhD, a professor in intellectual disabilities at King’s College London, 

. “The results will help to inform the work of National Health Service England’s LeDeR programme to reduce inequalities and premature mortality in people with Down Syndrome and learning disabilities.”

Citing a lack of conclusive research into the potential links between genetic factors in Down syndrome and risk of developing diabetes, investigators designed the current study to estimate potential associations with Down syndrome and incidence of diabetes as well as the relationship with obesity across the life span of these individuals compared with control subjects. With this in mind, investigator set out to conduct a matched population-based cohort study using data obtained from the UK Clinical Practice Research Datalink database from 1990-2020. From the database, investigators obtained data related to 9917 people with Down syndrome and 38,266 controls without Down syndrome for inclusion in their analyses.

Upon analysis, results indicated the rate of incident diabetes was greater among people with Down syndrome (iRR, 3.67 [95% CI, 2.43-5.55]; 

 <.0001) and peaked at a younger age (median age at diagnosis: 38 [IQR, 28-49] years vs 53 [IQR, 43-61] years) than among those without Down syndrome. When assessing risk for type 1 diabetes specifically, results indicated incidence rates per 1000 person-years were 0.44 (95% CI, 0.31-0.61) and 0.13 (95% CI, 0.09-0.17) among those with Down syndrome and without Down syndrome, respectively.

When assessing risk for type 2 diabetes, results suggested rates were greater among those with Down syndrome compared to control patients across age groups ranging from 5 years old up to 34 years old. Investigators also pointed out the peak mean BMI was greater and occurred at younger age for patients with Down syndrome (males: 31.2 kg/m2 at age 31 years; females: 32.1 kg/m2 at 43 years) compared to control patients (males 29.5 kg/m2 at 54 years; females 29.2 kg/m2 at 51 years).

“Currently there is a sizeable gap in research into the condition, which affects around 40,000 people in the UK. To help plug this gap in knowledge, we are conducting further research into how genetics affects a person with Down Syndrome’s predisposition to diabetes and obesity, and hope to shed further light on this important medical issue,” said senior investigator Li Chan, PhD, reader in molecular endocrinology and metabolism and a consultant pediatric endocrinologist at Queen Mary University of London, in the aforementioned statement.

Diabetes and Obesity in Down Syndrome Across the Lifespan: A Retrospective Cohort Study Using U.K. Electronic Health Records,

An analysis of data from more than 9900 people with Down syndrome and 38,000 controls provides new insight into the apparent increase in risk of developing diabetes among children and young adults with Down syndrome. 

Study Finds Children, Young Adults with Down Syndrome More Likely to Develop Diabetes

The Endocrine Society has released new guidance related to use of telehealth as part of endocrine care.

Announced on October 4, the new policy perspective, which was published in 

The Journal of Clinical Endocrinology and Metabolism, 

was created as a result of the rapid growth of telehealth during the COVID-19 pandemic and is broken down into 5 specific focus areas to determine appropriateness of telehealth in different settings.

“Clinicians will need to draw upon their own knowledge of each patient and their clinical goals to decide when to incorporate telehealth into their care,” said lead author Varsha G. Vimalananda, MD, MPH, of Veterans Affairs Bedford Healthcare System in Bedford, MA, and Boston University School of Medicine, in a 

. “Telehealth visits can be considered as an option each time we schedule an appointment. Patient preference should be elicited, and decisions guided by weighing the factors we describe in the perspective piece.”

Composed by Vimalananda and a team of 8 colleagues from institutions throughout the US, the 10-page document, which cites 60 references, with the aim of provided a guide for clinicians practicing endocrinology in the use of telehealth for outpatient care. With this in mind, the 9-person panel, which boasts notable experience in multiple aspects of care and telehealth, performed a literature search to identify relevant suites published since 2000 about telehealth in endocrinology.

