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Clinical Question: Is there a role for oral
antihyperglycemics in gestational diabetes and type 2 diabetes during
pregnancy?
Bottom Line: Based on the currently available data, it
appears that glyburide could be safely and effectively utilized in the
management of GDM. However, more intensive investigation regarding the
safety and feasibility of oral agents in pregnancies complicated by type 2
diabetes is necessary. It is important to emphasize that it is the level of
metabolic control achieved and not the mode of therapy that is crucial to
improving outcomes in these pregnancies.
Reference: Treat Endocrinol. 2004;3(3):133-9.Is there a
role for oral antihyperglycemics in gestational diabetes and type 2 diabetes
during pregnancy? Homko CJ, Sivan E, Reece AE.
Study Design: Review
Synopsis: Diabetes mellitus is a heterogeneous disorder of
glucose intolerance that is generally classified into the following
categories: type 1 and type 2 diabetes and gestational diabetes (GDM).
Currently, the number of pregnancies complicated by type 2 diabetes and GDM
exceed those affected by type 1 diabetes. Numerous studies have established
a direct relationship between maternal glycemic control and neonatal
outcomes for all types of diabetes. Therefore, modern treatment protocols
during pregnancy emphasize strict glycemic control by a combination of diet
and medication. Traditionally, insulin therapy has been considered the gold
standard for management because of its efficacy in achieving tight glucose
control and the fact that it does not cross the placenta. Since GDM and type
2 diabetes are characterized by insulin resistance and relatively decreased
insulin secretion, treatment with oral antihyperglycemic agents that target
these defects is of potential interest. However, because of concerns
regarding transplacental passage and, therefore, the possibility of fetal
teratogenesis and prolonged neonatal hypoglycemia, these agents are not
currently recommended in pregnancy. There are no randomized controlled
trials on which to draw conclusions regarding the teratogenicity of these
oral agents. However, most retrospective studies and the published clinical
experience have not demonstrated an increased risk of malformed infants
among women treated with oral antihyperglycemic agents. Rather, the data
indicate that the increased risk for major congenital anomalies appears to
be related to maternal glycemic control prior to and during conception.
These studies and currently available data on the use of both metformin and
sulfonylureas in pregnancy have also failed to demonstrate an increased risk
of neonatal hypoglycemia and other neonatal morbidities. To date, there has
only been one randomized controlled trial to test the effectiveness and
safety of sulfonylurea therapy (glyburide [glibenclamide]) in the management
of women with GDM. Both the insulin- and glyburide-treated women were able
to achieve satisfactory glucose control and had similar perinatal outcomes.
Glyburide was not detected in the cord serum of any infant in the glyburide
group.
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