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Using oral hypoglycemics in pregnancy to manage type 2 gestational diabetes.

Oral hypoglycemic are commonly used to treat type 2 diabetes in non pregnant adults, but data are limited on the safety and efficacy for treatment of pre-existing diabetes in pregnancy. Glyburide is an acceptable alternative to insulin for treatment of gestational diabetes that does not respond to diet and insulin.

Epidemiology/Incidence: Although commonly used in non pregnant adults, data on use of oral hypoglycemic to treat pre-existing diabetes in pregnancy are limited. 

Risk factors/associations: 

  • Glyburide directly stimulates insulin release from the pancreas and is transferred in low-levels across the placenta. 
  • Metformin enhances insulin sensitivity in the liver and peripheral tissues and is readily transferred across the placenta.

Management

  • Given the limited data on safety, especially in the first trimester, women on oral agents should be switched to insulin therapy.
  • Since gestational diabetes is due to inadequate maternal response to increased insulin resistance occurring typically after 20 weeks’ gestation, oral hypoglycemics may be an acceptable alternative to insulin. 
  • Compared to insulin, glyburide does not appear to be associated with an increase in neonatal complications and only 4% of women in a clinical trial required conversion to insulin.
  • Glyburide is started at 2.5 mg once or twice a day and may be increased to a daily maximum of 20 mg.
  • Compared to insulin, metformin does not appear to be associated with an increase in perinatal complications, but 46% of women in a clinical trial required conversion to insulin.
  • Metformin is started at 500 mg once or twice daily and increased to a daily maximum of 2,500 mg.
  • Attainment of euglycemia is the goal of therapy regardless of the therapy utilized and the targets are the same whether insulin or oral agents are used.

Post-partum/breastfeeding: Exposure of infants to oral hypoglycemic agents through breastmilk is minimal; mothers on these agents should be encouraged to breastfeed.



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