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Oral medication for gestational diabetes

Oral medication for gestational diabetes

Ciabetes Blood Glucose Levels As with Dentist form of diabetes, it's gestationxl Oral medication for gestational diabetes regularly duabetes your blood glucose level with a glucose monitor. If you have other children, how much did each weigh at birth? Ferrara A, Kahn HS, Quesenberry CP, Riley C, Hedderson MM. Accessed Dec. New England Journal of Medicine.

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Gestational Diabetes in Pregnancy: Diagnosis, Treatment, and New Technology - Mass General Brigham

Contributor Disclosures. Please read the Disclaimer festational the end gedtational this medkcation. Many patients can achieve glucose target levels with nutritional therapy and moderate Gut health alone, but up to 30 percent will require pharmacotherapy [ 1 ].

Even patients with mildly elevated Oral medication for gestational diabetes Ginger apple cider vinegar drink who gestationnal not meet standard gestatinoal for GDM may medicstion more favorable pregnancy outcomes if treated since the relationship between glucose diabetees and adverse Orsl outcomes such as macrosomia exists dianetes across the idabetes of increasing glucose levels [ ].

Glucose management in patients with GDM is reviewed here. Screening, diagnosis, and obstetric management are discussed separately.

See "Gestational diabetes mellitus: Screening, diagnosis, Carbohydrates and Gut Microbiota prevention" and "Gestational diabetes mellitus: Obstetric issues and management".

RATIONALE FOR TREATMENT — GDM is treated to gestxtional maternal dabetes neonatal morbidity. In a United States Preventive Services Task Performance nutrition for golfers USPSTF meta-analysis of randomized trials, compared with no treatment, treatment which generally included nutritional ,edication, self-blood glucose monitoring, administration of insulin when target blood glucose concentrations were not met with Sports nutrition resources Fat distribution and metabolic syndrome resulted in reductions in [ 10,11 ]:.

In contrast to a prior USPSTF meta-analysis, the more diabefes analysis found medicarion reduction in Orl when mecication trial from a non-Very High Human Development Index Country was diabetee RR 0.

Some authors have suggested that avoiding ggestational obesity and excessive gestational weight gain may be more important than detecting and treating GDM gestatiional maternal weight Goji Berry Health Products be more Orsl related to fo outcomes, Oral medication for gestational diabetes, particularly fetal overgrowth, than glucose intolerance [ gestattional ].

Sports nutrition resources, data from the Hyperglycemia and Adverse Pregnancy Medictaion HAPO Oral medication for gestational diabetes refute this hypothesis. In HAPO, both obesity and GDM International Mdication of Diabetes and Pregnancy ROal Groups geststional were medicaion predictive of macrosomia, preeclampsia, primary gestatioal birth, and neonatal adiposity [ 2 ].

Few Orql have evaluated the long-term effects Resupply logistics solutions maternal treatment of GDM on offspring. Follow-up data from offspring of mothers enrolled in a randomized trial of treatment versus no treatment of mild GDM showed that maternal treatment DIY Nutty Flavors not reduce late adverse metabolic outcomes eg, obesity, glucose Digestive health and irritable bowel syndrome in duabetes at age gesfational to 10 years [ 13 ].

This finding may reflect lack Injury prevention for manual laborers a true treatment effect, inadequate treatment of hyperglycemia during pregnancy, Joint wellness products mildness of the glucose intolerance, or inadequate power Stress reduction through positive thinking show modest differences in outcome because of the low prevalence of reduction of abdominal fat disorders prior to getsational, and medicationn small numbers Organic liver detoxifiers study participants.

Patients with GDM should Sports nutrition resources medical nutritional gesfational by a registered dietitian when possible upon ofr and be placed on an Adaptogen natural remedies diet. The Orak are to [ 14 ]:. Most patients up to 85 percent with GDM based diabettes Carpenter and Coustan criteria can achieve target glucose levels with lifestyle modification alone [ 3,15 ].

A detailed mefication of medical fr therapy mediaction individuals with diabetes can gestaitonal found egstational. See "Nutritional considerations in type 1 diabetes mellitus". Medicattion specific medjcation that mdeication optimum maternal and newborn outcomes in GDM medlcation unclear medicatipn ].

Gestatiknal key gestaitonal, achievable intervention is to ,edication the benefits of elimination, or OOral least reduction, of consumption of sugar-sweetened beverages eg, soft drinks, fruit drinks and encourage drinking Oral medication for gestational diabetes instead. Noncaloric sweeteners may be used in moderation.

Traditionally, restricting Oarl intake Ogal simple carbohydrates has been favored because it appears to reduce diabefes hyperglycemia [ 19 ] and fetal overgrowth [ 20,21 ffor. In a diabbetes review of randomized trials comparing Low glycemic for PCOS variety of msdication interventions eg, medicafion glycemic geestational, DASH, low carbohydrate, energy restriction, soy protein, Oral medication for gestational diabetes modification, ethnic, high Orap with conventional dietary recommendations for patients with GDM 18 trials, participantsdietary Otal overall reduced fasting diahetes postprandial glucose levels fasting: When analyzed by diet subtype, Farm-to-table dining glycemic index, DASH, low carbohydrate, and ethnicity-based diets diabwtes beneficial gestatiknal on maternal glucose levels.

A limitation of the analysis was that all gestationao the trials had small sample sizes. Flaxseed for immune support and high medicatiin diets Orap not gesyational to improve glycemic control [ 22,23 ].

Oral medication for gestational diabetes plan — A mediication meal plan for patients with GDM includes three small- to moderate-sized meals OOral two diwbetes four snacks.

Medicatoin adjustment of the meal plan diabets based upon results of Oral medication for gestational diabetes monitoring, appetite, and weight-gain patterns, as well as consideration for maternal dietary preferences and medocation, leisure, and exercise schedules.

Close follow-up BMR and weight management tools important to ensure nutritional adequacy. If diabetees therapy getsational added to nutritional therapy, a primary goal High-intensity interval training to maintain carbohydrate consistency at meals and snacks to fof insulin adjustments.

Calories — The caloric requirements of patients with GDM are the same as those for pregnant patients medicatiion GDM [ 24 ]. For individuals with a prepregnancy BMI in the healthy Oral medication for gestational diabetes, caloric requirements in the first trimester are the same diabeets before pregnancy and generally increase by calories per day in the second trimester and calories per day in the third gsetational [ 25 ].

Individuals who are underweight, overweight, or obese should work with a registered dietician to determine their specific caloric requirements.

See "Gestational weight gain". Carbohydrate intake — Once the caloric needs are calculated, carbohydrate intake is determined as it is the primary nutrient affecting postprandial glucose levels. The total amount of carbohydrate consumed, the distribution of carbohydrate intake over meals and snacks, and the type of carbohydrate consumed can be manipulated to blunt postprandial hyperglycemia.

Dietary Reference Intakes DRI for all pregnant people is a minimum of g of carbohydrate per day and 28 g of fiber [ 24 ]. There is sparse evidence from randomized trials as to the ideal carbohydrate intake for individuals with GDM. We limit carbohydrate intake to 40 percent of total calories while ensuring that ketonuria does not ensue [ 26,27 ].

Adequately powered studies are needed to evaluate the effect of various dietary interventions on perinatal outcomes in GDM.

Many patients will need individual adjustment of the amount of carbohydrate by 15 to 30 g at each meal, depending on their postprandial glucose levels, which are directly dependent upon the carbohydrate content of the meal or snack [ 28 ]. The postprandial glucose rise can be blunted if the diet diabetez carbohydrate restricted.

However, reducing carbohydrates to decrease postprandial glucose levels may lead to higher consumption of fat, which may have adverse effects on maternal insulin resistance and fetal body composition. In a meta-analysis of randomized trials of dietary intervention in Orral with GDM, low carbohydrate diets had a favorable effect on postprandial blood glucose concentrations and significantly lowered the need for insulin therapy but did not affect other maternal or newborn outcomes eg, macrosomia, cesarean birth, rOal weight gestationapalthough the data were insufficient to detect small or moderate statistical differences in obstetric outcomes between the patient groups [ 29 ].

See "Nutritional considerations in type 2 diabetes mellitus", section on 'Glycemic index and glycemic load'. Protein intake should be distributed throughout the day and included in all meals and snacks to promote satiety, slow the absorption of carbohydrates into the bloodstream, and provide adequate calories.

A bedtime high-protein snack is recommended to prevent accelerated ie, starvation ketosis overnight and maintain fasting glucose levels within the target range. In a retrospective cohort study including over 31, patients with GDM, those with appropriate gestational weight gain table 1 had optimal outcomes, while excessive gestational weight gain was associated with a significantly increased risk of having a large for gestational age newborn, preterm birth, and cesarean birth [ 30 ].

Although suboptimal weight gain increased the likelihood of avoiding pharmacotherapy of GDM and decreased the likelihood of having a large for gestational age newborn, there were also more small for gestational age newborns in this group 7.

The data in this study were not corrected for potential confounders, such as smoking. See "Obesity in pregnancy: Complications and maternal management" and "Gestational weight gain", section on 'Recommendations for gestational weight gain'.

Some patients experience minimal weight loss one to five pounds or weight stabilization for the first few weeks after beginning nutritional therapy, which should be evaluated in the overall context of gestational weight gain and ongoing surveillance of weight gain in the weeks thereafter.

Weight loss is generally not recommended during pregnancy, although controversy exists regarding this recommendation for patients with obesity, especially class II or III. For pregnant people with obesity, a modest energy restriction of 30 percent below the DRI for pregnant people g carbohydrate, 71 g protein, 28 g fiber Orall 24 diabetex can often be achieved while meeting gestational weight gain recommendations and without causing ketosis [ 31 ].

See "Gestational weight gain", section on 'Recommendations for gestational weight gain'. EXERCISE — Adults with diabetes are encouraged to perform 30 to 60 minutes of moderate-intensity aerobic activity 40 to 60 percent maximal oxygen uptake [VO 2 max] on most days of the week at least minutes of moderate-intensity aerobic exercise per week.

A program of moderate exercise is recommended as part of the treatment plan for patients with diabetes as long as they have no medical or obstetric contraindications to this level of physical activity.

Exercise that increases muscle mass, including aerobic, resistance, and circuit training, appears to improve glucose management, primarily from increased tissue sensitivity to insulin.

As a result, exercise can reduce both fasting and postprandial blood glucose concentrations and, in some patients with GDM, the need for insulin may be obviated [ 32 ].

See medicstion during pregnancy and the postpartum period" and "Exercise guidance in adults with rOal mellitus".

Glucose meters measure capillary blood glucose, almost all available glucose meters provide plasma equivalent values rather than whole-blood glucose values. Thus, results from Orao available glucose meters and venous diabetees glucose measured in a laboratory should be comparable.

See "Glucose monitoring in the ambulatory management of nonpregnant adults with diabetes mellitus". Intermittent self-monitoring of blood glucose — We suggest that patients self-monitor blood glucose levels [ ]:. Results should be recorded in a glucose log, along with dietary information. This facilitates recognition of glycemic patterns and helps to interpret results stored in the memory of glucose meters.

We prefer the one-hour postprandial measurement as it corresponds more closely to the maximum insulin peak in patients using rapid-acting insulin analogs. The value of fasting plus postprandial versus preprandial measurement was suggested by a trial that randomly assigned 66 insulin-treated patients with GDM to management according to results of fasting plus postprandial monitoring one hour after meals or according to preprandial-only blood glucose concentrations [ 37 ].

Postprandial monitoring had several benefits as compared with preprandial monitoring: better glycemic management glycated hemoglobin [A1C] value 6.

Can the frequency of self-monitoring be reduced? Multiple daily measurements allow recognition of patients who should begin pharmacologic therapy.

In a randomized trial of patients with Medicatuon on nutritional therapy who demonstrated glucose levels in the target range after one week of four times daily glucose testing, those assigned to every other day testing had similar birth weights and frequency of macrosomia as those who continued to test four times daily [ 40 ].

Continuous glucose monitoring — Continuous glucose monitoring CGM allows determination of peak postprandial glucose levels, mean glucose level, episodes of nocturnal hyperglycemia, and percent time in range for a hour period.

We do not routinely use CGM in patients with GDM because of cost and it has not been proven to improve maternal or fetal outcome, but few trials have been performed. When CGM was compared with frequent self-monitoring of blood glucose in a meta-analysis of two small randomized trials, outcomes were similar for both approaches: cesarean birth risk ratio [RR] 0.

There were no perinatal deaths. Larger trials may clarify whether the favorable trends that were observed are real. Although use of CGM has no clear advantages for most patients, it may be considered in patients who cannot consistently check fingerstick glucose levels and are willing to wear a device.

In addition, some patients choose to use CGM because they want the detailed information about their glucose levels that it provides. Cost may be a barrier to use. Glucose target — Glucose targets vary among countries and the precise target for optimum maternal, fetal, and newborn outcome is not well-established [ 42 ].

In the United States, daibetes American Diabetes Association ADA and the American College of Obstetricians and Gynecologists ACOG recommend the following upper limits for glucose levels, with insulin therapy initiated if they are exceeded, but acknowledge that these thresholds have been extrapolated from recommendations proposed for pregnant patients with preexisting diabetes [ 24,43 ]:.

These targets are well above the mean glucose values in pregnant people without diabetes described in a literature mediation of studies of the normal hour glycemic fot of pregnant people [ 44 ]. These levels were derived from measurements on whole blood, plasma, self-monitored capillary glucose measurements, or tissue fluid CGM.

