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Recommendations Summary

GDM: Pharmacological Therapy for Treatment of GDM 2006

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    GDM: Pharmacological Therapy for Treatment of GDM

    When optimal blood glucose levels have not been maintained with medical nutrition therapy (MNT) and/or the rate of fetal growth is excessive, the Registered Dietitian (RD) should recommend the initiation of pharmacological therapy for treatment of women with gestational diabetes mellitus (GDM).  Research indicates that pharmacological therapy, such as the use of insulin, insulin analogs and glyburide, improves glycemic control and reduces the incidence of poor maternal and neonatal outcomes.

    Rating: Strong
    Conditional

    • Risks/Harms of Implementing This Recommendation

      • Use of pharmacological therapy to control blood glucose levels may result in hypoglycemia
      • All medications taken in pregnancy should be reviewed for FDA-approved Pregnancy classification

    • Conditions of Application

      • This recommendation applies to women with gestational diabetes mellitus when optimal blood glucose levels have not been maintained with medical nutrition therapy (MNT) and/or the rate of fetal growth is excessive.
      • Not all healthcare professionals recommend the use of oral antidiabetes agents in pregnancy.

      Recommended target blood glucose levels vary among organizations: 

        Fasting 1-hour 2-hour
      American Diabetes Association

      <105 mg/dL

      <5.8 mmol/L

      <155 mg/dL

      <8.6 mmol/L

      <130 mg/dL

      <7.2 mmol/L

      American College of Obstetrics and Gynecology

      <95 mg/dL

      <5.3 mmol/L

      <130 - 140 mg/dL

      <7.2 - 7.8 mmol/L

      <120 mg/dL

      <6.7 mmol/L

      Fifth International Workshop-Conference on GDM

      90 - 99 mg/dL

      5.0 - 5.5 mmol/L

      <140 mg/dL

      <7.8 mmol/L

      <120-127 mg/dL

      <6.7 - 7.0 mmol/L

    • Potential Costs Associated with Application

      • Although costs of MNT sessions and reimbursement vary, medical nutrition therapy sessions are essential for improved outcomes.
      • Additional costs of medication,  blood glucose monitoring and fetal monitoring

    • Recommendation Narrative

      Twenty-four studies were evaluated to investigate the use of pharmacological therapy for women with gestational diabetes mellitus. 

      • In conjunction with nutrition therapy, pharmacological therapy is indicated in women with gestational diabetes mellitus when optimal blood glucose levels have not been maintained and/or when the rate of fetal growth is excessive (Rossi et al, 2000; Simpson and Kast, 2000; Kjos et al, 2001; Svare et al, 2001; Bonomo et al, 2004; Schaefer-Graf et al, 2004). 
      • Insulin therapy has been shown to be safe and effective in maintaining optimal blood glucose levels and reducing incidence of macrosomia, fetal morbidity and mortality.  Five studies regarding the use of insulin analogs reported that lispro or aspart as rapid acting insulins may improve glycemic control and reduce the incidence of macrosomia in neonates (Franz et al, 1994; Bhattacharyya et al, 2001; Simmons et al, 2001; American Diabetes Association, 2002; Poyhonen-Alho et al, 2002; Pettitt et al, 2003; Leipold et al, 2005). 
      • Research on glargine is limited (Price et al, 2007). 
      • Eight studies reported that glyburide therapy is effective in maintaining glycemic control in conjunction with nutrition therapy, especially in women with less severe disease (Langer et al, 2000; Chmait et al, 2004; Conway et al, 2004; Kremer and Duff, 2004; Yogev et al, 2004; Bertini et al, 2005; Jacobson et al, 2005; Langer et al, 2005).
      • Research on metformin is limited (Hellmuth et al, 2000; Charles et al, 2006).
      • Further research on other antidiabetes agents in women with gestational diabetes mellitus is needed..   

    • Recommendation Strength Rationale

      • Conclusion Statement was given Grade II

    • Minority Opinions

      Consensus reached.