Sara Wilson Reece

Metformin in Gestational Diabetes Mellitus

As currently diagnosed, gestational diabetes mellitus (GDM) affects 5–9% of all pregnancies in the United States and is growing in prevalence.1 It is defined as carbohydrate intolerance of variable severity that is first recognized during pregnancy. Although GDM has been recognized for decades, the potential significance of the condition, as well as criteria for screening and diagnosis, remain debatable.1 Historically, GDM has been treated with lifestyle modifications and insulin, and oral antihyperglycemic agents have been used infrequently because of concerns regarding neonatal hypoglycemia and teratogenicity. Most recent studies suggest that oral hypoglycemic agents, specifically metformin, are safe to use during pregnancy (Table 1).2–13 Risk for developing GDM has been noted in women who are overweight before pregnancy, have had GDM in a previous pregnancy, or have a family history of diabetes. Poorer outcomes have been seen in both pregnant women and their developing fetuses, including induction of labor and caesarean delivery in women and death, shoulder dystocia, bone fracture, and nerve palsy in fetuses.1 Moreover, recent studies show that diagnosis and management of this disorder will have beneficial effects on both maternal and neonatal outcomes.14,15 According to the American College of Obstetrics and Gynecology, comprehensive screening techniques have been implemented by > 90% of practices in the United States.16 Reasons for the implementation of screening programs were developed from the evidence obtained in the Hyperglycemia and Adverse Pregnancy Outcomes study.17 This large, prospective, observational study found possible adverse effects associated with even mild maternal hyperglycemia. It included a cohort of women with glucose levels at the upper end of the normal range, as well as women with mild GDM. The investigators found a linear correlation between higher levels of maternal glucose and adverse outcomes, including increased birth weight, …

Retrospective Review of Maternal and Fetal Outcomes in Patients With Gestational Diabetes Mellitus in an Indigent Prenatal Clinic

Gestational diabetes mellitus (GDM) is diabetes that is diagnosed during the second or third trimester of pregnancy and is not clearly overt diabetes (1). Diagnosis is defined by severity of carbohydrate intolerance. The upper end of the GDM diagnostic glucose range is the same as would be indicative of diabetes outside of pregnancy, whereas the lower end of the GDM range is only slightly above normal and asymptomatic but still associated with increased risk of fetal morbidity (1,2). Diabetes during pregnancy is diagnosed by either a one-step approach involving a 75-g oral glucose tolerance test (OGTT) or a two-step approach starting with a 50-g (nonfasting) screen followed by a 100-g OGTT for those who initially screen positive (1). Glycemic goals for patients with a GDM diagnosis are as follows: preprandial ≤95 mg/dL and either 1-hour postprandial ≤140 mg/dL or 2-hour postprandial ≤120 mg/dL. Hyperglycemia throughout pregnancy carries increased risk for adverse fetal and maternal outcomes (3–8). Treatment of diabetes during pregnancy is aimed at decreasing the risk of perinatal outcomes such as macrosomia, birth trauma, neonatal metabolic abnormalities, and cesarean section (4,9–12). Lifestyle modification is first-line treatment and includes medical nutrition therapy (MNT), exercise, and glucose monitoring (13). Pharmacological therapy generally consists of insulin, glyburide, or metformin, and agents may be used adjunctly to MNT depending on presence and severity of hyperglycemia (13). Insulin is the preferred pharmacological treatment for management of diabetes in pregnancy if lifestyle modification is insufficient in achieving euglycemia (13). The setting of this review is the diabetes clinic located within the Hall County Health Department (HCHD) prenatal clinic in Gainesville, Ga. The population of Gainesville is ∼187,000 and includes a large percentage of Latino immigrants (14). The proportion of Latinos in the diabetes clinic has grown …

Sodium glucose co-transporter inhibitors for the management of diabetes mellitus: an opinion paper from the Endocrine and Metabolism Practice and Research Network of the American College of Clinical Pharmacy