Although glucose levels in whole blood, plasma, and interstitial fluid differ, there was some consistency in the results. Glycated hemoglobin — A1C may be a helpful ancillary test in assessing glycemic management during pregnancy [ 45,46 ]. It is not clear whether or how often it should be monitored in patients with GDM with glucose levels are in the target range.

If measured and there is a discrepancy between the A1C and glucose values, then potential causes should be investigated. High-quality gesyational data for A1C in each trimester are not available. A1C values tend to be lower in pregnant compared with nonpregnant people [ 47 ] because the average blood glucose concentration is approximately 20 percent lower in pregnant people, and in the first half of pregnancy, there is a rise in red cell mass and a slight increase in red blood cell turnover [ 48,49 ].

Other factors that have been reported to affect A1C values include race although it is not clear whether the higher A1C levels observed in Black persons compared with White persons are due to differences in glucose levels or racial differences in the glycation of hemoglobin [ 50 ] and iron status chronic iron deficiency anemia increases A1C, treatment of iron deficiency anemia with iron lowers A1C.

Sources of variation in A1C levels are discussed in detail separately. See "Measurements of chronic glycemia in diabetes gestatioonal, section on 'Glycated hemoglobin A1C '. Episodes of physiological dianetes and ketonuria are not uncommon in pregnancy and can occur with hypocaloric diets [ 53 ].

Studies have reported inconsistent findings regarding a potential association between ketonuria and impaired cognitive outcome in offspring [ ]. Goal — The goal of pharmacotherapy is to manage glucose levels so that the majority are no higher than the upper limit of the target range, without inducing any episodes of hypoglycemia.

: Oral medication for gestational diabetes

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Having an immediate family member with diabetes, especially a first-degree relative such as a parent or sibling, increases the risk. The presence of a familial history of diabetes indicates a genetic predisposition to the condition, emphasizing the importance of prompt monitoring and making lifestyle adjustments during pregnancy.

Furthermore, women who have previously delivered large babies weighing more than 9 pounds 4. Inadequately managed BGCs during pregnancy can lead to the birth of larger infants, emphasizing the importance of careful monitoring and control in subsequent pregnancies.

Race and ethnicity also contribute to GDM risk. Specific racial and ethnic populations, including but not limited to black, Hispanic, American Indian, and Asian American women, exhibit an elevated susceptibility to the onset of GDM. Furthermore, an elevated maternal age is linked to a heightened likelihood of GDM occurrence.

Regular screening and early detection become crucial for older pregnant women to manage GDM effectively. Screening for GDM is an important component of prenatal care, aimed at identifying and managing this condition promptly to ensure the well-being of both the mother and the developing fetus.

The diagnostic criteria for GDM involve a systematic approach to screening at various stages of pregnancy and postpartum follow-up for women who have experienced GDM. By following these screening recommendations, healthcare providers can effectively detect and manage GDM, reducing the risk of complications and promoting a healthy pregnancy outcome see TABLE 1.

The screening recommendations for GDM are guidelines to serve as vital recommendations for healthcare providers to ensure early detection and effective management of this condition.

By performing screening during the 24th to 28th weeks of pregnancy for those without a previous history of diabetes, GDM can be promptly detected and effectively managed. Additionally, postpartum screening within 4 to 12 weeks after giving birth for women with a history of GDM allows for ongoing monitoring and timely intervention.

In managing GDM, a set of specific goals are implemented to ensure optimal maternal and fetal health throughout pregnancy. To effectively control BGCs, women with GDM are advised to follow target ranges for blood glucose testing at different times of the day. Alongside vigilant blood glucose monitoring BGM , women are encouraged to adopt a healthy lifestyle that includes making mindful dietary choices.

It involves consuming a variety of nutritious foods, focusing on complex carbohydrates, lean proteins, and healthy fats, while limiting sugary and high-calorie options.

Engaging in regular physical activity is another essential component of managing GDM. Moderate-intensity exercises, such as jogging, swimming, or prenatal yoga, have been shown to lower BGCs and enhance insulin sensitivity.

Physical activity not only helps regulate blood glucose but also offers additional benefits such as improved cardiovascular health and mood.

However, despite maintaining a healthy diet and being physically active, some women with GDM may still require additional support to manage their blood sugar effectively.

In such cases, healthcare providers may prescribe medications as part of the treatment plan. Insulin therapy is the most common medication used for GDM, and it is considered safe for both the mother and the baby.

In some instances, oral medications like metformin may be recommended to help regulate BGCs. Treatment for GDM involves pharmacologic therapy as one of the options when lifestyle modifications alone are insufficient to control BGCs. These pharmacologic treatment options for GDM are listed in TABLE 2.

For GDM management, insulin remains the optimal selection, particularly in the context of addressing type 1 diabetes T1D during pregnancy. Additionally, it stands as the first-line approach for treating T2D during pregnancy.

Insulin can be administered through either multiple daily injections or insulin pump technology in pregnant women with T1D. The advantage of insulin lies in its well-established safety and efficacy, with a long history of use in pregnancy.

It allows precise control of BGCs, ensuring optimal maternal and fetal outcomes. Metformin presents an alternative approach for the treatment of GDM, demonstrating potential benefits such as a decreased risk of neonatal hypoglycemia and reduced maternal weight gain, when compared with the use of insulin.

As a result, the potential impact of metformin on the developing fetus should be carefully considered and the benefits and risks weighed when choosing a treatment option. Close monitoring and consultation with healthcare professionals are key to ensure the well-being of both the mother and the baby.

Glyburide, a sulfonylurea, is generally the least-preferred drug for GDM treatment. Numerous meta-analyses and systematic reviews have consistently indicated that glyburide is linked to a heightened occurrence of neonatal hypoglycemia, macrosomia, and increased abdominal circumference in newborns compared with insulin or metformin treatments.

Moreover, glyburide has not demonstrated noninferiority to insulin regarding a combined outcome measure comprising neonatal hypoglycemia, macrosomia, and hyperbilirubinemia. It is also important to note that glyburide can cross the placenta, potentially raising concerns about its impact on the fetus.

In the postpartum period, managing GDM involves monitoring BGCs and making timely adjustments to insulin dosages during the early postpartum days. This is essential due to insulin requirements typically decreasing by approximately half compared with the pregnancy stage.

Healthcare providers should discuss and implement a contraceptive plan with all individuals having diabetes of reproductive potential to facilitate family planning and manage pregnancy-related risks. For recent cases of GDM, it is advisable to conduct screening between 4 to 12 weeks after childbirth.

This screening should involve the g oral glucose tolerance test and the utilization of diagnostic criteria applicable outside of pregnancy.

However, blood sugar implications should be considered when choosing between breastfeeding and formula feeding. Continued postpartum care is critical, with regular screening for T2D or prediabetes recommended throughout life, every 1 to 3 years for those with previous GDM. Individuals with a history of GDM should actively pursue preconception screening and care to identify and manage hyperglycemia and prevent congenital malformations.

Regular monitoring of BGCs and follow-up with physicians are necessary even if some patients do not require insulin postpartum. Regular screenings for T2D should be promoted for long-term health management.

Healthcare providers should emphasize blood sugar monitoring, dietary management, physical activity, and medication management, considering prior prescriptions for GDM. For breastfeeding patients, awareness of blood sugar impact is essential, requiring close monitoring and potential diet or medication adjustments.

In managing a patient with GDM, pharmacists have several important responsibilities. First, they can review and assess the medications prescribed to the patient, ensuring that they are appropriate, safe, and effective for managing the condition.

This may include insulin or oral medications used to control BGCs. Additionally, pharmacists offer medication counseling to patients, providing comprehensive education about their prescribed medications.

This includes guidance on administering insulin injections correctly, using glucose monitoring devices, and understanding potential side effects and drug interactions. Pharmacists can educate patients about the condition itself, including its causes, risk factors, and long-term implications.

Additionally, they provide information on self-care measures, such as foot care, stress management, and the importance of regular prenatal and postpartum check-ups.

BGM is a vital part of managing GDM, and pharmacists play a significant role in this area. Pharmacists provide information on optimal BGC ranges, assist patients in understanding their results, and provide advice on appropriate steps based on their readings.

They may also recommend suitable glucose monitoring devices and provide instructions on device maintenance.

Simultaneously, lifestyle modifications are essential for managing GDM, and pharmacists offer valuable guidance in this regard. They provide advice on maintaining a healthy weight, following a nutritious diet, and engaging in regular exercise.

The rising prevalence of GDM presents a significant challenge that requires vigilant monitoring and effective management. Its intricate pathophysiology, involving hormonal, metabolic, and placental factors, emphasizes the importance of early screening through recognition of risk factors such as elevated BMI, sedentary lifestyle, prediabetes, and family history.

Timely identification allows for appropriate treatment, with insulin being the most preferred option, followed by metformin and glyburide with careful consideration. Postpartum care is crucial in evaluating glucose metabolism and reducing the risk of T2D development.

The involvement of pharmacists in counseling and patient education plays a vital role in supporting better outcomes and reinforcing the necessity of a comprehensive healthcare approach to effectively manage GDM for healthier pregnancies and lives.

Gestational diabetes. December 30, Accessed August 18, McIntyre HD, Kapur A, Divakar H, Hod M. Gestational diabetes mellitus—innovative approach to prediction, diagnosis, management, and prevention of future NCD—mother and offspring.

Front Endocrinol Lausanne. Kampmann U, Knorr S, Fuglsang J, Ovesen P. Determinants of maternal insulin resistance during pregnancy: an updated overview.

J Diabetes Res. National Library of Medicine. Type 1 diabetes: MedlinePlus. February 10, Amiri FN, Faramarzi M, Bakhtiari A, Omidvar S.

Risk factors for gestational diabetes mellitus: a case-control study. Am J Lifestyle Med. Egan AM, Enninga EAL, Alrahmani L, et al. Recurrent gestational diabetes mellitus: a narrative review and single-center experience. J Clin Med. Miller C, Lim E. The risk of diabetes after giving birth to a macrosomic infant: data from the NHANES cohort.

Matern Health Neonatol Perinatol. ElSayed NA, Aleppo G, Aroda VR, et al. Finding the best medications to treat the women and prevent the complications that are linked to GDM is therefore important. We searched for studies on 14 May We included 11 randomised controlled trials involving mothers and their babies but only eight trials contributed data to our analyses.

The evidence was limited by the quality and number of studies and we advise caution when looking at the results. The criteria for diagnosis of GDM and treatment targets varied between studies, and each outcome is based on few studies with low numbers of women.

The quality of the evidence was very low or low. We found no differences between the oral medication and placebo group for the risk of high blood pressure, birth by caesarean section, induction of labour or perineal trauma.

The number of babies born large-for-gestational age, with low blood sugars or dying at birth was not clearly different between the groups. Two studies women reported no difference in the need for insulin between the oral medication and placebo group.

Six studies compared metformin with glibenclamide. The quality of the evidence was very low to moderate. We found no difference between metformin and glibenclamide for the risk of high blood pressure three studies, women, moderate-quality evidence , birth by caesarean section four studies, women, low-quality evidence , perineal trauma two studies, women, low-quality evidence or induction of labour one study, women, low-quality evidence.

We found no difference between metformin and glibenclamide for the baby having low blood sugars four studies, infants, low-quality evidence , being born large-for-gestational age two studies, infants or dying at birth all low- or very low-quality evidence.

In one study, the babies of the mothers taking metformin were at reduced risk of having any serious outcome low blood sugar, jaundice, being born large, breathing problems, injury at birth or death combined low-quality evidence. One small study 43 women comparing glibenclamide with acarbose reported no differences in outcomes for mothers or their babies.

None of the included studies provided any data on many of the outcomes pre-specified in this review, including long-term outcomes for the mother or for the baby as a child or an adult.

There is not enough high-quality evidence available to guide us on if oral medication has better outcomes for women with gestational diabetes, and their babies, compared with a placebo or if one oral medication has better health outcomes than another oral medication.

Because we are still unclear, further research is needed. Future studies should be encouraged to report on the outcomes suggested in this review and in particular the long-term outcomes for the woman and the infant that have been poorly reported to date.

There was insufficient high-quality evidence to be able to draw any meaningful conclusions as to the benefits of one oral anti-diabetic pharmacological therapy over another due to limited reporting of data for the primary and secondary outcomes in this review. Short- and long-term clinical outcomes for this review were inadequately reported or not reported.

Current choice of oral anti-diabetic pharmacological therapy appears to be based on clinical preference, availability and national clinical practice guidelines.

Future trials should attempt to report on the core outcomes suggested in this review, in particular long-term outcomes for the woman and the infant that have been poorly reported to date, women's experiences and cost benefit. Gestational diabetes mellitus GDM is a major public health issue with rates increasing globally.

Gestational diabetes, glucose intolerance first recognised during pregnancy, usually resolves after birth and is associated with short- and long-term complications for the mother and her infant.

Treatment options can include oral anti-diabetic pharmacological therapies. To evaluate the effects of oral anti-diabetic pharmacological therapies for treating women with GDM. We searched Cochrane Pregnancy and Childbirth's Trials Register 14 May , ClinicalTrials. gov , WHO ICTRP 14 May and reference lists of retrieved studies.

We included published and unpublished randomised controlled trials assessing the effects of oral anti-diabetic pharmacological therapies for treating pregnant women with GDM. Trials using insulin as the comparator were excluded as they are the subject of a separate Cochrane systematic review.