Based on their review, investigators identified 5 specific domains of telehealth to highlight within their policy perspective. These 5 domains were:

Clinical factors, including whether an in-person physical exam or assessment is needed;

Patient factors, such as geographic distance to the clinic, access to transportation, work and family obligations, and comfort level with technology

The clinician’s physical surroundings and personal circumstances

Availability of infrastructure needed to provide quality telehealth services.

For each of these 5 domains, 2-3 members of the panel leveraged the results of the literature search and their own expert opinions to draft the section examining the effect of the domain’s component factors on the appropriateness of telehealth use within endocrine practice. The writing group noted appropriateness was assessed in the context of the 6 Institute of medicine aims for health quality.

Also included in the document is a figure the authors are hopeful can help guide appropriate use of telehealth visits for endocrine care. Of note, the entire document was reviewed and revised by all members prior to publishing.

Appropriate Use of Telehealth Visits in Endocrinology: Policy Perspective of the Endocrine Society

The Journal of Clinical Endocrinology & Metabolism.

On October 4, the Endocrine Society announced the release of a 10-page policy perspective outlining guidance related to optimal use of telehealth in endocrine care, which was composed by a 9-member panel led by Varsha G. Vimalananda, MD, MPH. 

The Endocrine Society Releases New Guidance for Telehealth Use

The Dexcom G7 Continuous Glucose Monitoring (CGM) System rollout is officially underway with Dexcom announcing its availability in 5 countries in an announcement on October 4.

Now available for people with diabetes aged 2 years and older in the United Kingdom, Ireland, Germany, Austria, and Hong Kong, 

, which was made during a global streaming event, also noted plans for a rollout of the Dexcom G7 CGM system in New Zealand and South Africa in the coming weeks.

“Since Dexcom G6 came to market, we’ve eliminated over 15 billion fingerpricks and helped improve the lives of more than 1.25 million people with diabetes around the world. We’re thrilled to begin the global rollout of Dexcom G7, our next-generation CGM technology, that vastly improves upon what everyone loves about G6,” said Kevin Sayer, chairman, president and CEO of Dexcom.

Billed as the company’s smallest, most-intuitive real-time CGM, the next-generation Dexcom G7 CGM system boasts several notable improvements compared to the previous Dexcom G6 CGM system, including being 60% smaller, a 30-minute sensor warm-up, and a 12-hour grace period to replace finished sensors. In addition to the system’s new features, the company also introduced a redesigned mobile app.

In their announcement, DexCom highlighted the Dexcom G7 CGM system will continue to corporate popular features from the Dexcom G6 CGM system, including delivery of real-time glucose readings sent directly to compatible devices, ability to share glucose data with up to 10 individuals, and not requiring finger sticks, scanning, or calibration. Dexcom also noted plans for a future software release that would allow for the system to send information directly to an Apple Watch.

“Dexcom CGM has become the gold standard of care for diabetes and bringing our technology to more and more people around the world continues to be a top priority,” Sayer added. “With this initial launch behind us, we look forward to introducing G7 in additional markets and bringing this life-changing technology to as many people as we can.”

Q2 2022 earnings call transcript on SeekingAlpha,

 Sayer noted a limited US rollout was targeted for late 2022 with a large commercial launch planned in Q1 of 2023. This delay is because of a change to the G7 software based on feedback from the US Food and Drug Administration.

Dexcom announced their Decom G7 CGM system is now available for people aged 2 years or older in the UK, Ireland, Germany, Austria, and Hong Kong beginning on October 4, with plans for a rollout in New Zealand and South Africa. 

Dexcom Announces Global Launch of Dexcom G7 Glucose Monitoring System

A recent study is providing new insight into the impact of age at diagnosis of 

 on risk of multiple adverse outcomes, including risk of multiple comorbidities and all-cause mortality.

A propensity scored-matched analysis of data recorded within the Health and Retirement Study from 1995-2018, results of the study indicate risk of various outcomes differ among the age groups examined in the study, with those in younger age groups at an elevated risk of cardiovascular disease, stroke, disability, cognitive impairment, and all-cause mortality compared to those diagnosed later in life.