Abstract Type 2 diabetes mellitus (T2DM) carries a high prevalence in the United States and worldwide. Therefore, the number of medication classes being developed and studied has grown. The individualized management of diabetes is accomplished by evaluating a medication’s efficacy, safety, and cost, along with the patient’s preference and tolerance to the medication. Sodium glucose co-transporter 2 inhibitors are a new therapeutic class indicated for the treatment of diabetes and have a unique mechanism of action, independent of beta-cell function. The first agent approved by the Food and Drug Administration (FDA) was canagliflozin in March 2013. Two agents – dapagliflozin and empagliflozin – were FDA-approved in January and July 2014, respectively. A clear understanding of the new class is needed to identify its appropriate use in clinical practice. Members of the American College of Clinical Pharmacy Endocrine and Metabolism Practice and Research Network reviewed available literature regarding this therapeutic class. The article addresses the advantages, disadvantages, emerging role, and patient education for sodium glucose co-transporter 2 inhibitors. Key limitations for this article include limited access to clinical trial data not published by the pharmaceutical company and limited data on products produced outside the United States.

Insulin Pump Class: Back to the Basics of Pump Therapy

In the early 1960s, Dr. Arnold Kadish developed the first insulin pump, which was the size of a Marine backpack.1 Over the years, insulin pumps have become much more refined and have decreased in bulk to the size and weight of a small pager. Insulin pump therapy, also known as continuous subcutaneous insulin infusion, is no longer seen as experimental and controversial, but rather is viewed as an acceptable alternative to multiple daily injection (MDI) therapy in the management of insulin-dependent diabetes2 (Table 1).3 The insulin pump is an electromechanical device that mimics the bodys natural insulin secretion from pancreatic β-cells by subcutaneously delivering rapid-acting insulin both at preset continuous basal rates and in extra bolus doses at mealtimes on demand.4 Insulin pumps allow for up to 24 different hourly basal rates in a 24-hour period. For bolus doses, pump users input their current blood glucose level and the number of carbohydrates they will consume, and the pump customizes their dose based on insulin currently on board (i.e., the remaining active insulin from the previous dose), their individualized insulin-to-carbohydrate ratio, and their individualized insulin sensitivity factor (i.e., their expected drop in blood glucose from 1 unit of insulin).1,5 Thus, insulin pumps are able to deliver insulin in a more physiological manner than other injection-based insulin regimens.5 In the late 1970s, results of the first human trials of insulin pump therapy were published. This was followed by numerous additional studies comparing insulin pump therapy to traditional MDI regimens with regard to long-term glycemic control and minimization of hypoglycemia.6–11 Then, in 1993, the Diabetes Control and Complications Trial12 confirmed the importance of intensive glycemic control using either insulin pump therapy or an MDI regimen along with frequent self-monitoring of …

Gestational Diabetes Clinic in the Public Health Setting

Gestational diabetes mellitus (GDM), or “carbohydrate intolerance of variable severity with onset or first recognition during pregnancy,” results from insulin resistance and relative insulin deficiency, usually in the second trimester.1 This condition affects between 4 and 9% of all pregnancies.2 With GDM, there are increased fetal complications of macrosomia, shoulder dystocia, and neonatal hyperglycemia, as well as maternal risks of preeclampsia and polyhydramnois.3,4 Also, it has been shown that 33% of GDM patients require Cesarean section compared to 20% of pregnant patients without GDM.5 Women who are of Hispanic or Asian descent are at the highest risk of developing GDM.6 According to the American Diabetes Association (ADA),7 assessment for undiagnosed type 2 diabetes should be completed at the first prenatal visit. Patients who are high risk (those with severe obesity, a history of GDM, a diagnosis of polycystic ovarian syndrome, a strong family history of type 2 diabetes, or glycosuria) should be screened using standard diagnostic testing. Diagnosis is based on the following results: A1C ≥ 6.5%, fasting plasma glucose level ≥ 126 mg/dl, 2-hour plasma glucose level ≥ 200 mg/dl during an oral glucose tolerance test (OGTT), or classic symptoms of hyperglycemia with a random blood glucose level ≥ 200 mg/dl.7 All remaining pregnant women who are not known to have diabetes should have testing for GDM at 24–28 weeks of gestation using a 75-g, 2-hour OGTT. Patients are diagnosed with GDM if they have any of the following plasma glucose values: fasting ≥ 92 mg/dl, 1-hour ≥ 180 mg/dl, or 2-hour ≥ 153 mg/dl.7 Upon diagnosis of GDM, medical nutrition therapy, self-monitoring of blood glucose (SMBG), and fetal monitoring are initiated. A study by Landon et al.8 found that treatment of mild GDM resulted in a lower …