Gestational diabetes medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
If lifestyle management and dietary changes fail to control the hyperglycemia, the next step is to initiate pharmacotherapy. Insulin is the drug of choice for the treatment of GDM. Some randomized clinical trials show metformin has an equal efficacy when compared to insulin, but there is lack of adequate evidence for the long term use of Metformin and its safety in pregnancy. | |||
==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 the 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) | Individual randomized controlled trials support the efficacy and short-term safety of [[metformin]] (pregnancy category B) and [[glyburide]] (pregnancy category B) in 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=== | ||
Insulin therapy in patients with GDM is based on pre-pregnancy BMI. | All exogenous [[Insulin|insulins]] are [[Pregnancy category|pregnancy category B]] except for [[Insulin Glargine|glargine]], [[Insulin Glulisine|glulisine]] and [[Insulin degludec|degludec]] which are labeled [[Pregnancy category|category C]]. Insulin therapy in patients with GDM is based on the pre-pregnancy BMI. | ||
** In the first trimester, the insulin requirement is approximately 0.7 units per kilogram body weight. | |||
** By the second trimester, the insulin requirement is 0.8 units per kilogram body weight. | |||
** By term, the insulin requirement is 0.9 -1.0 unit per kilogram body weight per day.<ref name="pmid7032287">{{cite journal |vauthors=Jovanovic L, Druzin M, Peterson CM |title=Effect of euglycemia on the outcome of pregnancy in insulin-dependent diabetic women as compared with normal control subjects |journal=Am. J. Med. |volume=71 |issue=6 |pages=921–7 |year=1981 |pmid=7032287 |doi= |url=}}</ref> | |||
===Oral Hypoglycemics=== | ===Oral Hypoglycemics=== | ||
====[[Sulfonylurea|Sulfonylureas]]==== | |||
Recent studies showed that sulfonylureas, such as [[glyburide]], may be inferior to insulin and [[metformin]] due to the increased risk of neonatal hypoglycemia and [[macrosomia]] with this class of drug.<ref name="pmid25609400">{{cite journal |vauthors=Balsells M, García-Patterson A, Solà I, Roqué M, Gich I, Corcoy R |title=Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis |journal=BMJ |volume=350 |issue= |pages=h102 |year=2015 |pmid=25609400 |pmc=4301599 |doi= |url=}}</ref> | |||
====Metformin==== | |||
It is associated with a lower risk of hypoglycemia and potential lower weight gain, and it may be preferable to insulin if it adequately controls hyperglycemia. However, [[metformin]] may slightly increase the risk of [[prematurity]].<ref name="pmid25609400">{{cite journal |vauthors=Balsells M, García-Patterson A, Solà I, Roqué M, Gich I, Corcoy R |title=Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis |journal=BMJ |volume=350 |issue= |pages=h102 |year=2015 |pmid=25609400 |pmc=4301599 |doi= |url=}}</ref><ref name="pmid25803270">{{cite journal |vauthors=Jiang YF, Chen XY, Ding T, Wang XF, Zhu ZN, Su SW |title=Comparative efficacy and safety of OADs in management of GDM: network meta-analysis of randomized controlled trials |journal=J. Clin. Endocrinol. Metab. |volume=100 |issue=5 |pages=2071–80 |year=2015 |pmid=25803270 |doi=10.1210/jc.2014-4403 |url=}}</ref><ref name="pmid25822253">{{cite journal |vauthors=Camelo Castillo W, Boggess K, Stürmer T, Brookhart MA, Benjamin DK, Jonsson Funk M |title=Association of Adverse Pregnancy Outcomes With Glyburide vs Insulin in Women With Gestational Diabetes |journal=JAMA Pediatr |volume=169 |issue=5 |pages=452–8 |year=2015 |pmid=25822253 |doi=10.1001/jamapediatrics.2015.74 |url=}}</ref> | |||
===Postnatal Care=== | ===Postnatal Care=== | ||
Approximately 50% women will develop type 2 diabetes within 5 years | Approximately 50% of women with gestational diabetes will develop type 2 diabetes within 5 years. The greatest risk factor for early-onset type 2 diabetes after a pregnancy complicated by GDM, is early gestational age at the time of diagnosis of GDM and elevated fasting glucose. The greatest long term risk factor was maternal obesity. Hence, postnatal care should entail follow-up screening of women who had GDM, with a 75 gm 2 hour oral glucose tolerance test. The children of women diagnosed with GDM are also at increased risk of obesity and abnormal glucose metabolism during childhood, adolescence and adulthood. One of the mechanisms thought to contribute to the long term complications in these babies is ‘early onset [[hyperinsulinemia]]’. Hence these children need close follow up. | ||
==References== | ==References== | ||
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{{WH}} | {{WH}} | ||
{{WS}} | {{WS}} | ||
[[Category:Obstetrics]] | [[Category:Obstetrics]] | ||
[[Category:Endocrinology]] | [[Category:Endocrinology]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
Latest revision as of 21:51, 29 July 2020
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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
If lifestyle management and dietary changes fail to control the hyperglycemia, the next step is to initiate pharmacotherapy. Insulin is the drug of choice for the treatment of GDM. Some randomized clinical trials show metformin has an equal efficacy when compared to insulin, but there is lack of adequate evidence for the long term use of Metformin and its safety in pregnancy.
Medical Therapy
Insulin is the first-line agent recommended for the 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) in 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
All exogenous insulins are pregnancy category B except for glargine, glulisine and degludec which are labeled category C. Insulin therapy in patients with GDM is based on the pre-pregnancy BMI.
- In the first trimester, the insulin requirement is approximately 0.7 units per kilogram body weight.
- By the second trimester, the insulin requirement is 0.8 units per kilogram body weight.
- By term, the insulin requirement is 0.9 -1.0 unit per kilogram body weight per day.[5]
Oral Hypoglycemics
Sulfonylureas
Recent studies showed that sulfonylureas, such as glyburide, may be inferior to insulin and metformin due to the increased risk of neonatal hypoglycemia and macrosomia with this class of drug.[6]
Metformin
It is associated with a lower risk of hypoglycemia and potential lower weight gain, and it may be preferable to insulin if it adequately controls hyperglycemia. However, metformin may slightly increase the risk of prematurity.[6][7][8]
Postnatal Care
Approximately 50% of women with gestational diabetes will develop type 2 diabetes within 5 years. The greatest risk factor for early-onset type 2 diabetes after a pregnancy complicated by GDM, is early gestational age at the time of diagnosis of GDM and elevated fasting glucose. The greatest long term risk factor was maternal obesity. Hence, postnatal care should entail follow-up screening of women who had GDM, with a 75 gm 2 hour oral glucose tolerance test. The children of women diagnosed with GDM are also at increased risk of obesity and abnormal glucose metabolism during childhood, adolescence and adulthood. One of the mechanisms thought to contribute to the long term complications in these babies is ‘early onset hyperinsulinemia’. 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.
- ↑ Jovanovic L, Druzin M, Peterson CM (1981). "Effect of euglycemia on the outcome of pregnancy in insulin-dependent diabetic women as compared with normal control subjects". Am. J. Med. 71 (6): 921–7. PMID 7032287.
- ↑ 6.0 6.1 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.