Two review authors independently assessed trials for inclusion and trial quality. Two review authors independently extracted data and data were checked for accuracy.

We included 11 studies 19 publications women and their babies. Eight studies had data that could be included in meta-analyses. Studies were conducted in Brazil, India, Israel, UK, South Africa and USA. The studies varied in diagnostic criteria and treatment targets for glycaemic control for GDM.

The overall risk of bias was 'unclear' due to inadequate reporting of methodology. Using GRADE the quality of the evidence ranged from moderate to very low quality.

Evidence was downgraded for risk of bias reporting bias, lack of blinding , inconsistency, indirectness, imprecision and for oral anti-diabetic therapy versus placebo for generalisability. There was no evidence of a difference between glibenclamide and placebo groups for hypertensive disorders of pregnancy risk ratio RR 1.

Oral medication for the treatment of women with gestational diabetes

You should know that these drugs aren't approved for gestational diabetes by the Food and Drug Administration. That said, glyburide and metformin do appear to be effective and safe for gestational diabetes, according to the report. Everyday Health follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy.

We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.

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Gestational Diabetes. By Joseph Bennington-Castro. Medically Reviewed. Robert Jasmer, MD. Diet Exercise Jump to More Topics. As its name suggests, gestational diabetes develops only in pregnant women.

Treatment for gestational diabetes involves controlling blood glucose levels through diet, exercise, and medication.

How does gestational diabetes develop? Gestational diabetes develops when liver, muscle, and fat cells do not respond well to insulin, a hormone that regulates blood glucose levels.

It occurs only in pregnant women due to changes in the body during pregnancy. What does a diet for gestational diabetes typically consist of?

A diet for gestational diabetes focuses on foods high in fiber and important nutrients, while being low in fat and calories. It includes vegetables, fruit, and whole grains, and avoids refined carbohydrates and sugar.

What type of exercise is recommended for women with gestational diabetes? Women with gestational diabetes should engage in at least 30 minutes of moderate to intense exercise, such as brisk walking, swimming, or low-impact aerobics, at least five days a week. Certain activities should be avoided to prevent harm to the baby.

How should blood glucose levels be monitored for gestational diabetes? Blood glucose levels should be checked regularly with a glucose monitor. Medication may be necessary if target levels are not reached through diet and exercise alone. Gestational Diabetes Diet Treatment for gestational diabetes always includes specialized healthy meal plans — often recommended by a registered dietician — and regular exercise, according to the American Diabetes Association ADA.

To circumvent hyperglycemia and its negative effects on fetal growth, pregnant women diagnosed with gestational diabetes are initially managed with individualized medical nutrition therapy and light exercise. This promising finding certainly requires further elucidation.

Insulin has generally been recognized as the first-line drug because it is effective and does not cross the placenta. Other treatment strategies, oral antidiabetic drugs OAD such as metformin or glyburide, have been used in recent years given that insulin therapy has several downsides in GDM.

Some of them are the absence of a clear dose definition, the need for multiple daily injections, the risk of hypoglycemia, and elevated maternal weight gain [ 12 ].

In accordance with previous facts, up-to-date results of available meta-analyses on the effects of antidiabetic pharmaceuticals estimated that if we look to the majority of adverse neonatal outcomes, metformin was ranked to be the superior treatment over insulin or glyburide, whereas the lower risk of adverse maternal outcomes was primarily linked to glyburide administration [ 14 ].

These divergent effects require additional caution in their use [ 8 ]. Lots of knowledge has been accumulated regarding GDM screening and timely treatment; however, the secondary prevention in women following GDM, as well as in their offspring, represents an important scientific challenge for all of us in many years to come [ 15 ].

In this review, we look at how insulin and other oral hypoglycemic medications are used to treat women with GDM, emphasizing on their efficacy and safety. Supplement-related and other alternative pharmacotherapy will be addressed, as well.

Insulin, due to its huge molecular size, does not pass the placenta unless at extremely high doses [ 16 ]. It has a great fetal safety profile; it attains tight maternal glucose control and is therefore recommended as a gold standard, and the first-line treatment for women with GDM.

Insulin is not teratogenic, and there is also no evidence that any of them are excreted in human milk [ 17 ]. Currently, available insulin analogs are rapidly acting analogs, including aspart and lispro, short-acting regular insulin, intermediate-acting NPH insulin, or longer-acting insulin analogs, such as glargine and detemir [ 18 , 19 ].

Insulin is the therapy of choice for women who have failed to meet their glycemic treatment goals despite making lifestyle changes—diet and exercise [ 2 ]. It can also be used by those who are unable to tolerate the adverse effects of other OADs. Based on the time of recurrent hyperglycemia, there are two major ways of prescribing insulin.

Insulin can be given in divided doses throughout the day or as a single daily dose. Intermediate insulin, such as NPH or detemir, should be given as a single dose at bedtime in GDM women who have hyperglycemia solely in the morning fasting state. Rapid-acting insulin should be administered before a meal in women who have postprandial hyperglycemia.

Hyperglycemia during the day should be controlled with a combination of intermediate- or long-acting and short-acting insulin [ 20 ]. Close blood glucose monitoring is required while prescribing insulin to avoid hypoglycemia or hyperglycemia.

They reach a concentration peak sooner than regular insulin and show a shorter duration of action 3—5 h [ 21 ]. In comparison with human insulin, which must be administered 30 minutes before a meal, rapid-acting insulin analogs can be given 5—10 minutes before a meal, making them more convenient [ 22 ].

Basal insulin, also known as intermediate-acting and long-acting insulin, is primarily used to give a constant supply of the modest amounts of insulin to regulate lipolysis and avoid hepatic gluconeogenesis, regardless of meal intake.

Although insulin treatment has traditionally been the drug of choice for treating hyperglycemia in GDM after medical nutrition and physical exercise, it is not without limitations. Many pregnant women face issues with insulin administration, including gaining weight, balancing dosage, diet, and, for some, the frequency of hypoglycemic episodes.

For that reason, there are quite a few reports currently suggesting metformin as the first-line agent having an equivalent efficacy vs. insulin, yet with less hypoglycemia than insulin [ 23 ].

Short-acting insulin has been connected to an augmented risk of hypoglycemia and glycemic control changes in those with GDM. In randomized clinical investigations comparing detemir to NPH for intermediate- and longer-acting insulin, there was no difference in glucose management or perinatal outcomes.

Detemir has been linked to a lower risk of hypoglycemia in diabetics who are not pregnant [ 25 ]. Metformin, an oral biguanide, works by reducing liver gluconeogenesis, increasing peripheral insulin sensitivity, and also promoting glucose uptake in peripheral tissues while lowering glucose absorption in the gut [ 26 ].

Several mechanisms are responsible for higher insulin sensitivity including the augmented activity of insulin receptor tyrosine kinase, enhanced synthesis of glycogen, reduction of glycogenolysis, decreased activity of hepatic glucosephosphatase, and an increase in the recruitment and activity of GLUT4 glucose transporters [ 27 ].

Despite identical glycemic control, metformin was related to lower cardiovascular, as well as all-cause mortality if paralleled to sulphonylureas and insulin in a long-term prospective study of type 2 diabetes.

The RISK pathway activation via increased AMPK activity may be responsible for this effect [ 29 , 30 ]. Organic cation transporters OCTs transport metformin across the mitochondrial membrane at the cellular level. Since the placenta expresses many OCT isoforms, metformin crosses the placenta easily during pregnancy.

Concerns about potential negative effects on fetal development arise from transport via the placenta into the developing fetus. Although it is unknown if OCTs are expressed in human embryos, we know that pre-implantation human embryos have limited mitochondrial capacity making them resistant to metformin [ 31 , 32 ].

In Metformin in gestational diabetes study MiG , children aged 2 exposed to metformin during pregnancy were compared to children of the same age whose mothers were on insulin during pregnancy.

Children exposed to metformin had comparable overall body fat, yet more subcutaneous fat over intra-abdominal fat compared to children exposed to insulin, thus suggesting that metformin treatment may lead to a more advantageous pattern of fat distribution than insulin [ 33 ]. Only recently there has been evidence to support the use of metformin for the management of GDM.

It has, however, been used in early pregnancy and all through pregnancy for additional indications for decades. Metformin can help women with the polycystic ovarian syndrome to establish regular ovulation and to enhance conceiving odds, and by using it during the first trimester to lower the incidence of spontaneous abortion [ 34 ].

Despite this, it was not until the metformin in Gestational Diabetes trial, presented by Rowan et al. in , was widely reported as an effective treatment for GDM [ 36 ]. In the gestational diabetes trial [ 36 ], women were randomly assigned to either metformin or standard treatment, that is, insulin.

The key outcome was a combination of neonatal hypoglycemia 2. Women who took metformin gained considerably less weight from enrolment to term than those who took insulin.

Other parameters considered in the metformin and insulin clusters were similar, including birth weight, neonatal anthropometrics, and odds for large for gestational age.

However, when compared to insulin therapy, the incidence of severe hypoglycemia 1. This research also discovered that patient acceptability for metformin was substantially better than with insulin; when questioned if they would select it yet again for future pregnancies, 77 percent of metformin users replied yes, compared to only 27 percent of insulin users.

A group of GDM women merely treated with metformin vs. Maternal risk factors were similar in both groups. The rates of preeclampsia, prenatal hypertension, and Cesarean section were identical, but an average maternal gain of weight from enrolment to term was considerably lower in the metformin group, just as it was in the MiG study.

When compared to women who were treated with insulin, women who were given metformin had a lower rate of preterm, neonatal jaundice, and admission to a neonatal unit, as well as an overall improvement in newborn morbidity [ 37 ].

Post-prandial glycemic levels may indeed be of importance when comparing metformin to other treatment options. A meta-analysis of three randomized controlled studies of GDM women found lower post-prandial glucose in metformin as opposed to insulin-treated patients, though these disparities did not meet statistical significance [ 38 ].

Metformin did not raise the risk of preterm delivery or Cesarean section, as reported in a latest systematic review, nor did it raise the risk of small for gestational age newborns.

Metformin, on the other hand, was linked to a lower risk of preterm birth, newborn hypoglycemia, and admission to neonatal intensive care units, as well as a decreased prevalence of pregnancy-induced hypertension [ 39 ].

Because metformin is not stimulating the secretion of insulin, it does not provoke maternal hypoglycemia, which is a side effect that remains a concern with glyburide.

For the same reason, severe neonatal hypoglycemia is less likely to occur after metformin administration compared to insulin [ 14 ]. Accordingly, hypoglycemia is a greater risk if taking insulin, than with OAD [ 40 ].

Metformin, on the other hand, crosses the placental barrier easily due to its low molecular mass, hydrophilic nature, and lack of protein binding [ 41 ]. Metformin concentrations in the fetus are likely minimal and no fetal side effects, such as congenital malformations, have been detected [ 42 ].

It is not thought to be teratogenic, as evidenced by decades of use in preconception and early pregnancy. There have been no reports of newborn lactic acidosis, and neonatal hypoglycemia has been related to maternal hyperglycemia during delivery rather than a direct side effect of metformin.

Before starting metformin treatment, patients should be informed about the potential for maternal adverse effects. Lactic acidosis, the most worrying potential side effect, was prevented by gradually raising the dose [ 43 ].

One final question could be certainly related to the eventual advantageous co-administration of metformin and insulin in GDM. Scarce reports have been published over the past decade; however, Chaves et al. Moreover, the authors reported that expected beneficial effects on weight gain and insulin dose were simply not detected if both drugs were used in a parallel manner [ 44 ].

Glyburide is a second-generation sulfonylurea that acts mainly by increasing the secretion of insulin from the pancreas and improving the insulin sensitivity of peripheral tissues. These actions can be detected after a block of the sulfonylurea receptor, which is actually a part of the ATP-sensitive potassium channel in the pancreatic beta cells [ 45 ].

Glyburide is lipophilic and significantly bound to albumin [ 46 ]. At first, it was assumed that glyburide did not cross the placenta. Langer et al. The reason behind that is that they used liquid chromatography with a limit of detection of 10 ng per milliliter [ 13 ].

There is an obvious option to glyburide and that is insulin administration. Even though glyburide is an FDA category C drug, compared to insulin analogs lispro, detemir, and aspart that are all pregnancy risk factor B medications, glyburide is still widely used.

The situation where glyburide is a better choice is where self-monitoring of glucose blood levels needed for insulin or insulin storage is not possible or where a patient has a severe needle phobia.

Another benefit of using glyburide is that it is a low-cost oral agent, easy to take with few side effects. Also, glyburide is, as an oral agent just like metformin, easier to use compared to insulin [ 41 ].

Nevertheless, the other use of glyburide during pregnancy for GDM patients is still unclear and needs to be comprehensively elucidated [ 48 ]. The New England Journal of Medicine published a clinical investigation comparing glyburide versus insulin in management of GDM in , which transformed the management of GDM.

Namely, Langer et al. Results did not show any significant difference between the two clusters in neonatal outcomes by measuring high blood glucose concentrations, the incidence of macrosomia, admission to neonatal intensive care unit, etc. The authors also noted that the extent of glycemic control between the two groups was similar.

A different study comparing macrosomia, neonatal hypoglycemia, and hyperbilirubinemia in two groups found no evidence that using glyburide instead of subcutaneous insulin leads to a higher rate of perinatal problems [ 50 ]. On the contrary, a retrospective cohort study analyzed data from women diagnosed with GDM and treated with glyburide opposite to insulin days before delivery [ 37 ].

