Gestational diabetes medical therapy: Difference between revisions
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==Medical Therapy== | ==Medical Therapy== | ||
Insulin is the first-line agent recommended for treatment of GDM in the U.S. <br> | Insulin is the first-line agent recommended for treatment of GDM in the U.S. <br> | ||
Individual randomized controlled trials support the efficacy and short-term safety of metformin (pregnancy category B) and glyburide (pregnancy category B) for the treatment of GDM. However, both agents cross the placenta, and long term safety data are not available for either agent.<ref name="pmid18463376">{{cite journal |vauthors=Rowan JA, Hague WM, Gao W, Battin MR, Moore MP |title=Metformin versus insulin for the treatment of gestational diabetes |journal=N. Engl. J. Med. |volume=358 |issue=19 |pages=2003–15 |year=2008 |pmid=18463376 |doi=10.1056/NEJMoa0707193 |url=}}</ref><ref name="pmid23724063">{{cite journal |vauthors=Gui J, Liu Q, Feng L |title=Metformin vs insulin in the management of gestational diabetes: a meta-analysis |journal=PLoS ONE |volume=8 |issue=5 |pages=e64585 |year=2013 |pmid=23724063 |pmc=3664585 |doi=10.1371/journal.pone.0064585 |url=}}</ref><ref name="pmid11036118">{{cite journal |vauthors=Langer O, Conway DL, Berkus MD, Xenakis EM, Gonzales O |title=A comparison of glyburide and insulin in women with gestational diabetes mellitus |journal=N. Engl. J. Med. |volume=343 |issue=16 |pages=1134–8 |year=2000 |pmid=11036118 |doi=10.1056/NEJM200010193431601 |url=}}</ref> | Individual randomized controlled trials support the efficacy and short-term safety of metformin (pregnancy category B) and glyburide (pregnancy category B) for the treatment of GDM. However, both agents cross the placenta, and long term safety data are not available for either agent.<ref name="pmid18463376">{{cite journal |vauthors=Rowan JA, Hague WM, Gao W, Battin MR, Moore MP |title=Metformin versus insulin for the treatment of gestational diabetes |journal=N. Engl. J. Med. |volume=358 |issue=19 |pages=2003–15 |year=2008 |pmid=18463376 |doi=10.1056/NEJMoa0707193 |url=}}</ref><ref name="pmid23724063">{{cite journal |vauthors=Gui J, Liu Q, Feng L |title=Metformin vs insulin in the management of gestational diabetes: a meta-analysis |journal=PLoS ONE |volume=8 |issue=5 |pages=e64585 |year=2013 |pmid=23724063 |pmc=3664585 |doi=10.1371/journal.pone.0064585 |url=}}</ref><ref name="pmid11036118">{{cite journal |vauthors=Langer O, Conway DL, Berkus MD, Xenakis EM, Gonzales O |title=A comparison of glyburide and insulin in women with gestational diabetes mellitus |journal=N. Engl. J. Med. |volume=343 |issue=16 |pages=1134–8 |year=2000 |pmid=11036118 |doi=10.1056/NEJM200010193431601 |url=}}</ref><ref name="pmid17596473">{{cite journal |vauthors=Coustan DR |title=Pharmacological management of gestational diabetes: an overview |journal=Diabetes Care |volume=30 Suppl 2 |issue= |pages=S206–8 |year=2007 |pmid=17596473 |doi=10.2337/dc07-s217 |url=}}</ref> | ||
===Insulin Therapy=== | ===Insulin Therapy=== | ||
Revision as of 21:07, 5 December 2016
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]
Overview
Medical Therapy
Insulin is the first-line agent recommended for treatment of GDM in the U.S.
Individual randomized controlled trials support the efficacy and short-term safety of metformin (pregnancy category B) and glyburide (pregnancy category B) for the treatment of GDM. However, both agents cross the placenta, and long term safety data are not available for either agent.[1][2][3][4]
Insulin Therapy
Insulin therapy in patients with GDM is based on pre-pregnancy BMI. Women who are lean before conception, the insulin dose requirement is 0.8U/Kg and for the obese women it is 0.9-1U/kg. There is insufficient evidence available regarding the safety of the insulin analogues, Aspart and Lispro hence regular human insulin is the treatment of choice and can be combined with intermediate or basal insulin such as NPH/ lente/ ultralente. There isn’t enough data regarding the safety of the long acting insulin glargine in pregnancy.
Oral Hypoglycemics
The use of oral medications is considered when diet and exercise do not adequately control blood sugars. Some studies have recently evaluated the safety and efficacy of Glyburide (sulphonylurea) after the first trimester for treatment of GDM. The older sulphonylureas were not recommended for use in pregnancy because they crossed the placenta. Glyburide only minimally crosses the placenta. It has been shown that it is as effective as insulin, more cost effective than insulin and safe for use in pregnancy. Both American Diabetic Association [ADA] and American college of Obstetricians and Gynecologists [ACOG] await more research related to the effect of glyburide on maternal and perinatal outcomes before approving its use. There is inadequate data in regards to the safety and efficacy of other oral antidiabetic medications such as Metformin, thiazolidinediones and Acarbose.
Postnatal Care
Approximately 50% women will develop type 2 diabetes within 5 years of development of gestational diabetes. The greatest risk factor for early-onset type 2 diabetes after pregnancy was early gestational age at the time of diagnosis and elevated fasting glucose. The greatest long term risk factor was maternal obesity. Hence these women should be screened by a 75 gm 2 hour oral glucose tolerance test. The children of women diagnosed with GDM are at increased risk of obesity and abnormal glucose metabolism during childhood, adolescence and adulthood. One of the mechanisms thought to be contributing to the long term complications in these babies is ‘early onset hyperinsulinimia’. Hence these children need close follow up.
References
- ↑ Rowan JA, Hague WM, Gao W, Battin MR, Moore MP (2008). "Metformin versus insulin for the treatment of gestational diabetes". N. Engl. J. Med. 358 (19): 2003–15. doi:10.1056/NEJMoa0707193. PMID 18463376.
- ↑ Gui J, Liu Q, Feng L (2013). "Metformin vs insulin in the management of gestational diabetes: a meta-analysis". PLoS ONE. 8 (5): e64585. doi:10.1371/journal.pone.0064585. PMC 3664585. PMID 23724063.
- ↑ Langer O, Conway DL, Berkus MD, Xenakis EM, Gonzales O (2000). "A comparison of glyburide and insulin in women with gestational diabetes mellitus". N. Engl. J. Med. 343 (16): 1134–8. doi:10.1056/NEJM200010193431601. PMID 11036118.
- ↑ Coustan DR (2007). "Pharmacological management of gestational diabetes: an overview". Diabetes Care. 30 Suppl 2: S206–8. doi:10.2337/dc07-s217. PMID 17596473.