Background
It is estimated that 16.2% of live births to women in 2015 had some form of hyperglycaemia in pregnancy. An estimated 85.1% cases were due to gestational diabetes, 7.4% due to other types of diabetes first detected in pregnancy and 7.5% due to diabetes detected prior to pregnancy.1 In India, gestational diabetes mellitus (GDM) has been estimated to affect over 5 million women.
Human insulins have been the choice of treatment in pregnancy. Insulin glargine provides an action which lasts up to 24 h and control the blood glucose levels with minimal fluctuations. However, due to its uncertain safety profile in pregnancy, the use of this drug is limited. Nonetheless, a large number of clinicians do use glargine in pregnant women with diabetes and achieve satisfactory outcomes. 
Aim
To understand the clinicians’ perspective on using insulin glargine in patients with diabetes in pregnancy
Method
A survey questionnaire was prepared and was validated with endocrinologists and diabetologists. The questionnaire was designed to assess percentage of women with GDM and pre-gestational diabetes , usage of glargine, use of different insulin regimens and OADs, preferred site of injection, occurrence of hypoglycaemia, average birth weight of the babies born and neonatal hypoglycaemia.

The survey was administered through interaction in person, telephonic, and through e-mails to clinician who routinely treat pre gestational and gestational diabetes. Responses were collected from 72 clinicians in person, 30 clinicians by telephonically and 13 responses through email. 
Results
Of all the clinicians, 25.86% used glargine in GDM- 34.15% of endocrinologists, 27.03% of diabetologists and 16.21% of consultant physicians are using glargine in pregnancy. Overall 42.24% of clinicians continue insulin glargine in women with pre-gestational diabetes, when they conceive. The median initiation dose of glargine was 10 IU (range of 4 IU to 25 IU). For pre gestational diabetes patients, 53.44% of clinicians continue glargine post-partum. 
The preferred options for changing treatment from glargine based therapy in pre-gestational diabetes were human premixed 30/70(56.90%) followed by human premixed 50/50(26.72%), detemir (24.13%), other insulins and OADs(24.13%).
Amongst basal insulin regimens, basal with three doses of short acting insulins is the most (50%) preferred, followed by basal with two doses of short acting insulins(22.5%), basal plus one dose of short acting insulin(20%) and basal supported oral therapy(17.5%). Preferred short acting insulin for was regular insulin(60%) followed by aspart(32.13%) and lispro(28.85%). 

Metformin was used by 76.72% and glibenclamide by 7.75% of the clinicians in pregnancy.
Thigh(52.59%) was the preferred site of injection followed by abdomen(48.28%), arms(12.93%) and buttocks(1.72%). About 5% of patients who were on glargine experienced hypoglycaemia. Occurrence of neonatal hypoglycaemia and macrosomia due to glargine were negligible.

Table 1
Participants 	GDM (%) 	Pre-gestational diabetes (%) 
Overall 	75(20-98) 	27.5(2-100) 
Consultant physicians 	70(40-90) 	30(10-100) 
Diabetologists 	70(25-90) 	30(10-100) 
Endocrinologists 	80(20-98) 	20(2-80) 
Table 2
Participants 	Opinion on maternal hypoglycaemia (%) 
Overall 	5(1-30) 
Consultant physicians 	8.75(1-30) 
Diabetologists 	5(0.2-20) 
Endocrinologists 	5(1-10) 
Data are presented as median (range).
Discussion
It was evident from survey that a large number of clinicians in India are using glargine routinely to treat GDM and pre gestational diabetes. Use of glargine has not resulted in any troublesome hypoglycaemia or adverse pregnancy outcomes. Some clinicians preferred treating with human insulins and OADs like metformin and glibenclamide.
Glargine has been used safely and effectively in diabetes. Its use in pregnancy is limited as no large scale randomized trials has been done to establish its safety and efficacy.Thus this drug must be used during pregnancy only if the potential benefit justifies the potential risk. Although several case reports have ascertained the safe use of glargine in pregnancy, large prospective studies are necessary to conclusively prove the safety and efficacy. 
References:
1. International Diabetes Federation. IDF Diabetes Atlas. 7th ed. Brussels, Belgium: IDF; 2015.

Use of insulin glargine in pre gestational and gestational diabetes mellitus in India: A cross sectional survey