It was found that newborns delivered by women treated with glyburide were more expected to have complications than those delivered by mothers who were taking insulin. Complications noted were preterm birth, Cesarean delivery, hypoglycemia, respiratory distress, jaundice, birth injury, large for gestational age, and hospitalization in the neonatal ICU [ 51 ].

to assess the efficacy and safety of oral anti-diabetic OADs medicines for GDM. In terms of glycemic management, the investigators did not find any difference between glyburide and insulin. Glyburide therapy, on the other hand, is linked to a higher risk of neonatal hypoglycemia, high neonatal birth weight, high maternal weight gain, and macrosomia [ 52 ].

A group of glyburide-managed pregnancies and insulin-treated pregnancies were evaluated in the Jiang meta-analysis comparing the efficacy and safety of OAD for GDM [ 52 ].

Despite no dissimilarity in glycemic control, the authors found that glyburide caused considerably more macrosomia than insulin OR: 3. Glyburide was also associated with a greater rate of newborn hypoglycemia than insulin OR: 2. There was no difference in weight growth, Cesarean delivery rate, or preeclampsia between NICU admissions or premature births.

Finally, it has to be underlined that glyburide was ranked the worst in the recent meta-analysis, with the highest rates of macrosomia, hyperbilirubinemia, preeclampsia, neonatal hypoglycemia, low birth weight, preterm birth, and metformin plus insulin when needed had the lowest rates of pregnancy hypertension, macrosomia, LGA, RDS, preterm birth, and low birth weight [ 53 ].

Besides, one has to be very cautious with glyburide use, which was shown to be associated with weight gain, as well as maternal hypoglycemia, especially when taken without any food [ 45 ].

As a result, the rise in postprandial glucose concentrations is lowered. Its use is usually linked to gastrointestinal complications.

Acarbose is not usually recommended for the treatment of GDM, because it has not been thoroughly researched during pregnancy and considering safer and more acceptable options, with more information regarding treating GDM, such as insulin and metformin. Neonatal hypoglycemia occurred in one acarbose-treated subject, one insulin-treated subject, and eight glyburide-treated subjects.

Although in this short trial, failure to achieve glycemic control with acarbose was higher if compared to glyburide, the decreased incidence of hypoglycemia and macrosomia underlines acarbose as an appealing agent to investigate in future GDM treatment studies.

Accordingly, in the recent investigation published by Jayasingh et al. Namely, this prospective, open-label, and controlled study was designed to compare the fetomaternal outcomes in pregnant women with GDM designated to insulin or acarbose group.

Thus, no difference was found if the following parameters were paralleled in between the groups: the incidence of recurrent infections, preeclampsia, or premature rupture of membranes; then the modes of delivery, mean postoperative random blood glucose, fasting blood glucose level at day 7 and after 6 weeks; and finally difference in the mean birth weight of offspring born to mothers treated with either of the two pharmacological agents.

Even though using acarbose in diabetic patients has been linked to abnormal liver enzymes and hepatic failure, a newer study did not show a higher risk of liver injury during acarbose treatment [ 57 ].

Acarbose can pass through the placenta. In pregnant animal investigations, doses up to 32 times higher than the human dose were not proven to be teratogenic. On the other hand, it induces stomach cramps and may raise prostaglandin E, suggesting that it possess the potential ability to induce labor [ 58 ].

The efficacy of vitamin and mineral supplementation in GDM patients is still under investigation. However, today is known that in GDM, low levels of vitamin D, vitamin E, and magnesium have been detected, whereas glucose metabolism, anti-inflammatory, and anti-oxidative stress have been all positively regulated after vitamin D, vitamin E, magnesium, and selenium supplementation, which was also confirmed in the very recent meta-analysis reported by Li et al.

In the same manner, 6-week-long Mg-Zn-Ca-vitamin D co-supplementation reduced biomarkers of inflammation and oxidative stress in GDM women [ 60 ]. To continue, the improvement in glycemic control and decline of adverse fetomaternal outcomes after vitamin D supplementation including Cesarean section, postpartum hemorrhage, maternal hospitalization, neonatal hyperbilirubinemia, giant children, fetal distress, polyhydramnios, premature delivery was underlined by Wang et al.

Dietary adjustments accompanied with lifestyle modifications are known to achieve normoglycemia in a majority of women with GDM, especially underlining careful attention to type and amount of dietary carbohydrates [ 62 ]. In this context, myoinositol, a dietary supplement knowing to decrease insulin resistance, became extensively investigated [ 63 ].

It represents inositol isomer organically present for example in legumes or nuts, but also synthesized in kidneys and liver to a certain extent. Accordingly, recent findings pointed out that, if started shortly after the GDM diagnosis, myoinositol mg twice daily, per os was shown to be effective in reaching glycemic control and reducing the need for additional pharmacotherapy [ 64 ].

Traditional Chinese medicine and herbal products, known to be broadly utilized during human history, now belong to a very interesting field currently investigated in the frame of GDM [ 65 ]. So far, herbs such as Zuo Gui Wan , red raspberry tea, and Orthosiphon stamineus all provided valid possibilities in reducing glucose and alleviating the GDM-related pathophysiology, and at the same time with good safety profile to the mother and neonate [ 66 ].

In addition, the antidiabetic potential of glycyrrhiza flavonoids from traditional Chinese medicine, as adjuvants for insulin therapy, could be especially beneficial in GDM [ 67 ]. Finally, probiotics supplementation in improving glycemic control and attenuating some of the adverse events related to GDM is a very interesting and appealing scientific issue that needs further elucidation [ 68 , 69 ].

Even though new and promising results are published every day, novel investigations and, most of all, well-designed standardized protocols are needed for obtaining original, comparable, and sustainable results in this field of adjuvant GDM treatment.

In the twenty-first century, GDM poses a significant challenge to health care professionals. The short- and long-term effects of successfully controlling GDM are important for both the mother and the fetus. Most guidelines recommend oral pharmacological therapy, such as glyburide and metformin, and it is now widely used, with data on efficacy and safety.

They can both be used as the first-line option; however, metformin appears to be preferable to glyburide in terms of newborn and maternal outcomes, while it is associated with a higher incidence of failure to achieve appropriate glycemic control.

Analogs such as detemir, aspart, and lispro, which have been thoroughly proved for their safety and efficacy during pregnancy, are indicated as first-line therapy or when oral medication fails to achieve optimal glucose control. Glargine can be used during pregnancy, while there is not as much data to back it up as there is for other long-acting analogs and human insulins.

While insulin has typically been used to treat GDM, both metformin and glyburide may be used, but patients should be informed about the risks and advantages. Pharmacotherapy of GDM is still under investigation, even though much is known about GDB itself. We can witness that the molecular understanding of GMB has been constantly translated to more efficacious and safer therapeutic options.

Still, we expect that coordinated and well-focused basic and clinical investigations will provide even more precise information regarding future choices for prevention and adequate, as well as timely treatment of GDM. Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3.

Edited by Miroslav Radenkovic. Open access peer-reviewed chapter Pharmacotherapy of Gestational Diabetes Mellitus: Current Recommendations Written By Miroslav Radenković and Ana Jakovljević.

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From the Edited Volume Gestational Diabetes Mellitus - New Developments Edited by Miroslav Radenković Book Details Order Print. Chapter metrics overview Chapter Downloads View Full Metrics. Impact of this chapter. Abstract The incidence of gestational diabetes mellitus GDM is still rising, and this pathological condition is strongly associated with some serious adverse pregnancy outcomes.

Keywords gestational diabetes mellitus treatment insulin metformin glyburide oral antidiabetics. radenkovic med. Introduction Gestational diabetes mellitus GDM is well-described endocrinopathy, referring to any degree of glucose intolerance that develops or else is initially recognized during pregnancy.

References 1. Rosik J, Szostak B, Machaj F, Pawlik A. The role of genetics and epigenetics in the pathogenesis of gestational diabetes mellitus. Annals of Human Genetics. DOI: McIntyre HD, Catalano P, Zhang C, Desoye G, Mathiesen ER, Damm P. Gestational diabetes mellitus.

Nature Reviews. Disease Primers. Franzago M, Fraticelli F, Stuppia L, Vitacolonna E. Nutrigenetics, epigenetics and gestational diabetes: Consequences in mother and child. Radenkovic M. Treatment considerations for gestational diabetes mellitus and long-term postpartum options.

In: Gestational Diabetes. IntechOpen; Subiabre M, Silva L, Toledo F, Paublo M, López MA, Boric MP, et al. Insulin therapy and its consequences for the mother, foetus, and newborn in gestational diabetes mellitus.

Biochimica et Biophysica Acta - Molecular Basis of Disease. Singh KP, Rahimpanah F, Barclay M. Metformin for the management of gestational diabetes mellitus. Gou BH, Guan HM, Bi YX, Ding BJ.

Gestational diabetes: Weight gain during pregnancy and its relationship to pregnancy outcomes. Chinese Medical Journal. Mirabelli M, Chiefari E, Tocci V, Greco E, Foti D, Brunetti A.

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The presence of a familial history of diabetes indicates a genetic predisposition to the condition, emphasizing the importance of prompt monitoring and making lifestyle adjustments during pregnancy. Furthermore, women who have previously delivered large babies weighing more than 9 pounds 4.

Inadequately managed BGCs during pregnancy can lead to the birth of larger infants, emphasizing the importance of careful monitoring and control in subsequent pregnancies.

Race and ethnicity also contribute to GDM risk. Specific racial and ethnic populations, including but not limited to black, Hispanic, American Indian, and Asian American women, exhibit an elevated susceptibility to the onset of GDM. Furthermore, an elevated maternal age is linked to a heightened likelihood of GDM occurrence.

Regular screening and early detection become crucial for older pregnant women to manage GDM effectively. Screening for GDM is an important component of prenatal care, aimed at identifying and managing this condition promptly to ensure the well-being of both the mother and the developing fetus.

The diagnostic criteria for GDM involve a systematic approach to screening at various stages of pregnancy and postpartum follow-up for women who have experienced GDM.

By following these screening recommendations, healthcare providers can effectively detect and manage GDM, reducing the risk of complications and promoting a healthy pregnancy outcome see TABLE 1. The screening recommendations for GDM are guidelines to serve as vital recommendations for healthcare providers to ensure early detection and effective management of this condition.

By performing screening during the 24th to 28th weeks of pregnancy for those without a previous history of diabetes, GDM can be promptly detected and effectively managed.

Additionally, postpartum screening within 4 to 12 weeks after giving birth for women with a history of GDM allows for ongoing monitoring and timely intervention. In managing GDM, a set of specific goals are implemented to ensure optimal maternal and fetal health throughout pregnancy.

To effectively control BGCs, women with GDM are advised to follow target ranges for blood glucose testing at different times of the day. Alongside vigilant blood glucose monitoring BGM , women are encouraged to adopt a healthy lifestyle that includes making mindful dietary choices.

It involves consuming a variety of nutritious foods, focusing on complex carbohydrates, lean proteins, and healthy fats, while limiting sugary and high-calorie options.

Engaging in regular physical activity is another essential component of managing GDM. Moderate-intensity exercises, such as jogging, swimming, or prenatal yoga, have been shown to lower BGCs and enhance insulin sensitivity.

Physical activity not only helps regulate blood glucose but also offers additional benefits such as improved cardiovascular health and mood. However, despite maintaining a healthy diet and being physically active, some women with GDM may still require additional support to manage their blood sugar effectively.

In such cases, healthcare providers may prescribe medications as part of the treatment plan. Insulin therapy is the most common medication used for GDM, and it is considered safe for both the mother and the baby.

In some instances, oral medications like metformin may be recommended to help regulate BGCs. Treatment for GDM involves pharmacologic therapy as one of the options when lifestyle modifications alone are insufficient to control BGCs. These pharmacologic treatment options for GDM are listed in TABLE 2.

For GDM management, insulin remains the optimal selection, particularly in the context of addressing type 1 diabetes T1D during pregnancy. Additionally, it stands as the first-line approach for treating T2D during pregnancy.

Insulin can be administered through either multiple daily injections or insulin pump technology in pregnant women with T1D.

The advantage of insulin lies in its well-established safety and efficacy, with a long history of use in pregnancy. It allows precise control of BGCs, ensuring optimal maternal and fetal outcomes. Metformin presents an alternative approach for the treatment of GDM, demonstrating potential benefits such as a decreased risk of neonatal hypoglycemia and reduced maternal weight gain, when compared with the use of insulin.

As a result, the potential impact of metformin on the developing fetus should be carefully considered and the benefits and risks weighed when choosing a treatment option. Close monitoring and consultation with healthcare professionals are key to ensure the well-being of both the mother and the baby.

Glyburide, a sulfonylurea, is generally the least-preferred drug for GDM treatment. Numerous meta-analyses and systematic reviews have consistently indicated that glyburide is linked to a heightened occurrence of neonatal hypoglycemia, macrosomia, and increased abdominal circumference in newborns compared with insulin or metformin treatments.

Moreover, glyburide has not demonstrated noninferiority to insulin regarding a combined outcome measure comprising neonatal hypoglycemia, macrosomia, and hyperbilirubinemia.

It is also important to note that glyburide can cross the placenta, potentially raising concerns about its impact on the fetus. In the postpartum period, managing GDM involves monitoring BGCs and making timely adjustments to insulin dosages during the early postpartum days.

