Oral Antihyperglycemic Agents and Diabetes in Pregnancy
Source: Dr. Langer
Key Points
▸ The level of glycemic control achieved—not the mode of therapy—is the key to improving outcomes in GDM and type 2 diabetes in pregnancy.
▸ Medical therapy with oral agents should be reserved for patients whose fasting plasma glucose levels remain above 95 mg/dL (or whose postprandial levels remain above 120 mg/dL) despite diet therapy and for those who are not appropriate candidates for diet therapy alone.
▸ The aim of therapy is to provide the minimal dose that will result in a desirable level of glycemic control and the least amount of complications for the mother.
▸ Well-designed studies have shown no association between oral antihyperglycemic agents and congenital malformations.
▸ Glyburide, metformin, and insulin are equally effective for GDM treatment at all disease severity levels.
▸ Glyburide is as effective as insulin for the treatment of obese GDM patients.
▸ Combination therapy or insulin therapy should be initiated if desired levels of glucose control are not achieved with one oral agent.
▸ Medication is just one component of intensive therapy. “Whole” patient care is also important.
Source: Dr. Langer
Treating Gestational Diabetes
Within our society there are several conditions that are currently demanding a significant amount of our attention. Among them are obesity and diabetes.
In certain populations—in ethnic minority groups and among Native Americans in particular—there has clearly been a rise in gestational diabetes. There is also an association between the increased incidence of diabetes in pregnancy and an increasingly obese population. The two problems, we are learning, are truly entwined.
In the Master Class published in September, we addressed the diabetes pandemic, which some refer to as “diabesity” because of its association with obesity, and how diabetes complicates pregnancy for the mother and threatens fetal development and outcome.
Sometimes diabetes during pregnancy is of the type 2 variety. Gestational diabetes and type 2 diabetes are sometimes confused in their presentation and hence their diagnosis, however. Admittedly, a precise diagnosis of type 2 diabetes is often made in retrospect following the conclusion of the pregnancy. The diagnostic distinction is important, however, as a diagnosis of type 2 diabetes often drives a more serious approach to glycemic control.
In light of the increasing incidence of diabetes in pregnancy, the age-old problem of optimum treatment takes on even more significance.
Diet is still a mainstay. Insulin therapy remains difficult for patients to accept because it requires injections on a daily basis. Oral agents have been avoided for years because of concerns about safety and the lack of well-controlled data to establish whether such agents cross the placenta and may be potentially harmful to the fetus.
We are now at a juncture in our therapeutic maturity, however, where an increasing amount of information and data are available on the use of therapeutic options such as oral antidiabetic agents.
In light of this crossroads—the convergence of significantly more knowledge and a significantly higher prevalence of diabetes—we thought it high time to review the subject of gestational diabetes, and particularly the contemporary therapeutic options that are now available and can be applied in pregnancy.
I have again invited Oded Langer, M.D., Ph.D., who in September discussed why diabetes must be detected early and treated seriously, to discuss the latest research on oral antidiabetic agents in pregnancy and provide some useful perspective on diabetes management in our patient population.
Dr. Langer is an internationally recognized expert on diabetes in pregnancy who has written and lectured extensively on this subject. He is the Babcock Professor and chairman of the department of obstetrics and gynecology at St. Luke's–Roosevelt Hospital Center, a hospital affiliated with Columbia University in New York.
