Insulin for the treatment of women with gestational diabetes

Abstract

The main comparison in this review is insulin versus oral anti-diabetic pharmacological therapies. Insulin and oral anti-diabetic pharmacological therapies have similar effects on key health outcomes. The quality of the evidence ranged from very low to moderate, with downgrading decisions due to imprecision, risk of bias and inconsistency.For the other comparisons of this review (insulin compared with non-pharmacological interventions, different insulin analogies or different insulin regimens), there is insufficient volume of high-quality evidence to determine differences for key health outcomes.Long-term maternal and neonatal outcomes were poorly reported for all comparisons.The evidence suggests that there are minimal harms associated with the effects of treatment with either insulin or oral anti-diabetic pharmacological therapies. The choice to use one or the other may be down to physician or maternal preference, availability or severity of GDM. Further research is needed to explore optimal insulin regimens. Further research could aim to report data for standardised GDM outcomes.

Gestational diabetes mellitus: A pragmatic approach to diagnosis and management

“…Insulin treatment in GDM is safe and effective and is usually the first choice of pharmacotherapy for GDM. 31,32 Few women are unable to manage insulin injections. In over 30 years at our centre, we have encountered no serious episodes of hypoglycaemia.…”

SMFM Statement: Pharmacological treatment of gestational diabetes

“…Rather, recent meta-analyses and systematic reviews support the efficacy and safety of oral agents. 7,10 The purpose of this Society for Maternal-Fetal Medicine (SMFM) Publications Committee statement is to review the available scientific literature regarding pharmacological treatment of GDM and to provide additional guidance to obstetric care providers regarding treatment of these women. Although this statement differs in some respects from the the American College of Obstetricians and Gynecologists Practice Bulletin, the SMFM Publications Committee acknowledges that this difference is based on the values placed by different experts and providers on the evidence available in the medical literature and is not meant to represent an exclusive course of management.…”

“…In a 2017 Cochrane review, the rate of maternal hypoglycemia was not significantly higher in women treated with insulin vs oral agents (RR 3.01, 95% CI 0.74 to 12.27), and several studies report no maternal hypoglycemia in either group. 10 Metformin is an oral biguanide that primarily acts to decrease hepatic glucose production by inhibiting gluconeogenesis. It also increases glucose uptake in peripheral tissues and decreases glucose absorption in the gastrointestinal tract.…”

“…Although acknowledging weaknesses in the data, they describe a general "trend" in favor of metformin over insulin or glyburide and suggest either metformin or insulin if glucose levels are not adequately controlled with dietary and lifestyle modifications. 8 Finally, two Cochrane Reviews in 2017 addressed oral hypoglycemic agents and insulin for management of GDM (9,10). In these reviews, the authors concluded that there was insufficient high-quality evidence to assess whether one oral hypoglycemic agent is superior to another or to insulin, and note that the choice to use one or the other may reasonably be based on physician or maternal preference, availability, or the severity of GDM.…”

“…In these reviews, the authors concluded that there was insufficient high-quality evidence to assess whether one oral hypoglycemic agent is superior to another or to insulin, and note that the choice to use one or the other may reasonably be based on physician or maternal preference, availability, or the severity of GDM. 9,10 It should be also noted that both maternal and perinatal outcomes are influenced not only by the type of agent that is used to treat GDM, but by many other variables, including indications for screening (who is screened), timing of screening, type of screening (one-vs two-step screening and the screening protocol chosen), criteria for GDM diagnosis, criteria to start therapy after failure of dietary and lifestyle interventions alone, dosage and frequency of initial therapy, frequency of glucose monitoring, target glucose values, criteria for pharmacologic therapy dosage adjustment, and criteria for adding or switching pharmacologic therapy.…”