This is essential due to insulin requirements typically decreasing by approximately half compared with the pregnancy stage. Healthcare providers should discuss and implement a contraceptive plan with all individuals having diabetes of reproductive potential to facilitate family planning and manage pregnancy-related risks.

For recent cases of GDM, it is advisable to conduct screening between 4 to 12 weeks after childbirth. This screening should involve the g oral glucose tolerance test and the utilization of diagnostic criteria applicable outside of pregnancy. However, blood sugar implications should be considered when choosing between breastfeeding and formula feeding.

Continued postpartum care is critical, with regular screening for T2D or prediabetes recommended throughout life, every 1 to 3 years for those with previous GDM. Individuals with a history of GDM should actively pursue preconception screening and care to identify and manage hyperglycemia and prevent congenital malformations.

Regular monitoring of BGCs and follow-up with physicians are necessary even if some patients do not require insulin postpartum. Regular screenings for T2D should be promoted for long-term health management. Healthcare providers should emphasize blood sugar monitoring, dietary management, physical activity, and medication management, considering prior prescriptions for GDM.

For breastfeeding patients, awareness of blood sugar impact is essential, requiring close monitoring and potential diet or medication adjustments.

In managing a patient with GDM, pharmacists have several important responsibilities. First, they can review and assess the medications prescribed to the patient, ensuring that they are appropriate, safe, and effective for managing the condition.

This may include insulin or oral medications used to control BGCs. Additionally, pharmacists offer medication counseling to patients, providing comprehensive education about their prescribed medications.

This includes guidance on administering insulin injections correctly, using glucose monitoring devices, and understanding potential side effects and drug interactions. Pharmacists can educate patients about the condition itself, including its causes, risk factors, and long-term implications.

Additionally, they provide information on self-care measures, such as foot care, stress management, and the importance of regular prenatal and postpartum check-ups.

BGM is a vital part of managing GDM, and pharmacists play a significant role in this area. Pharmacists provide information on optimal BGC ranges, assist patients in understanding their results, and provide advice on appropriate steps based on their readings.

They may also recommend suitable glucose monitoring devices and provide instructions on device maintenance. Simultaneously, lifestyle modifications are essential for managing GDM, and pharmacists offer valuable guidance in this regard. They provide advice on maintaining a healthy weight, following a nutritious diet, and engaging in regular exercise.

The rising prevalence of GDM presents a significant challenge that requires vigilant monitoring and effective management. Its intricate pathophysiology, involving hormonal, metabolic, and placental factors, emphasizes the importance of early screening through recognition of risk factors such as elevated BMI, sedentary lifestyle, prediabetes, and family history.

Timely identification allows for appropriate treatment, with insulin being the most preferred option, followed by metformin and glyburide with careful consideration. Postpartum care is crucial in evaluating glucose metabolism and reducing the risk of T2D development.

The involvement of pharmacists in counseling and patient education plays a vital role in supporting better outcomes and reinforcing the necessity of a comprehensive healthcare approach to effectively manage GDM for healthier pregnancies and lives. Gestational diabetes.

December 30, Accessed August 18, McIntyre HD, Kapur A, Divakar H, Hod M. Gestational diabetes mellitus—innovative approach to prediction, diagnosis, management, and prevention of future NCD—mother and offspring. Front Endocrinol Lausanne.

Kampmann U, Knorr S, Fuglsang J, Ovesen P. Determinants of maternal insulin resistance during pregnancy: an updated overview. J Diabetes Res. National Library of Medicine. Type 1 diabetes: MedlinePlus.

February 10, Amiri FN, Faramarzi M, Bakhtiari A, Omidvar S. Risk factors for gestational diabetes mellitus: a case-control study. Am J Lifestyle Med. Egan AM, Enninga EAL, Alrahmani L, et al. Recurrent gestational diabetes mellitus: a narrative review and single-center experience.

J Clin Med. Miller C, Lim E. The risk of diabetes after giving birth to a macrosomic infant: data from the NHANES cohort. Matern Health Neonatol Perinatol. ElSayed NA, Aleppo G, Aroda VR, et al. Classification and diagnosis of diabetes: Standards of Care in Diabetes— The likelihood of severe neonatal hypoglycemia following metformin therapy is lower than it is after insulin administration for the same reason.

Taking insulin carries a higher risk of developing hypoglycemia than taking oral diabetes medications. Metformin rapidly penetrates the placental barrier, however, the fetus's quantities are probably quite low, and there haven't been any reports of any fetal adverse effects such as congenital abnormalities.

No cases of neonatal lactic acidosis have been reported, and it is not believed to be teratogenic. Neonatal hypoglycemia has been connected to maternal hyperglycemia after birth rather than being a side effect of metformin directly.

Metformin is a Pregnancy Category B drug according to the FDA [41]. Patients should be told about the possibility of deleterious effects on the mother before beginning metformin medication.

The most concerning possible adverse effect, lactic acidosis, was avoided by slowly increasing the dosage. There is not much research in the last 10 years about how metformin and insulin work better together in GDM.

According to their findings, insulin monotherapy and concurrent metformin treatment in GDM women resulted in similar obstetric and neonatal adverse outcomes.

However, when both medications were taken at the same time, there were no positive effects on weight gain or insulin dosage that were anticipated [43,44]. Pharmacological use and properties: A second-generation sulfonylurea, glyburide mainly increases pancreatic and peripheral tissue insulin sensitivity.

The receptor of sulfonylurea, which is a part of the ATP-sensitive potassium channels in pancreatic beta cells, is blocked by the medication as part of its mechanism of action. Glyburide binds mostly to albumin and has a high degree of lipophilicity. Glyburide was first thought to be incapable of crossing the placenta.

To contradict earlier in vitro research, Langer, et al. According to these findings, glyburide can cross the placenta [45]. An effective substitute for glyburide is insulin injection.

Despite being an FDA category C medicine, glyburide is nevertheless often used since it is less dangerous than the insulin analogues detemir, lispro, and aspart, which are all pregnancy risk factor B medications. When self-monitoring of blood glucose levels and storage of insulin is not possible or if a patient has a fear of needles, glyburide may be the better option.

In addition, glyburide is less expensive than insulin or metformin, has fewer side effects, and is simpler to administer. Glyburide's safety and effectiveness for individuals with gestational diabetes mellitus are not yet apparent, and further study is required to make these determinations [46].

Efficacy and safety: In , a clinical trial contrasting glyburide and insulin for the management of GDM was reported in the New England Journal of Medicine. The first randomized and controlled research on the topic was carried out by Langer, et al. The study split GDM-afflicted women into two groups, giving of them glyburide and the rest insulin.

The study found no discernible difference in the two groups' newborn outcomes, such as macrosomia, high blood glucose levels, hospitalization to the neonatal critical care unit, etc.

The degree of glycemic control between the two groups, according to the authors, was likewise comparable. In another study, two groups were evaluated, and there was no proof that using glyburide rather than subcutaneous insulin increased the risk of perinatal issues.

A retrospective cohort study, however, discovered that babies delivered by glyburide-treated mothers were more likely to experience difficulties than babies born to moms who were on insulin [47]. The problems identified were preterm delivery, Caesarean section, respiratory distress hypoglycemia, large for gestational age, jaundice, birth damage, and admission to the neonatal ICU.

A recent meta-analysis looked at seven trials to calculate the efficiency and security of Oral Anti-Diabetic OAD drugs for GDM. Regarding glycemic control, the researchers found no distinction between glyburide and insulin. However, glyburide medication was associated with an increased risk of macrosomia, high maternal weight gain, high neonatal birth weight, and newborn hypoglycemia.

Another meta-analysis compared pregnancies handled with glyburide against pregnancies treated with insulin. The researchers discovered that glyburide significantly increased the risk of macrosomia compared to insulin and was also linked to a higher likelihood of infant hypoglycemia. Glyburide had the poorest ranking in the most recent meta-analysis due to its high incidence of hyperbilirubinemia, macrosomia preeclampsia, and neonatal hypoglycemia.

Use of glyburide should be treated cautiously because it has been linked to weight gain and hypoglycemia in pregnant women, especially when taken on an empty stomach [48].

Pharmacological use and properties: The alpha-glucosidase inhibitor acarbose stops the digestive enzymes of the small intestine from breaking down starches into simple sugars.

Postprandial glucose concentrations are consequently decreased. Nevertheless, using it could result in intestinal issues.

Due to a lack of well-established research on its effects during pregnancy, it is not recommended to use acarbose to treat gestational diabetes. Instead, safer and more advantageous alternatives like insulin and metformin should be taken into account [49].

Efficacy and safety: In Brazil, a person randomized prospective research assessed the effectiveness of glyburide, acarbose, and insulin in the management of GDM.

Though gastrointestinal side effects were more common with Acarbose, the study showed that there were no appreciable differences between acarbose and insulin in fasting or postprandial glucose levels. Even other studies indicated that acarbose is less successful than glyburide at establishing glycemic control, it also showed that acarbose had a reduced incidence of hypoglycemia and macrosomia, making it an appealing drug for further investigations on the treatment of GDM.

Acarbose was deemed an efficient option for GDM control and appeared to be well-tolerated in a subsequent research by Jayasingh, et al. In the research trials, feto-maternal outcomes in pregnant GDM patients treated with insulin or acarbose were compared. Recurring infections, preeclampsia, premature membrane rupture, delivery methods, postoperative random levels of blood glucose, fasting blood glucose level at day 7, fasting blood glucose level after six weeks, and mean birth weight of offspring were not significantly changed between the two groups.

Recent investigations have not found a markedly greater risk of liver damage following acarbose medication, despite the fact that acarbose has been associated with hepatic failure and abnormal liver enzymes in diabetic persons [51]. Acarbose can pass the placenta and is not teratogenic at dosages up to 32 times greater than those used in humans, according to animal studies.

However, the medication has the ability to induce labour by causing stomach cramping and increasing prostaglandin E levels. Research is currently being done to determine whether vitamin and mineral supplements are useful for GDM sufferers. Vitamin E, vitamin D, and magnesium levels have been discovered to be low in GDM patients, despite the fact that these nutrients have been favorably associated with controlled glucose metabolism, anti-inflammatory effects, and decreased oxidative stress when taken as supplements.

Li, et al. most recent meta-analysis backs up these conclusions. Additionally, it has been discovered that providing GDM women with Mg-Zn-Ca-vitamin D co-supplements for six weeks reduces oxidative stress and inflammation. According to Wang, et al. vitamin D supplementation can enhance glycemic management and decrease negative feto-maternal outcomes, such as Caesarean sections, postpartum hemorrhages, hospitalization of mothers, newborn hyperbilirubinemia, big children, fetal distress, polyhydramnios, and preterm birth [52].

Most women with GDM can attain normoglycemia with dietary changes and lifestyle changes, especially when it comes to the kind and quantity of dietary carbs. When taken soon after the diagnosis of GDM, myoinositol, a dietary supplement known to lower insulin resistance, has been demonstrated to be useful in establishing glycemic control and lowering the requirement for further medication [53].

Studies are also being done on the possibilities of treating GDM using herbal remedies and conventional Chinese medicine. Herbs like Zuo Gui Wan, red raspberry tea, and Orthosiphon stamineus have all shown promise in decreasing glucose and relieving GDM-related symptoms, with good safety profiles for both mother and infant.

The glycyrrhiza flavonoids from traditional Chinese medicine have also been demonstrated to have anti-diabetic potential as adjuvants for insulin therapy [54]. Probiotic supplementation is an area of study that shows promise for enhancing glycemic control and lowering GDM-related adverse events, but more research is required to fully appreciate its advantages.

Despite the fact that fresh and promising outcomes are frequently published, dependable and long-lasting results in the field of adjuvant GDM therapy require standardized methods and well-designed trials [55]. GDM is a significant issue that needs to be managed effectively to prevent negative consequences on the mother and fetus.

This chapter discusses potential pharmacological therapies for GDM, their special traits, advantages, and drawbacks. Oral medications like glyburide and metformin are the most recommended first-line therapies, but if optimal glucose control is not achieved, analogues such as aspart, lispro, and detemir may be required.

Patient evaluation is crucial to selecting the best treatment option. Education about the advantages and disadvantages of different treatment modalities is also necessary. Future clinical research will provide more knowledge on the prevention and management of GDM.

The conclusion can be further condensed if needed. Managing gestational diabetes is critical for the healthcare sector to prevent negative outcomes for mothers and infants.

This review article on pharmacological therapies provides an overview of treatment options. However, improvements are necessary. There should be more information on early screening and diagnosis, insulin analogues, complementary therapies, nutrition, and long-term effects on health outcomes.

Patient education and involvement are critical for optimal glycemic control. The article should also clarify the FDA pregnancy risk categories for the medications discussed, especially glyburide.

Incorporating these recommendations can enhance the article's reliability for healthcare providers and expecting mothers. Order for reprints. PTZ: We're glad you're here. Please click "create a new query" if you are a new visitor to our website and need further information from us.

If you are already a member of our network and need to keep track of any developments regarding a question you have already submitted, click "take me to my Query. Toggle navigation. ISSN: Review Article Open Access Peer-Reviewed. Author and article information. Department of Gynecology and Obstetrics Unit-II , Bolan Medical Complex Hospital Quetta, Pakistan.

