Transcript Treatment of GDM

Treatment of GDM

Life style changes and nutrition consultation should
be followed
 Tight glycaemic control, both pre- and postprandially
impacts on neonatal outcome1,2
 ADA and the ACOG do not endorse the use of oral anti-
hyperglycemic agents during pregnancy and such therapy has not
been approved by the Unites States Food and Drug
Administration for treatment of GDM
1. Jovanovic et al. Am J Obstet Gynecol 1991;164:103–11
Presentation
titleDiabetes Care 1992;15:1251–57
Slide no 1
2. Combs et al.
Date
NUTRITIONAL
THERAPY
The goals of medical nutritional therapy are
to:
•Achieve normoglycemia
•Prevent ketosis
•Provide adequate weight gain
•Contribute to fetal well-being
The major components to consider when
creating a nutritional plan for women with
GDM are caloric allotment, carbohydrate
intake, and calorie distribution.
The suggested caloric intake is approximately ;
•30 kcal per kg current weight per day in pregnant
women who are BMI 22 to 25.
•24 kcal per kg current weight per day in overweight
pregnant women (BMI 26 to 29).
•12 to 15 kcal per kg current weight per day for
severely obese pregnant women (BMI >30).
•40 kcal per kg current weight per day in pregnant
women who are less than BMI 22.
Carbohydrate intake is restricted to 33 to 40 percent
of calories, with the remainder divided between
protein (about 20 percent) and fat (about 40
percent) .With this calorie distribution, 75 to 80
percent of women with GDM will achieve
normoglycemia.
Calorie distribution
Most programs suggest three meals and
three snacks;
•Breakfast — The breakfast meal should be small
(approximately 10 percent of total calories) to help maintain
postprandial euglycemia .Carbohydrate intake at breakfast is
also limited since insulin resistance is greatest in the morning.
•Lunch — 30 percent of total calories
•Dinner — 30 percent of total calories
•Snacks — Leftover calories (approximately 30 percent of total
calories) are distributed, as needed, as snacks.
One hour postprandial monitoring benefits as
compared to preprandial monitoring:
•Better glycemic control (HbA1c value 6.5 versus
8.1 percent)
•A lower incidence of large-for-gestational age
infants (12 versus 42 percent)
•A lower rate of cesarean delivery for cephalopelvic
disproportion (12 versus 36 percent)
HbA1C =
FPG + PPG
FPG = fasting plasma glucose; PPG = postprandial plasma glucose
Presentation title
Slide no 8
Date
Glycosylated hemoglobin (HbA1C(
 Relative risk for congenital malformations during pregnancy reported
to be 1.63-2.34 per 1% increase in HbA1c
 Risk of adverse outcome is halved with each percentage of HbA1c
reduction
Mathiesen
E. et al.Women’s
Presentation
title Health,2008,4(2),119-124
Slide no 9
Date
HbA1C is a helpful ancillary test in assessing
glycemic control during pregnancy .We measure
HbA1c every two to four weeks to provide the
patient with feedback and to ascertain that blood
glucose monitoring is accurately reflecting
maternal glycemic control.
Treatment of GDM

