Planning Pregnancy With Type 2 Diabetes: Do I Need to Switch From Tablets to Insulin?

The big picture

When you are planning pregnancy, the priority is safe, steady blood sugar control before conception and throughout pregnancy.

High sugars around the time of conception and in early pregnancy raise the risk of miscarriage and birth defects (congenital malformations).

That is why doctors become extra strict about glucose control in this phase.

Do you “have to” switch to insulin?

Often, yes, many women will need insulin at some stage, because:

• It is the most reliable and adjustable way to control sugars in pregnancy.
• It does not cross the placenta in clinically significant amounts, so fetal drug exposure is minimal.
• It fits with almost all international guidelines as first‑line therapy for pre‑existing type 2 diabetes in pregnancy.

But the correct answer is more nuanced:

• Metformin:

  • May be continued or used in some women with type 2 diabetes during pregnancy, especially if it helps control sugars and weight, and the clinician feels benefits outweigh uncertainties.

  • Major guidelines (ADA, NICE) allow metformin in selected women with pre‑existing type 2 diabetes, usually as an add‑on to insulin rather than a complete replacement.
• Most other diabetes tablets (sulfonylureas, SGLT2 inhibitors, GLP‑1 receptor agonists, DPP‑4 inhibitors, thiazolidinediones) are usually stopped when planning pregnancy or as soon as pregnancy is confirmed because:

  • Safety data in early pregnancy are limited, or

  • There are specific concerns (for example, SGLT2 inhibitors and fetal kidney effects, GLP‑1 RAs and animal data).

So this is not “Tablets always wrong.” It is: “Insulin is the main tool metformin is sometimes used; most other tablets are avoided.”

The simplest rule to remember

Do not stop or change medicines on your own.

If tablets are stopped suddenly and sugars rise, that is also unsafe, especially just before or in early pregnancy. 

Your doctor will plan a smooth switch, usually over days to weeks, with home glucose monitoring to keep levels in target.

What typically happens in real life

A common plan looks like this:

Step A: Pre‑pregnancy visit

• Check HbA1c and daily glucose patterns
• Review current medicines, including:

  • Diabetes tablets.

  • Blood pressure drugs (ACE inhibitors/ARBs are usually changed).
  • Cholesterol tablets (statins are usually stopped in pregnancy).
• Start folic acid as advised by your obstetrician.
• Set glucose targets and a home monitoring plan (fasting and post‑meal targets).

Step B: Medication plan

• If sugars are above target, insulin is usually started or intensified to reach safer control before conception.
• Metformin may be continued or added in selected women (for example, those with marked insulin resistance, obesity, or PCOS), based on your doctor’s judgment and local guidelines.
• Other non‑insulin diabetes drugs are usually discontinued and replaced with an insulin‑based plan before or at confirmation of pregnancy.

Step C: Once pregnant

• Monitoring becomes tighter (frequent SMBG or CGM).
• Insulin doses often need regular adjustment because pregnancy hormones increase insulin resistance as gestation progresses.

Why insulin is preferred in pregnancy

• It can be titrated very precisely to match food and activity
• It has the longest and strongest safety record for diabetes in pregnancy (type 1, type 2, and gestational)
• It allows you and your care team to aim for strict pregnancy targets without exposing the baby to multiple oral agents

If metformin is allowed, why not just stay on tablets?

Because pregnancy is a special, high‑stakes situation:

• Even when metformin is used, many women still need insulin to reach tight pregnancy targets (fasting, 1‑hour and 2‑hour post‑meal).
• Metformin does cross the placenta, so the baby is exposed; long‑term follow‑up data are mostly reassuring but still being studied (some studies show slightly higher childhood BMI; others show no major harm).
• The aim in pregnancy is not convenience, but predictable, safe control for mother and baby.

So, in real life, metformin is often:

• Continued or added But.
• Insulin remains the backbone of treatment in most women with type 2 diabetes in pregnancy.

What you should do next

1. Book a preconception appointment with your endocrinologist and obstetrician (or maternal-fetal medicine specialist).
2. Do not stop tablets suddenly without a replacement plan. Let your team transition you safely, often onto an insulin‑based regimen.
3. Ask your doctor directly:

   • “Can metformin be continued in my case?”

   • “Which medicines must I stop before or as soon as I am pregnant?”
   • “What glucose targets do you want me to reach before we start trying?”
4. Start or intensify home glucose monitoring (fasting and 1-2 hours after meals) so adjustments can be made quickly.