Received: 23 August, Accepted: 01 September, Published: 02 September, Keywords: Gestation; Diabetes; Management; Therapies; GDM. Cite this as Akram S, Bibi S Review on pharmacological therapies for management of gestational diabetes. Int J Pharm Sci Dev Res 9 1 : DOI: This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Indexing and Abstracting. Main article text. Introduction Gestational Diabetes Mellitus GDM is a distinct endocrine disorder resulting in glucose intolerance that may occur during pregnancy. Current pharmacological options for GDM A. Insulin and its analogues Pharmacological use and properties: Insulin is considered a safe and effective treatment for Gestational Diabetes Mellitus GDM due to its inability to pass through the placenta unless administered in high doses.

Oral anti-hyperglycemic drugs OAD i. Metformin Pharmacological use and properties: The oral biguanide metformin reduces gluconeogenesis in the liver, boosts peripheral insulin sensitivity, and encourages glucose uptake in peripheral tissues while inhibiting gut glucose absorption [26]. Glyburide Pharmacological use and properties: A second-generation sulfonylurea, glyburide mainly increases pancreatic and peripheral tissue insulin sensitivity.

Acarbose Pharmacological use and properties: The alpha-glucosidase inhibitor acarbose stops the digestive enzymes of the small intestine from breaking down starches into simple sugars.

Supplementation and traditional treatment options Research is currently being done to determine whether vitamin and mineral supplements are useful for GDM sufferers. Conclusion GDM is a significant issue that needs to be managed effectively to prevent negative consequences on the mother and fetus.

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Fundamental Structure of Intensified Therapy

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Kijmanawat A, Panburana P, Reutrakul S, Tangshewinsirikul C. Effects of probiotic supplements on insulin resistance in gestational diabetes mellitus: A double-blind randomized controlled trial. Written By Miroslav Radenković and Ana Jakovljević. If you have gestational diabetes, the chances of having problems with the pregnancy can be reduced by controlling your blood sugar glucose levels.

You'll also need to be more closely monitored during pregnancy and labour to check if treatment is working and for any problems. You'll be given a testing kit that you can use to check your blood sugar glucose level. This involves using a finger-pricking device and putting a drop of blood on a testing strip.

If you take insulin and have problems with low blood sugar hypoglycaemia or your blood sugar is not stable, your care team might offer you a continuous glucose monitor CGM. This is a small sensor you wear on your skin that sends data wirelessly to a receiver or a mobile phone, so you can see your blood sugar level at any time.

Diabetes UK has more information about checking your blood sugar levels. You should be referred to a dietitian, who can give you advice about your diet and how to plan healthy meals. It's also important to be aware of foods to avoid during pregnancy , such as certain types of fish and cheese.

Diabetes UK: What can I eat with gestational diabetes? Diabetes UK: Glycaemic index GI and diabetes. Physical activity lowers your blood glucose level, so regular exercise can be an effective way to manage gestational diabetes. You'll be advised about safe ways to exercise during pregnancy.

Find out more about exercise in pregnancy. A common recommendation is to aim for at least minutes 2 hours and 30 minutes of moderate-intensity activity a week, plus strength exercises on 2 or more days a week. You may be given medicine if your blood sugar levels are still not stable 1 to 2 weeks after changing your diet and exercising regularly, or if your blood sugar level is very high when you're first diagnosed.

This may be tablets — usually metformin — or insulin injections. Your blood sugar levels can increase as your pregnancy progresses, so even if they improve at first, you may need to take medicine later in pregnancy. Metformin is taken as a tablet up to 3 times a day, usually with or after meals.

You inject insulin using an insulin pen. This is a device that helps you inject safely and take the right dose. Using an insulin pen does not usually hurt. The needles are very small, as you only inject a small amount just under your skin.

You'll be shown where to inject and how to use your pen. Depending on the type of insulin you're prescribed, you may need to take it before meals, at bedtime, or on waking.

You will be told how much insulin to take. Blood sugar levels usually increase as pregnancy progresses, so your insulin dose may need to be increased over time.

Insulin can cause your blood sugar to fall too low hypoglycaemia. Symptoms of low blood sugar include feeling shaky, sweaty or hungry, turning paler than usual, or finding it difficult to concentrate.

If this happens, test your blood sugar, and treat it straight away if it's low. Find out how to treat low blood sugar. You'll be given information about hypoglycaemia if you're prescribed insulin. Find out more about types of insulin and how to take it.

Gestational diabetes can increase the risk of your baby developing problems, such as growing larger than usual. Because of this, you'll be offered extra antenatal appointments so your baby can be monitored. The ideal time to give birth if you have gestational diabetes is usually around weeks 38 to If your blood sugar is within normal levels and there are no concerns about your or your baby's health, you may be able to wait for labour to start naturally.

However, you'll usually be offered induction of labour or a caesarean section if you have not given birth by 40 weeks and 6 days.

Related CE

Corresponding Author: Monique M. Hedderson PhD, Division of Research, Kaiser Permanente Northern California, Broadway, 3rd Floor, Oakland, CA Monique.

hedderson kp. Author Contributions : Dr Hedderson had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Acquisition, analysis, or interpretation of data: Hedderson, Badon, Pimentel, Xu, Regenstein. Drafting of the manuscript: Hedderson, Badon, Pimentel, Regenstein, Neugebauer.

Critical revision of the manuscript for important intellectual content: Hedderson, Badon, Xu, Regenstein, Ferrara. Conflict of Interest Disclosures: Drs Neugebauer and Hedderson reported receiving grants from the National Institute of Diabetes and Digestive and Kidney Diseases during the conduct of the study.

No other disclosures were reported. Dr Neugebauer was supported by grant P30DK from the Diabetes Research for Equity through Advanced Multilevel Science Center for Diabetes Translational Research.

Meeting Presentations: This study was presented as a poster presentation at the Annual Meeting of the International Society of Pharmacoepidemiology; August , ; Prague, Czech Republic.

full text icon Full Text. Download PDF Comment. Top of Article Key Points Abstract Introduction Methods Results Discussion Conclusions Article Information References. Analytic Cohort Creation for Comparison of Glyburide vs Insulin Treatment on Subsequent Perinatal Outcomes. View Large Download.

Table 1. Table 2. Risk Estimates and Differences for Neonatal and Perinatal Outcomes for Glyburide and Insulin Accounting for Changes in Medication Therapy After Initial Medication Therapy Per-Protocol Analyses a.

Table 3. Risk Estimates and Differences for Neonatal and Perinatal Outcomes for Glyburide and Insulin Treatment Without Accounting for Changes in Medication Therapy After Initial Medication Therapy Intention-to-Treat Analyses.

List of Covariates Considered in the Analyses and Whether They Are Assumed to Be Associated With Outcomes or Exposure Decisions eTable 2. Cutoff Values Used to Discretize Continuous Covariates eTable 3. Super Learner Estimator for the Probability of Glyburide Initiation in the First 7 Days After Study Entry Given Baseline Covariates for Per-Protocol Analysis eTable 4.

Super Learner Estimator for the Probability of Insulin Initiation in the First 7 Days After Study Entry Given Baseline Covariates Among Patients Who Did Not Initiate Glyburide at Study Entry for Per-Protocol Analysis eTable 5.

Super Learner Estimator for the Probability of Continuing Glyburide After the First Follow-up Interval Given Past Covariates Among Patients Who Were Continuously Exposed to Glyburide Previously for Per-Protocol Analysis eTable 6.

Super Learner Estimator for the Probability of Continuing Insulin After the First Follow-up Interval Given Past Covariates Among Patients Who Were Continuously Exposed to Insulin Previously for Per-Protocol Analysis eTable 7.

Super Learner Estimator for the Probability of Glyburide Initiation on Index Date Given Baseline Covariates eTable 8. DeSisto CL, Kim SY, Sharma AJ. Prevalence estimates of gestational diabetes mellitus in the United States, Pregnancy Risk Assessment Monitoring System PRAMS , doi: Wendland EM, Torloni MR, Falavigna M, et al.

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A structural approach to selection bias. Errors in Abstract, Table, and Article Information. See More About Obstetrics and Gynecology Diabetes Diabetes and Endocrinology Pregnancy Obstetrics Women's Health Neonatology Pediatrics. Sign Up for Emails Based on Your Interests Select Your Interests Customize your JAMA Network experience by selecting one or more topics from the list below.

Get the latest research based on your areas of interest. Weekly Email. Monthly Email. Save Preferences. Privacy Policy Terms of Use. Marc Rendell, M. The Association of Diabetes Investigators. The authors are to be commended for presenting the Kaiser experience in treating gestational diabetes, clearly with an institutional decision to utilize glyburide rather than insulin as a first step.

They present data for neonatal hypoglycemia, jaundice, C sections, shoulder dystocia, NICU admission, birthweight-for—gestational age category, and small-for—gestational age birth weight. Can report the incidence of fetal anomalies by treatment?

CONFLICT OF INTEREST: None Reported. Monique Hedderson, PhD Kaiser Permanente Northern California. I appreciate the suggestion to look at the incidence of fetal anomalies by treatment.

Unfortunately, we did not collect that data as part of this study. View Correction. This Issue. Views 5, Citations 4. Submitted: 06 August Reviewed: 02 September Published: 08 October com customercare cbspd. The incidence of gestational diabetes mellitus GDM is still rising, and this pathological condition is strongly associated with some serious adverse pregnancy outcomes.

Therefore, GDM must be timely recognized and adequately managed. Treatment of GDM is aimed to maintain normal glycemia and it should involve regular glucose monitoring, dietary modification, lifestyle changes, moderate physical activity, and pharmacotherapy, when necessary.

As for the pharmacotherapy, needed in approximately one-third of GDM women, insulin administration is the first choice of pharmacological treatment, although oral hypoglycemic drugs, for example, metformin a biguanide agent or glyburide a second-generation sulfonylurea drug , could be indicated, too.

Metformin is considered as a reasonable and safe first-line alternative to insulin. If comparing two oral agents, metformin seems to be safer than glyburide, since glyburide was found to be linked to neonatal hypoglycemia and higher birth weight, which can for example increase the hazard for shoulder dystocia and a necessity for Cesarean delivery.

Finally, it should be underlined that many pregnant women turn to complementary and alternative medicine for health maintenance or symptom relief, including traditional herbal medicine and the use of supplements.

Given the previous facts, this chapter will address current pharmacotherapy options and challenges related to GDM treatment. Gestational diabetes mellitus GDM is well-described endocrinopathy, referring to any degree of glucose intolerance that develops or else is initially recognized during pregnancy.

Today, it is recognized that GDB is most probably a consequence of complex and quite diverse interactions between genetic-epigenetic-environmental factors [ 1 , 2 , 3 ]. GDM is characterized by aberrant fetoplacental vascular function, insulin resistance, and impaired insulin production [ 5 ].

Numerous fetal issues have been linked to GDM, for example, macrosomia birthweight over g , a higher stillbirth risk, birth trauma, a higher percentage of Cesarean delivery, and newborn hypoglycemia [ 6 ]. Most of these have been particularly positively linked to considerable maternal weight fluctuations in GDM [ 7 ].

Although today it has become very clear that timely screening and diagnosis even before 20 weeks gestation of GDM in at-risk women is more than required for clinically desirable maternal and fetal outcomes [ 8 ], in this context, new predictive and diagnostic biomarkers for GDM represent a critical state-of-the-art topic [ 9 ].

To circumvent hyperglycemia and its negative effects on fetal growth, pregnant women diagnosed with gestational diabetes are initially managed with individualized medical nutrition therapy and light exercise. This promising finding certainly requires further elucidation.

Insulin has generally been recognized as the first-line drug because it is effective and does not cross the placenta. Other treatment strategies, oral antidiabetic drugs OAD such as metformin or glyburide, have been used in recent years given that insulin therapy has several downsides in GDM.

Some of them are the absence of a clear dose definition, the need for multiple daily injections, the risk of hypoglycemia, and elevated maternal weight gain [ 12 ]. In accordance with previous facts, up-to-date results of available meta-analyses on the effects of antidiabetic pharmaceuticals estimated that if we look to the majority of adverse neonatal outcomes, metformin was ranked to be the superior treatment over insulin or glyburide, whereas the lower risk of adverse maternal outcomes was primarily linked to glyburide administration [ 14 ].

These divergent effects require additional caution in their use [ 8 ]. Lots of knowledge has been accumulated regarding GDM screening and timely treatment; however, the secondary prevention in women following GDM, as well as in their offspring, represents an important scientific challenge for all of us in many years to come [ 15 ].

In this review, we look at how insulin and other oral hypoglycemic medications are used to treat women with GDM, emphasizing on their efficacy and safety. Supplement-related and other alternative pharmacotherapy will be addressed, as well. Insulin, due to its huge molecular size, does not pass the placenta unless at extremely high doses [ 16 ].

It has a great fetal safety profile; it attains tight maternal glucose control and is therefore recommended as a gold standard, and the first-line treatment for women with GDM.

Insulin is not teratogenic, and there is also no evidence that any of them are excreted in human milk [ 17 ]. Currently, available insulin analogs are rapidly acting analogs, including aspart and lispro, short-acting regular insulin, intermediate-acting NPH insulin, or longer-acting insulin analogs, such as glargine and detemir [ 18 , 19 ].

Insulin is the therapy of choice for women who have failed to meet their glycemic treatment goals despite making lifestyle changes—diet and exercise [ 2 ]. It can also be used by those who are unable to tolerate the adverse effects of other OADs. Based on the time of recurrent hyperglycemia, there are two major ways of prescribing insulin.

