Gestational diabetes medical therapy
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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
Sulfonylureas
Recent studies showed that sulfonylureas, such as glyburide, may be inferior to insulin and metformin due to increased risk of neonatal hypoglycemia and macrosomia with this class.[5]
Metformin
It is associated with a lower risk of hypoglycemia and potential lower weight gain, may be preferable to insulin for maternal health if it suffices to control hyperglycemia however, metformin may slightly increase the risk of prematurity.[5][6][7]
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.
- ↑ 5.0 5.1 Balsells M, García-Patterson A, Solà I, Roqué M, Gich I, Corcoy R (2015). "Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis". BMJ. 350: h102. PMC 4301599. PMID 25609400.
- ↑ Jiang YF, Chen XY, Ding T, Wang XF, Zhu ZN, Su SW (2015). "Comparative efficacy and safety of OADs in management of GDM: network meta-analysis of randomized controlled trials". J. Clin. Endocrinol. Metab. 100 (5): 2071–80. doi:10.1210/jc.2014-4403. PMID 25803270.
- ↑ Camelo Castillo W, Boggess K, Stürmer T, Brookhart MA, Benjamin DK, Jonsson Funk M (2015). "Association of Adverse Pregnancy Outcomes With Glyburide vs Insulin in Women With Gestational Diabetes". JAMA Pediatr. 169 (5): 452–8. doi:10.1001/jamapediatrics.2015.74. PMID 25822253.