Oral Agents for Gestational Diabetes Mellitus—Are We Stuck Using Insulin?
1:15 p.m. CT Friday, June 12
As gestational diabetes (GDM) global rates approach 1out of 7 women, oral agents are attractive to use compared to insulin. Yet there is no consensus amongst international guidelines on their use, although the ADA supports insulin as the first line agent. Metformin has been widely used in obesity, PCOS, and GDM, and there are ample data supporting short-term safety and that it is not a major teratogen. However, fetal and maternal concentrations are similar and there are concerns for potential long-term offspring risks due to its pleiotropic effects. Metformin is concentrated in mitochondria and may suppress mitochondrial activity and cell cycle proliferation, resulting in relative nutrient restriction that might affect function, growth, or differentiation of fetal or placental tissues. Long-term offspring data from some GDM and PCOS RCTs suggest it may increase the risk of childhood obesity, especially in a postnatal obesogenic environment. Glyburide also crosses the placenta, although less well than metformin. It has been considered inferior to insulin and sometimes to metformin to prevent adverse pregnancy outcomes, although metformin has a higher failure rate. However, glyburide is often not dosed according to its pharmacokinetic properties resulting in a high one-hour postprandial values and later hypoglycemia. Its ability to directly stimulate fetal beta cells to produce insulin is unknown and long-term offspring data is very limited. In this symposium, we will explore use of oral agents in GDM, their pharmacologic properties, mechanisms of action, and short-term and long-term benefits and potential risks.
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