Insulin can be given in divided doses throughout the day or as a single daily dose. Intermediate insulin, such as NPH or detemir, should be given as a single dose at bedtime in GDM women who have hyperglycemia solely in the morning fasting state.

Rapid-acting insulin should be administered before a meal in women who have postprandial hyperglycemia. Hyperglycemia during the day should be controlled with a combination of intermediate- or long-acting and short-acting insulin [ 20 ].

Close blood glucose monitoring is required while prescribing insulin to avoid hypoglycemia or hyperglycemia. They reach a concentration peak sooner than regular insulin and show a shorter duration of action 3—5 h [ 21 ]. In comparison with human insulin, which must be administered 30 minutes before a meal, rapid-acting insulin analogs can be given 5—10 minutes before a meal, making them more convenient [ 22 ].

Basal insulin, also known as intermediate-acting and long-acting insulin, is primarily used to give a constant supply of the modest amounts of insulin to regulate lipolysis and avoid hepatic gluconeogenesis, regardless of meal intake.

Although insulin treatment has traditionally been the drug of choice for treating hyperglycemia in GDM after medical nutrition and physical exercise, it is not without limitations. Many pregnant women face issues with insulin administration, including gaining weight, balancing dosage, diet, and, for some, the frequency of hypoglycemic episodes.

For that reason, there are quite a few reports currently suggesting metformin as the first-line agent having an equivalent efficacy vs. insulin, yet with less hypoglycemia than insulin [ 23 ]. Short-acting insulin has been connected to an augmented risk of hypoglycemia and glycemic control changes in those with GDM.

In randomized clinical investigations comparing detemir to NPH for intermediate- and longer-acting insulin, there was no difference in glucose management or perinatal outcomes. Detemir has been linked to a lower risk of hypoglycemia in diabetics who are not pregnant [ 25 ].

Metformin, an oral biguanide, works by reducing liver gluconeogenesis, increasing peripheral insulin sensitivity, and also promoting glucose uptake in peripheral tissues while lowering glucose absorption in the gut [ 26 ]. Several mechanisms are responsible for higher insulin sensitivity including the augmented activity of insulin receptor tyrosine kinase, enhanced synthesis of glycogen, reduction of glycogenolysis, decreased activity of hepatic glucosephosphatase, and an increase in the recruitment and activity of GLUT4 glucose transporters [ 27 ].

Despite identical glycemic control, metformin was related to lower cardiovascular, as well as all-cause mortality if paralleled to sulphonylureas and insulin in a long-term prospective study of type 2 diabetes. The RISK pathway activation via increased AMPK activity may be responsible for this effect [ 29 , 30 ].

Organic cation transporters OCTs transport metformin across the mitochondrial membrane at the cellular level. Since the placenta expresses many OCT isoforms, metformin crosses the placenta easily during pregnancy. Concerns about potential negative effects on fetal development arise from transport via the placenta into the developing fetus.

Although it is unknown if OCTs are expressed in human embryos, we know that pre-implantation human embryos have limited mitochondrial capacity making them resistant to metformin [ 31 , 32 ]. In Metformin in gestational diabetes study MiG , children aged 2 exposed to metformin during pregnancy were compared to children of the same age whose mothers were on insulin during pregnancy.

Children exposed to metformin had comparable overall body fat, yet more subcutaneous fat over intra-abdominal fat compared to children exposed to insulin, thus suggesting that metformin treatment may lead to a more advantageous pattern of fat distribution than insulin [ 33 ].

Only recently there has been evidence to support the use of metformin for the management of GDM. It has, however, been used in early pregnancy and all through pregnancy for additional indications for decades.

Metformin can help women with the polycystic ovarian syndrome to establish regular ovulation and to enhance conceiving odds, and by using it during the first trimester to lower the incidence of spontaneous abortion [ 34 ].

Despite this, it was not until the metformin in Gestational Diabetes trial, presented by Rowan et al. in , was widely reported as an effective treatment for GDM [ 36 ].

In the gestational diabetes trial [ 36 ], women were randomly assigned to either metformin or standard treatment, that is, insulin. The key outcome was a combination of neonatal hypoglycemia 2. Women who took metformin gained considerably less weight from enrolment to term than those who took insulin.

Other parameters considered in the metformin and insulin clusters were similar, including birth weight, neonatal anthropometrics, and odds for large for gestational age.

However, when compared to insulin therapy, the incidence of severe hypoglycemia 1. This research also discovered that patient acceptability for metformin was substantially better than with insulin; when questioned if they would select it yet again for future pregnancies, 77 percent of metformin users replied yes, compared to only 27 percent of insulin users.

A group of GDM women merely treated with metformin vs. Maternal risk factors were similar in both groups. The rates of preeclampsia, prenatal hypertension, and Cesarean section were identical, but an average maternal gain of weight from enrolment to term was considerably lower in the metformin group, just as it was in the MiG study.

When compared to women who were treated with insulin, women who were given metformin had a lower rate of preterm, neonatal jaundice, and admission to a neonatal unit, as well as an overall improvement in newborn morbidity [ 37 ].

Post-prandial glycemic levels may indeed be of importance when comparing metformin to other treatment options. A meta-analysis of three randomized controlled studies of GDM women found lower post-prandial glucose in metformin as opposed to insulin-treated patients, though these disparities did not meet statistical significance [ 38 ].

Metformin did not raise the risk of preterm delivery or Cesarean section, as reported in a latest systematic review, nor did it raise the risk of small for gestational age newborns. Metformin, on the other hand, was linked to a lower risk of preterm birth, newborn hypoglycemia, and admission to neonatal intensive care units, as well as a decreased prevalence of pregnancy-induced hypertension [ 39 ].

Because metformin is not stimulating the secretion of insulin, it does not provoke maternal hypoglycemia, which is a side effect that remains a concern with glyburide.

For the same reason, severe neonatal hypoglycemia is less likely to occur after metformin administration compared to insulin [ 14 ].

Accordingly, hypoglycemia is a greater risk if taking insulin, than with OAD [ 40 ]. Metformin, on the other hand, crosses the placental barrier easily due to its low molecular mass, hydrophilic nature, and lack of protein binding [ 41 ]. Metformin concentrations in the fetus are likely minimal and no fetal side effects, such as congenital malformations, have been detected [ 42 ].

It is not thought to be teratogenic, as evidenced by decades of use in preconception and early pregnancy. There have been no reports of newborn lactic acidosis, and neonatal hypoglycemia has been related to maternal hyperglycemia during delivery rather than a direct side effect of metformin.

Before starting metformin treatment, patients should be informed about the potential for maternal adverse effects. Lactic acidosis, the most worrying potential side effect, was prevented by gradually raising the dose [ 43 ].

One final question could be certainly related to the eventual advantageous co-administration of metformin and insulin in GDM. Scarce reports have been published over the past decade; however, Chaves et al.

Moreover, the authors reported that expected beneficial effects on weight gain and insulin dose were simply not detected if both drugs were used in a parallel manner [ 44 ].

Glyburide is a second-generation sulfonylurea that acts mainly by increasing the secretion of insulin from the pancreas and improving the insulin sensitivity of peripheral tissues.

These actions can be detected after a block of the sulfonylurea receptor, which is actually a part of the ATP-sensitive potassium channel in the pancreatic beta cells [ 45 ]. Glyburide is lipophilic and significantly bound to albumin [ 46 ]. At first, it was assumed that glyburide did not cross the placenta.

Langer et al. The reason behind that is that they used liquid chromatography with a limit of detection of 10 ng per milliliter [ 13 ]. There is an obvious option to glyburide and that is insulin administration.

Even though glyburide is an FDA category C drug, compared to insulin analogs lispro, detemir, and aspart that are all pregnancy risk factor B medications, glyburide is still widely used.

The situation where glyburide is a better choice is where self-monitoring of glucose blood levels needed for insulin or insulin storage is not possible or where a patient has a severe needle phobia.

Another benefit of using glyburide is that it is a low-cost oral agent, easy to take with few side effects. Also, glyburide is, as an oral agent just like metformin, easier to use compared to insulin [ 41 ].

Nevertheless, the other use of glyburide during pregnancy for GDM patients is still unclear and needs to be comprehensively elucidated [ 48 ]. The New England Journal of Medicine published a clinical investigation comparing glyburide versus insulin in management of GDM in , which transformed the management of GDM.

Namely, Langer et al. Results did not show any significant difference between the two clusters in neonatal outcomes by measuring high blood glucose concentrations, the incidence of macrosomia, admission to neonatal intensive care unit, etc. The authors also noted that the extent of glycemic control between the two groups was similar.

A different study comparing macrosomia, neonatal hypoglycemia, and hyperbilirubinemia in two groups found no evidence that using glyburide instead of subcutaneous insulin leads to a higher rate of perinatal problems [ 50 ].

On the contrary, a retrospective cohort study analyzed data from women diagnosed with GDM and treated with glyburide opposite to insulin days before delivery [ 37 ]. It was found that newborns delivered by women treated with glyburide were more expected to have complications than those delivered by mothers who were taking insulin.

Complications noted were preterm birth, Cesarean delivery, hypoglycemia, respiratory distress, jaundice, birth injury, large for gestational age, and hospitalization in the neonatal ICU [ 51 ]. to assess the efficacy and safety of oral anti-diabetic OADs medicines for GDM.

In terms of glycemic management, the investigators did not find any difference between glyburide and insulin. Glyburide therapy, on the other hand, is linked to a higher risk of neonatal hypoglycemia, high neonatal birth weight, high maternal weight gain, and macrosomia [ 52 ].

A group of glyburide-managed pregnancies and insulin-treated pregnancies were evaluated in the Jiang meta-analysis comparing the efficacy and safety of OAD for GDM [ 52 ].

Despite no dissimilarity in glycemic control, the authors found that glyburide caused considerably more macrosomia than insulin OR: 3. Glyburide was also associated with a greater rate of newborn hypoglycemia than insulin OR: 2.

There was no difference in weight growth, Cesarean delivery rate, or preeclampsia between NICU admissions or premature births. Finally, it has to be underlined that glyburide was ranked the worst in the recent meta-analysis, with the highest rates of macrosomia, hyperbilirubinemia, preeclampsia, neonatal hypoglycemia, low birth weight, preterm birth, and metformin plus insulin when needed had the lowest rates of pregnancy hypertension, macrosomia, LGA, RDS, preterm birth, and low birth weight [ 53 ].

Besides, one has to be very cautious with glyburide use, which was shown to be associated with weight gain, as well as maternal hypoglycemia, especially when taken without any food [ 45 ]. As a result, the rise in postprandial glucose concentrations is lowered.

Its use is usually linked to gastrointestinal complications. Acarbose is not usually recommended for the treatment of GDM, because it has not been thoroughly researched during pregnancy and considering safer and more acceptable options, with more information regarding treating GDM, such as insulin and metformin.

Neonatal hypoglycemia occurred in one acarbose-treated subject, one insulin-treated subject, and eight glyburide-treated subjects. Although in this short trial, failure to achieve glycemic control with acarbose was higher if compared to glyburide, the decreased incidence of hypoglycemia and macrosomia underlines acarbose as an appealing agent to investigate in future GDM treatment studies.

Accordingly, in the recent investigation published by Jayasingh et al. Namely, this prospective, open-label, and controlled study was designed to compare the fetomaternal outcomes in pregnant women with GDM designated to insulin or acarbose group.

Thus, no difference was found if the following parameters were paralleled in between the groups: the incidence of recurrent infections, preeclampsia, or premature rupture of membranes; then the modes of delivery, mean postoperative random blood glucose, fasting blood glucose level at day 7 and after 6 weeks; and finally difference in the mean birth weight of offspring born to mothers treated with either of the two pharmacological agents.

Even though using acarbose in diabetic patients has been linked to abnormal liver enzymes and hepatic failure, a newer study did not show a higher risk of liver injury during acarbose treatment [ 57 ].

Acarbose can pass through the placenta. In pregnant animal investigations, doses up to 32 times higher than the human dose were not proven to be teratogenic.

On the other hand, it induces stomach cramps and may raise prostaglandin E, suggesting that it possess the potential ability to induce labor [ 58 ]. The efficacy of vitamin and mineral supplementation in GDM patients is still under investigation.

However, today is known that in GDM, low levels of vitamin D, vitamin E, and magnesium have been detected, whereas glucose metabolism, anti-inflammatory, and anti-oxidative stress have been all positively regulated after vitamin D, vitamin E, magnesium, and selenium supplementation, which was also confirmed in the very recent meta-analysis reported by Li et al.

In the same manner, 6-week-long Mg-Zn-Ca-vitamin D co-supplementation reduced biomarkers of inflammation and oxidative stress in GDM women [ 60 ]. To continue, the improvement in glycemic control and decline of adverse fetomaternal outcomes after vitamin D supplementation including Cesarean section, postpartum hemorrhage, maternal hospitalization, neonatal hyperbilirubinemia, giant children, fetal distress, polyhydramnios, premature delivery was underlined by Wang et al.

Dietary adjustments accompanied with lifestyle modifications are known to achieve normoglycemia in a majority of women with GDM, especially underlining careful attention to type and amount of dietary carbohydrates [ 62 ].

In this context, myoinositol, a dietary supplement knowing to decrease insulin resistance, became extensively investigated [ 63 ]. It represents inositol isomer organically present for example in legumes or nuts, but also synthesized in kidneys and liver to a certain extent. Accordingly, recent findings pointed out that, if started shortly after the GDM diagnosis, myoinositol mg twice daily, per os was shown to be effective in reaching glycemic control and reducing the need for additional pharmacotherapy [ 64 ].

