The use of double-strength insulin (Humalog U-200) in a pregnant woman with type 1 diabetes on hybrid closed-loop therapy: a case report  — ASN Events
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The use of double-strength insulin (Humalog U-200) in a pregnant woman with type 1 diabetes on hybrid closed-loop therapy: a case report  (#142)

Evangelia Haralabopoulos 1 , Annabelle Lamprecht 1 2
  1. Department of Obstetric Medicine/Endocrinology, Gold Coast University Hospital, Queensland Health, Southport, Queensland, Australia
  2. School of Medicine, Griffith University, Gold Coast Campus, Queensland, Australia

Background
Maintaining optimal glycaemic control in pregnancy in women with type one diabetes is challenging with superimposed progressive insulin resistance. Concentrated insulin formulations may reduce treatment burden in those with high insulin requirements and optimise glycaemic control.

Case
A 32-year-old woman with type 1 diabetes (diagnosed age 13) was managed with a hybrid closed-loop system (Medtronic 780G®) and smartguard prior and during pregnancy. She required additional subcutaneous insulin injections due to rising insulin resistance and subsequently reaching the limit of pump insulin delivery during her pregnancy. She was on metformin modified release 2000mg mane, additional Optisulin 45 units daily and subcutaneous boluses of novorapid. Her total daily dose (TDD) in her insulin pump was 107 units of Novorapid. Her history included hypertension and elevated BMI of 40. In terms of her obstetric history, her previous two pregnancies were complicated by preeclampsia and special care nursery admissions for neonatal hypoglycaemia. 

Prior to switching to double-strength insulin, her glucose management indicator was 7.1%, with mean glucose 8.7 mmol/L, TIRp (Time in Range) (3.9-7.8 mmol/l) 38%, TAR (time above range) 7.9-13.9 mmol/l 17% and >13.9mmol/l 44%. Glycaemic control subsequently worsened in the third trimester despite frequent pump adjustments.

At 32 weeks, insulin was switched to Humalog U-200. Pump settings were adjusted to reflect insulin concentration, including increasing active insulin time to 3 hours. Her CHO was 1.5g; and ISF 1:1 (effectively CHO 1U/0.75g and ISF 0.5). Following this change, mean glucose decreased to 7.8 mmol/L and TIRp increased to 53%. Glycaemic targets were improved thereafter, with TIRp consistently >50% and no significant increase in hypoglycaemia. By late pregnancy, TDD reached 87.1 units.

Delivery by caesarean section resulted in a healthy infant (3.3 kg) without complications and no special care nursery admission. Her basal rate was reduced to 1.0 (equivalent to 48 units of U100 daily), CHO 9g and active insulin time of 3 hours.

Conclusions
Humalog U-200 use in pregnancy may improve glycaemic control in women with type 1 diabetes and high insulin requirements with superimposed insulin resistance, potentially reducing treatment burden and optimising glycaemic control, and prevent special care nursery admission.