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__NOTOC__
__NOTOC__
{{Gestational diabetes}}
{{Gestational diabetes}}
{{CMG}}
{{CMG}};{{AE}}{{MehdiP}}
 
==Overview==
==Overview==
Specific treatment will be determined by the physician(s) based on:
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.
* age, overall health, and medical history
==Medical Therapy==
* extent of the disease
Insulin is the first-line agent recommended for the treatment of GDM in the U.S. <br>
* tolerance for specific medications, procedures, or therapies
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>
* expectations for the course of the disease
 
* opinion or preference <ref name=UMM>{{cite web | Content was last reviewed by a University of Maryland Medicine expert  | title =Gestational Diabetes | publisher=University of Maryland Medicine | work =An overview of gestational diabetes, including risk factors and treatment | url=http://www.umm.edu/diabetes-info/gesta.htm | year = 2003 | month= May 14 | accessdate=2006-11-29}}</ref>
===Insulin Therapy===
Treatment for gestational diabetes focuses on keeping blood glucose levels in the normal range. Treatment may include:
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.  
* special diet
** In the first trimester, the insulin requirement is approximately 0.7 units per kilogram body weight.
* exercise
** By the second trimester, the insulin requirement is 0.8 units per kilogram body weight.
* daily blood glucose monitoring
** 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>
* insulin injections
 
* there is evidence that certain oral glycemic agents such as [[glyburide]] are safe in pregnancy, or at least, are significantly less dangerous to the developing fetus than poorly controlled diabetes.  However, few studies have been performed as of this time.
==Medical Therapy ==
=== Diet and Exercise ===
All women diagnosed with GDM require nutritional counseling for the appropriate amount of weight gain during pregnancy as well as dietary control. Women with a normal BMI [20-25], can consume about 30kcal/kg/d while those who are obese [BMI >25-34] should restrict their diet to 25 kcal/kg/d and those that have a BMI >34 should consume 20kcal/kg/d or less. These patients should restrict fat intake and substitute simple or refined sugars in their diet to more complex [[carbohydrates]].
Moderate amount of non-weight bearing exercise is an important adjunct to dietary advice. It is recommended that pregnant women exercise for about 20-30 minutes everyday or at least most days of the week. 
It is a critical point in time for changing the lifestyles of these women since they are at a high risk for development of type 2 diabetes.
===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===
===Oral Hypoglycemics===
The use of oral medications is considered when diet and exercise do not adequately control blood sugars.
====[[Sulfonylurea|Sulfonylureas]]====
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.
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>
There is inadequate data in regards to the safety and efficacy of other oral antidiabetic medications such as [[Metformin]], [[thiazolidinediones]] and [[Acarbose]].
 
====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===
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==
{{reflist|2}}
 
{{Reflist|2}}
 
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[[Category:Disease]]
 
[[Category:Obstetrics]]
[[Category:Obstetrics]]
[[Category:Endocrinology]]
[[Category:Endocrinology]]
[[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

  1. 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.
  2. 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.
  3. 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.
  4. 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. 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. 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.
  7. 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.
  8. 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.

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