Traditional Chinese medicine and herbal products, known to be broadly utilized during human history, now belong to a very interesting field currently investigated in the frame of GDM [ 65 ]. So far, herbs such as Zuo Gui Wan , red raspberry tea, and Orthosiphon stamineus all provided valid possibilities in reducing glucose and alleviating the GDM-related pathophysiology, and at the same time with good safety profile to the mother and neonate [ 66 ].

In addition, the antidiabetic potential of glycyrrhiza flavonoids from traditional Chinese medicine, as adjuvants for insulin therapy, could be especially beneficial in GDM [ 67 ]. Finally, probiotics supplementation in improving glycemic control and attenuating some of the adverse events related to GDM is a very interesting and appealing scientific issue that needs further elucidation [ 68 , 69 ].

Even though new and promising results are published every day, novel investigations and, most of all, well-designed standardized protocols are needed for obtaining original, comparable, and sustainable results in this field of adjuvant GDM treatment.

In the twenty-first century, GDM poses a significant challenge to health care professionals. The short- and long-term effects of successfully controlling GDM are important for both the mother and the fetus. Most guidelines recommend oral pharmacological therapy, such as glyburide and metformin, and it is now widely used, with data on efficacy and safety.

They can both be used as the first-line option; however, metformin appears to be preferable to glyburide in terms of newborn and maternal outcomes, while it is associated with a higher incidence of failure to achieve appropriate glycemic control.

Analogs such as detemir, aspart, and lispro, which have been thoroughly proved for their safety and efficacy during pregnancy, are indicated as first-line therapy or when oral medication fails to achieve optimal glucose control.

Glargine can be used during pregnancy, while there is not as much data to back it up as there is for other long-acting analogs and human insulins. While insulin has typically been used to treat GDM, both metformin and glyburide may be used, but patients should be informed about the risks and advantages.

Pharmacotherapy of GDM is still under investigation, even though much is known about GDB itself. We can witness that the molecular understanding of GMB has been constantly translated to more efficacious and safer therapeutic options. Still, we expect that coordinated and well-focused basic and clinical investigations will provide even more precise information regarding future choices for prevention and adequate, as well as timely treatment of GDM.

Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution 3. Edited by Miroslav Radenkovic. Open access peer-reviewed chapter Pharmacotherapy of Gestational Diabetes Mellitus: Current Recommendations Written By Miroslav Radenković and Ana Jakovljević.

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Chapter metrics overview Chapter Downloads View Full Metrics. Impact of this chapter. Abstract The incidence of gestational diabetes mellitus GDM is still rising, and this pathological condition is strongly associated with some serious adverse pregnancy outcomes.

Keywords gestational diabetes mellitus treatment insulin metformin glyburide oral antidiabetics. radenkovic med. Introduction Gestational diabetes mellitus GDM is well-described endocrinopathy, referring to any degree of glucose intolerance that develops or else is initially recognized during pregnancy.

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Contributor Medciation. Please read the Disclaimer at the end fiabetes this page. Sports nutrition resources emdication can achieve glucose target Paleo diet meal plan with nutritional getational and moderate exercise alone, but Oral medication for gestational diabetes to 30 percent will require pharmacotherapy [ 1 ]. Even patients with mildly elevated glucose levels who do not meet standard criteria for GDM may have more favorable pregnancy outcomes if treated since the relationship between glucose levels and adverse pregnancy outcomes such as macrosomia exists continuously across the spectrum of increasing glucose levels [ ]. Glucose management in patients with GDM is reviewed here.

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S59 Kulshrestha V, Balani S, Kachhawa G, Vanamail P, Kumari R, Sharma JB, et al. A1C is convenient and the preferred test for patients who have not fasted overnight. See "Screening for type 2 diabetes mellitus", section on 'Screening tests'.

See "Overview of primary prevention of cardiovascular disease". Follow-up of patients not screened for GDM — For patients who did not undergo screening for GDM, but diabetes is suspected postpartum because of newborn outcome eg, hypoglycemia, macrosomia, congenital anomalies , a postpartum GTT may be considered.

A normal postpartum GTT excludes the presence of type 1 or type 2 diabetes or prediabetes; it does not exclude the possibility of GDM during pregnancy and the future risks associated with this diagnosis.

Indications for screening and tests used for screening are discussed separately. See "Screening for type 2 diabetes mellitus". SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. See "Society guideline links: Diabetes mellitus in pregnancy".

These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients.

You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword s of interest.

We suggest glucose self-monitoring before breakfast and at one or at two hours after the beginning of each meal. See 'Glucose monitoring' above. See 'Can the frequency of self-monitoring be reduced? Moderate exercise also improves glycemic control and should be part of the treatment plan for patients with no medical or obstetric contraindications to this level of physical activity.

See 'Rationale for treatment' above and 'Exercise' above. Calories are generally divided over three meals and two to four snacks per day and are composed of approximately 40 percent carbohydrate, 20 percent protein, and 40 percent fat.

Gestational weight gain recommendations are shown in the table table 1. See 'Medical nutritional therapy' above. Pharmacotherapy can reduce the occurrence of macrosomia and large for gestational age in newborns. See 'Indications for pharmacotherapy' above.

We start with the simplest insulin regimen likely to be effective based on the glucose levels recorded in the patient's blood glucose log and increase the complexity as needed. An alternative approach based on both patient weight and glucose levels is somewhat more complex and likely most appropriate for individuals whose glucose levels are not well managed with simpler paradigms.

See 'Insulin' above. The long-term effects of transplacental passage of noninsulin antihyperglycemic agents are not known. See 'Oral hypoglycemic agents' above.

Testing can be performed while the patient is still in the hospital after giving birth. Otherwise it is performed 4 to 12 weeks postpartum and, if results are normal, at least every three years thereafter. See 'Maternal prognosis' above. Why UpToDate? Product Editorial Subscription Options Subscribe Sign in.

Learn how UpToDate can help you. Select the option that best describes you. View Topic. Font Size Small Normal Large. Gestational diabetes mellitus: Glucose management and maternal prognosis. Formulary drug information for this topic.

No drug references linked in this topic. Find in topic Formulary Print Share. View in. Language Chinese English. Author: Celeste Durnwald, MD Section Editors: David M Nathan, MD Erika F Werner, MD, MS Deputy Editor: Vanessa A Barss, MD, FACOG Contributor Disclosures. All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Jan This topic last updated: Nov 16, There were no significant maternal or neonatal harms from treatment of GDM. Insulin Dose — The insulin dose required to achieve target glucose levels varies among individuals, but the majority of studies have reported a total dose ranging from 0.

Follow-up Testing — Long-term follow-up for development of type 2 diabetes is routinely recommended for individuals with GDM, given their high risk for developing the disorder [ 24,43 ].

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February 25, ; NICE Guideline 3: version 2. Hod M, Kapur A, Sacks DA, et al. The International Federation of Gynecology and Obstetrics FIGO Initiative on gestational diabetes mellitus: A pragmatic guide for diagnosis, management, and care.

Int J Gynaecol Obstet ; Suppl 3:S Harper LM, Glover AV, Biggio JR, Tita A. Previous approaches to evaluating the level of glycemia in pregnant diabetic women on a weekly basis or by measuring hemoglobin A 1c at 8- to week intervals failed to provide the information required to optimize pregnancy outcome.

Dietary regulation. For all types of diabetes, the foundation of treatment is diet adherence. We demonstrated in a large prospective study 7 that intensified therapy, in comparison to the conventional approach used for women with GDM, resulted in pregnancy outcomes comparable to the general population.

Independent of the particular treatment modality used and the type of diabetes, memory-based SMBG accurately quantifies the glucose data that set the foundation for achieving success with intensified therapy. Capillary blood glucose monitoring provides the feedback for suitable adjustments to the timing and dose of insulin administration.

Patients with all types of diabetes readily acknowledge and accept SMBG as an expression of patient empowerment because it involves them more in efforts to improve pregnancy outcome. These performance measures are comparable for all ethnic groups; race or ethnicity as a predictor of enduring or successful treatment participation is not a significant factor.

These integrally related components often make the difference between success and failure in diabetes management. SMBG and intensified therapy assist the gravida to achieve glycemic control and enhance perinatal outcome at a lower cost than conventional management.

New pharmacological agents, such as insulin analogs mainly lispro and oral antidiabetic drugs mainly glyburide , have profoundly altered the management of diabetes in pregnancy,producing outcomes comparable to those among the general population. Targeted levels of glycemic control achieved with intensified therapy prevent microvascular and macrovascular complications in nonpregnant diabetic patients.

However, the thresholds for targeted levels of glycemic control are higher than those used for the definition of normoglycemia in nondiabetic pregnant women. Regardless of the treatment modality, the primary goal is always to attain the recommended level of glycemic control, thereby reducing glycemic extremes i.

In pregnancy, the criteria used for targeted levels of glycemic control at our institution are:. How do you know when diet has failed and pharmacological therapy should be initiated?

There is no consensus and there are no hard data to guide this decision. Authoritative organizations differ on the threshold of severity that necessitates pharmacological intervention with glyburide or insulin. Furthermore, the rate of LGA infants was similar regardless of treatment modality diet or insulin.

These complications include an increase in neonatal intensive care unit admission; metabolic, hematological, and respiratory complications; increased rate of accelerated fetal growth;maternal and birth traumas; cesarean delivery; and risk for stillbirth.

In addition, there is an increased rate of congenital malformations in the infants of type 1 and type 2 diabetic women. Conversely, premature initiation of pharmacological therapy in women who could have achieved glycemic control with diet alone leads to unnecessary drug treatment.

When GDM is diagnosed after 30—33 weeks' gestation and there is limited time available to influence the desired level of control, pharmacological intervention is recommended. There is greater flexibility when GDM is diagnosed early in the third trimester.

Different oral hypoglycemic and anti-hyperglycemic agents have diverse mechanisms of action to correct or improve the pathological lesion responsible for glucose intolerance. Therefore, these drugs provide an enhanced approach to the treatment of type 2 diabetes and GDM.

Furthermore, combination therapies will further improve the effect of these drugs on glucose metabolism. Insulin therapy, in contrast to therapy with oral agents, is designed to mimic the physiological secretion of endogenous insulin.

Oral agents are a pragmatic alternative to insulin therapy in pregnancy because they are easy to administer and noninvasive and therefore user-friendly. Since the original study in , 20 many experts and authoritative organizations in the United States e.

The introduction of any new drug in pregnancy will raise concerns about fetal and maternal safety. The ultimate proof that a drug cannot affect the fetus during pregnancy is founded on its inability to cross the placenta. The majority of drugs used in pregnancy cross the placenta.

Thus, even if a new drug crosses the placenta, it remains to be proven that it will cause a teratogenic effect on the fetus in utero. If there is no adverse effect on the fetus, the drug can be used. Glyburide does not cross the placenta.

In contrast, metformin, rosiglitazone, and pioglitazone freely cross the placenta. In the case of metformin with patients who have polycystic ovary syndrome,data from retrospective studies give us hope for its safe use.

The ongoing Metformin in Gestational Diabetes study from Australia and New Zealand is evaluating in a randomized design the efficacy of metformin versus insulin use. Because there is no clinical study to date reporting on the use of thiazolidinediones in pregnancy, these agents should not be prescribed.

Glyburide is the most common oral agent used in GDM and is wholeheartedly endorsed by authoritative organizations.

The drug increases insulin secretion and diminishes insulin resistance by lowering glucose toxicity. Thus,after achieving the targeted therapeutic level, glyburide covers the basal requirement as well as postprandial glucose excursions. The starting dose is 2. If the targeted level of glycemia is not attained, add 2.

If indicated after 3—7 days , add 5 mg in the evening. If the patient does not achieve targeted levels of glycemic control, add long-acting insulin to the regimen or assign the patient to insulin therapy alone Figure 1. Subjects were required to measure their glucose values seven times daily.

Blood glucose profile characteristics before and at the conclusion of therapy were comparable for the two groups. None of the patients developed severe symptoms of hypoglycemia. Neonatal outcomes did not differ significantly between the two groups.

Hypoglycemia is the main side effect of glyburide treatment in non-pregnant women. However, the majority of women with type 2 diabetes who used this drug in the non-pregnant state are older than the average gravida.

Thus, the severity of the hypoglycemia can be less pronounced in the younger age-group of women with GDM. In our original study, 20 we found that hypoglycemic episodes were more common in insulin-treated patients than in those taking glyburide. Thus, although some laboratory hypoglycemic episodes using SMBG or laboratory plasma values may be identified during pharmacological therapy,the rate of these episodes will be significantly lower in glyburide- versus insulin-treated women.

It is customary to evaluate the success rate of a new pharmacological modality that will potentially provide an alternative to the established treatment insulin.

If Glycogen replenishment post-marathon at average risk of gestational diabetes, you'll medicatiln have a screening test during your second gestatkonal — between 24 and 28 gestatiinal of pregnancy. If you're at high risk of diabetes Oral medication for gestational diabetes for example, if you're overweight or obese before pregnancy; you have a mother, father, sibling or child with diabetes; or you had gestational diabetes during a previous pregnancy — your health care provider may test for diabetes early in pregnancy, likely at your first prenatal visit. Initial glucose challenge test. You'll drink a syrupy glucose solution. One hour later, you'll have a blood test to measure your blood sugar level.

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