Focus on lifestyle and insulin for gestational diabetes

Continue to use insulin first-line. If insulin isn’t an option, consider metformin (Glucophage).....
Mahitab Hany, BS Pharm, PGDipClinPharm, PGDipClinNutrition, BCNSP

As a nutrition support pharmacist, you should focus on lifestyle for gestational diabetes. Gestational diabetes rates have risen sharply in the past few years, likely driven by obesity, which was worsened by the pandemic. We know these patients are at increased risk of C-section, fetal macrosomia, future diabetes, etc.

Emphasize a “lifestyle Rx”, with a healthy diet and exercise. If that’s not enough, discuss medications. Think of a similar approach for gestational diabetes or preexisting diabetes in pregnancy. Continue to use insulin first-line. It has the longest track record, and is easier to fine-tune as pregnancy progresses. Plus oral medications aren’t always enough in these patients. If insulin isn’t an option, consider metformin (Glucophage). It causes less weight gain than insulin, but has less overall safety data. Save glyburide (Daonil) as a last resort. It’s linked to worse outcomes (fetal macrosomia, etc) than metformin or insulin. Avoid other sulfonylureas AND other diabetes medications (GLP-1 agonists, SGLT2 inhibitors, etc), due to lack of long-term data.

  • Recommend checking blood glucose 4 times a day, using a standard blood glucose meter. Evidence with continuous glucose monitors is limited in gestational diabetes.
  • Aim for a fasting glucose of less than 95 mg/dL, and less than 140 mg/dL 1 hour after meals OR less than 120 mg/dL 2 hours after meals.
  • If patients are well managed with lifestyle changes alone after a few weeks, it’s often okay to reduce to twice-daily glucose checks.
  • After delivery, follow up to identify and manage possible prediabetes, type 2 diabetes, CV risks, etc.

References

  1. Gregory EC, Ely DM. Trends and Characteristics in Gestational Diabetes: United States, 2016-2020. Natl Vital Stat Rep. 2022 Jul;71(3):1-15.
  2. American Diabetes Association Professional Practice Committee. 15. Management of Diabetes in Pregnancy: Standards of Medical Care in Diabetes-2022. Diabetes Care. 2022;45(Suppl 1):S232-S243.
  3. ACOG Practice Bulletin No. 190: Gestational Diabetes Mellitus. Obstet Gynecol. 2018 Feb;131(2):e49-e64.
  4. US Preventive Services Task Force. Screening for Gestational Diabetes: US Preventive Services Task Force Recommendation Statement. JAMA. 2021;326(6):531–538.
  5. Society of Maternal-Fetal Medicine (SMFM) Publications Committee. Electronic address: pubs@smfm.org. SMFM Statement: Pharmacological treatment of gestational diabetes. Am J Obstet Gynecol. 2018 May;218(5):B2-B4.
Mahitab Hany, BS Pharm, PGDipClinPharm, PGDipClinNutrition, BCNSP