“In this cohort study using 23 years of longitudinal data for adults 50 years and older drawn from a national health interview survey, we provide evidence of the differential association of diabetes with incident distal outcomes across varying ages at diabetes diagnosis while accounting for diabetes duration,” wrote investigators. “Our use of an (matched control) group helped us separate the association of diabetes with these outcomes from the association with increasing age.”

Conducted by a team from Michigan Medicine and NYU Gross School of Medicine, the current study was designed with the intent of providing further insight into the associations of age at diagnosis and duration of diabetes with risk of negative health outcomes among older patients in real-world settings. To do so, investigators leveraged data from the 1995-2018 waves of the Health and Retirement Study, which was a population-based, biennial longitudinal health interview survey of older adults in the US.

Using data from the survey, investigators classified patients into 3 age-at-diagnosis groups, defined as 50-59, 60-69, and 70 years and older. The primary outcomes of interest were association of diabetes with incidence of disease, stroke, disability, cognitive impairment, and all-cause mortality. Investigators noted a propensity score-matched control group of individuals who never developed diabetes were created for each age-at-diagnosis group.

From survey waves occurring from 1995-2018, investigators obtained data from 36,060 adults aged 50 years or older without diabetes at entry. Of these individuals, 7739 developed diabetes during the follow-up and 28,321 did not develop diabetes. This cohort had a mean age of 67.4 (SD, 9.9) years at diagnosis and 55.1% were women. In terms of age at diagnosis distribution, 1866 were diagnosed at 50-59 years, 2834 were diagnosed at 60-69 years, and 3039 were diagnosed at 70 years or older.

Compared to matched controls, those with an age at diagnosis of 50-59 years had significantly greater risk for incident heart disease [HR], 1.66 [95% CI, 1.40-1.96]), stroke (HR, 1.64 [95% CI, 1.30-2.07]), disability (HR, 2.08 [95% CI, 1.59-2.72]), cognitive impairment (HR, 1.30 [95% CI, 1.05-1.61]), and mortality (HR, 1.49 [95% CI, 1.29-1.71]) (

for all <.05), even when accounting for diabetes duration. Further analysis indicated these associations significantly decreased with advancing age at diagnosis, with those diagnosed at 70 years or older only exhibiting a significant association with increased risk of mortality (HR, 1.08 [95% CI, 1.01-1.17]).

“We believe this study provides a framework for future studies that can explore other key variables associated with diabetes-related health outcomes. Metabolic mechanisms, lifestyle and behaviors, social determinants of health, and diabetes management all affect age at diabetes diagnosis and aging with diabetes,” investigators added.

Associations of Age at Diagnosis and Duration of Diabetes With Morbidity and Mortality Among Older Adults

A propensity-scored matched analysis is providing clinicians with new insight into the impact of age at diagnosis on risk of adverse health outcomes among people with diabetes. 

Earlier Age at Diagnosis Increases Risk of Adverse Outcomes in Diabetes

 experienced a lower rate of adverse perinatal outcomes if they achieved glycemic control within the first 8 weeks of diagnosis, according to the results of a new study.

A population-based cohort study of more than 26,000 individuals with gestational diabetes, results indicate those with optimal glucose control and those who improved to optimal control within the first 8 weeks of diagnosis had a lower risk of cesarean delivery, shoulder dystocia, large-for-gestational-age, and neonatal intensive care unit admission than their counterparts with suboptimal control trajectories.

“Glycemic control is a cornerstone of gestational diabetes management, so it’s important to learn in detail about the trajectory of control between diagnosis and delivery,” said lead investigator Yeyi Zhu, PhD, a research scientist with the Kaiser Permanente Division of Research, in

. “This study goes beyond identifying whether a patient has control of their blood sugar and offers insights into the role of timing of glycemic control.”