Life style changes and nutrition consultation
should be followed
 Tight glycaemic control, both pre- and postprandially
impacts on neonatal outcome1,2
 ADA and the ACOG do not endorse the use of oral anti-
hyperglycemic agents during pregnancy and such therapy has
not been approved by the Unites States Food and Drug
Administration for treatment of GDM
1. Jovanovic et al. Am J Obstet Gynecol 1991;164:103–11
2. Combs et al. Diabetes Care 1992;15:1251–57
Presentation title
Slide no 11
Date
Insulin
Approximately 15 percent of women with GDM
are placed on insulin therapy because target
glucose levels are exceeded despite dietary
therapy .
The American College of Obstetricians and
Gynecologists suggest insulin administration :
•Fasting glucose concentration ≥95
mg/dL or
•One hour postprandial glucose >130
to 140 mg/dL or
Two hour-postprandial blood
concentration ≥120 mg/dL
Glucose target
We suggest insulin administration if blood glucose
concentrations reach the values below on two or more
occasions within a two-week interval despite dietary therapy ;
•Fasting blood glucose concentration ≥90 mg/dL .
•One-hour postprandial blood glucose concentration
≥120 mg/dL .
Control of GDM
 ONLY insulin could be considered safe so far considering below types
of insulin:
 Crystal human insulin(Regular)
 Neutral Protaminated Hagedorn (NPH) insulin
 Aspart insulin
 Lispro insulin
Cunningham FG, Leveno KJ, Bloom SL. Williams Obstetrics, (23rd Edition) Hauth JC, Rouse DJ, Spong CY. Princtone,
MC Graw Hill, 2010, chapter 52
Presentation title
Slide no 15
Date
Type of insulin
Use of insulin preparations of low antigenicity will
minimize the transplacental transport of insulin
antibodies: human insulin is the least immunogenic
of the commercially available preparations.
Importance of Prandial Glucose Regulation (PGR) for better glycaemic
control
80
Fasting Hyperglycemia
Postprandial
Contribution (%)
60
40
20
0
(<7.3)
(7.3-8.4)
(8.5-9.2)
(9.3-10.2)
(>10.2)
HbA1c quintiles
Monnier et al., Diabetes Care 2003;26.
NNIran/MIR/0
13/Jul.201
0/1
NN-Iran/MIR/013/Jul.2010/1
Meal-related insulin profile
Normal free insulin levels
(Mean)
70
Insulin (mU/l)
60
50
Simulated s.c. injected
soluble human insulin +
NPH
40
Simulated s.c. injected
NovoRapid® + NPH
30
20
10
0
0600 0900
1200
1500
1800
2100
2400 0300
Time of day
Breakfast Lunch
Adapted from Polonsky KS et al. NEJM 1988;318:1231
Dinner
NPH
0600
Limitations of human insulin
Need for
dissociation of
insulin Hexamers
Prolongation of
insulin absorption
for at least 30 min
from injection site
Patients' less
compliance with
recommended
30-minute
injection–meal interval
Suboptimal
prandial
insulin
therapy
Need for meal time insulins with lower duration of absorption
to reach to the glyceamic targets
NNIran/MIR/0
13/Jul.201
Overmann H, Heinemann L. Injection-meal interval: recommendations of diabetologists and how patients handle it. Diabetes Res Clin Pract
1999;43: 137-142
0/1
Insulin
 Remains one of the most powerful tools we have to
control blood glucose
 Dosing potential and HbA1C reduction only limited by
risk of hypoglycemia
Analogous insulins designed to be more physiologic
 More rapid onset
 More predictable time-action profiles
 Less weight gain
 Lower risk of hypoglycemia
Nathan DM, et al. Diabetes Care. 2006;29:1963-1972.
NNIran/MIR/0
13/Jul.201
0/1
Type of insulin
The three rapid acting insulin analogs (lispro,
aspart, glulisine) are comparable in
immunogenicity to human Regular insulin, but
only lispro and aspart have been investigated
in pregnancy and shown to have acceptable
safety profiles, minimal transfer across the
placenta, and no evidence of teratogenesis.
NovoRapid vs. HI
NovoRapid Pharmacological profiles
NovoRapid v.s. soluble human insulin
 Pharmacokinetics
- Twice as fast absorption rate
- Twice as high peak concentration
- Similar bioavailability
 Pharmacodynamics
- Faster onset of action: 10–20 vs. 30–60 minutes
- Shorter duration of action: 4–5 vs. 6–8 hours
Heinemann L, Kapitza C, Starke A, Heise T. Time-action pro.le of the insulin analogue B28Asp. Diabetic Med 1996;13:683–684.
NNIran/MIR/0
13/Jul.201
0/1
Based on available data, we prefer use of human NPH
insulin as part of a multiple injection regimen in
pregnant women . There are good data supporting the
safety and effectiveness of NPH in pregnancy and doses
can be adjusted frequently and quickly in response to
changing requirements in pregnant women.
The dose and type of insulin used is
calculated based upon the specific
abnormality of blood glucose noted during
monitoring
The titration of insulin dose to blood glucose
levels is based upon frequent self-monitoring.
Four or more glucose measurements each day
are needed to optimize therapy .
In women who require insulin therapy, we suggest
monitoring glucose upon awakening and one hour
after each meal to guide medical management .
Gestational Diabetes Mellitus
Goals for glycaemic control
 For women with pre existing type 1 or type 2 diabetes who become
pregnant, a recent consensus statement recommends the following as
optimal glycaemic goals, if they can be achieved without excessive
hypoglycaemia:
 premeal, bedtime, and overnight glucose 60–99 mg/dl
 peak postprandial glucose 100 –129 mg/dl
 A1C < 6.0%
Presentation
title
Slide no
28in Diabetes—2010. Diabetes Care 2010 Jan;33 Suppl 1:S11-61
American
Diabetes Association.
Standards of Medical
Care
Date
Gestational Diabetes Mellitus
Goals for glycaemic control
 Pre prandial ≤ 95 mg/dl and either
 1-h post meal ≤ 140 mg/dl
or
 2-h post meal ≤ 120 mg/dl
Slide no 29
American Diabetes Association. Standards of Medical Care in Diabetes—2010. Diabetes Care 2010 Jan;33 Suppl 1:S11-61
Presentation title
Date
 Our goal for fasting blood glucose concentration is <90
mg/dL and for one-hour postprandial blood glucose
concentration the goal is <120 mg/dL.