As the community has developed a greater understanding of glycemic control and outcomes with diabetes mellitus, the impact of suboptimal glycemic control among women with gestational diabetes has become a major research focus. With this in mind, Zhu and a team of colleagues from Kaiser Permanente designed the current research endeavor as a population-based cohort study with the intent of assessing the impact of glycemic control and time to control on risk of perinatal complications.

For their study cohort, investigators used data from women enrolled in a Kaiser Permanente Northern California Regional Perinatal Service Center (RSPC) telehealth program for people with gestational diabetes between January 2007 and December 2017. As part of their participation in an RSPC program, individuals were offered standardized telephone counseling on diet, physical activity, glucose monitoring, and medications to improve glycemic control. Additionally, all participants were asked to closely self-monitor blood glucose levels 4 times per day.

Using the information obtained from the study cohort investigators developed 4 distinct glycemic control trajectories. These were defined as stably optimal glycemic control, rapidly improving to optimal glycemic control, slowly improve to near-optimal glycemic control, and slowly improving to suboptimal glycemic control. Investigators noted optimal glycemic control was defined as meeting targets in at least 80% of study measurements. Rapidly improving to optimal glycemic control trajectory was defined as reaching optimal control by 8 weeks after diagnosis and painting it through the last 2 weeks prior to delivery.

Overall, 26,774 were identified for inclusion. This cohort had a mean age of 32.9 (SD, 5.0) years, 41.8% identified Asian or Pacific Islander, 28.0% identified as Hispanic, 22.6% identified as non-Hispanic White, and 4.0% identified as non-Hispanic Black. Regarding glycemic trajectories for the cohort, 39.3% had stably optimal glycemic control, 34.2% had rapidly improving to optimal trajectory glycemic control, 15.5% had slowly improving to near-optimal glycemic control, and 11.0% had slowly improving to suboptimal glycemic control.

The primary outcomes of interest, which were assessed using multivariable Poisson regression models, were associations of glycemic control trajectories with cesarean delivery, preterm birth, shoulder dystocia, large- and small-for-gestational-age, and neonatal intensive care unit admission and stay of 7 days or longer.

Upon analysis, results pointed to a gradient of increasing risk for most outcomes across the trajectories. Compared to those in the rapidly improving to optimal glycemic control group, those in the stably optimal group had lower risks of cesarean delivery (adjusted relative risk [aRR], 0.93 [95% CI, 0.89-0.96]), shoulder dystocia (aRR, 0.75 [95% CI, 0.61-0.92]), large-for-gestational age (aRR, 0.74 [95% CI, 0.69-0.80]), and neonatal intensive care unit admission (aRR, 0.90 [95% CI, 0.83-0.97]). An increased risk of cesarean delivery (aRR, 1.18 [95% CI, 1.12-1.24]; 

 for trend <.001), shoulder dystocia (aRR, 1.41 [95% CI, 1.12-1.78]; 

 for trend <.001), large-for-gestational-age (aRR, 1.42 [95% CI, 1.31-1.53]; 

 for trend <.001), and neonatal intensive care unit admission (aRR, 1.33 [95% CI, 1.20-1.47]; 

 for trend <.001) was observed for Those with slowly improving to suboptimal glycemic control trajectory compared to those with rapidly improving to optimal trajectory. 

Investigators noted an increased risk was observed for risk of small-for-gestational-age among those in the stably optimal group (aRR, 1.10 [95% CI, 1.02-1.20]) while a decreased risk was observed for the slowly improving to suboptimal group (aRR, 0.63 [95% CI, 0.53-0.75]) when compared to their counterparts in the rapidly improving to optimal glycemic control group.

“Managing one’s blood sugars in pregnancy can be difficult, and we give patients personalized care from very knowledgeable, caring staff members,” said study investigator Mara Greenberg, MD, a maternal-fetal medicine specialist with The Permanente Medical Group, in the aforementioned statement. “This study shows great outcomes for the majority of our patients and we’re very proud of that.”

Glycemic Control Trajectories and Risk of Perinatal Complications Among Individuals With Gestational Diabetes,”