Very tight vs. tight control: what should be the criteria for pharmacologic therapy dose adjustment in diabetes in pregnancy? Evidence from randomized controlled trials

Abstract

When evaluating RCTs which included criteria for pharmacologic GDM therapy dose adjustment, the most common criterion for diagnosis was the two-step test, and the most common used therapies were insulin and metformin. Regarding glucose monitoring, the most common frequency was four times per day, fasting and two hours after each main meal, using as target glucose values 95 and 120 mg/dL, respectively. Importantly, we found six different criteria for pharmacologic GDM therapy dose adjustment, with the majority using very tight criteria of either one or two values per week higher than the target values, of which two-thirds used only one value, and one-third used two values.

Single site pilot clinical investigation of a novel app-assisted self-management programme for gestational diabetes

“…Treatment initiation is proposed when either one or two blood glucose readings in a seven-to-14-day block are above set thresholds. Once treatment has been commenced criteria for dose adjustment of hypoglycaemic agents is equally contentious with six different strategies reported in one review [114,115]. As part of this study, we sought to determine glucose thresholds in our own population beyond which a benefit for hypoglycaemic agents was identified.…”

“…The delivery of insulin for gestational diabetes as multiple daily injections has been found to be the most efficacious. Insulin dosages are adjusted based on glycaemic indices which are most frequently assessed four times a day [26,114].…”

Recent advances in the antepartum management of diabetes

“…Although therapy adjustment based on postprandial blood glucose levels is associated with improved outcomes 15 , there are currently no standardised criteria regarding the precise steps that should be taken to optimise glucose control. A recent meta-analysis identified RCTs which used various levels of strictness for intensifying glucose control, ranging from a single recorded value exceeding target values to more than 50% of recordings being above target values, and concluded that there is not enough evidence to recommend one approach over the other given the wide variations seen across the included studies 16 . A retrospective study by Scifres et al .…”

Gestational diabetes mellitus: A pragmatic approach to diagnosis and management

“…The following values are published in the Australasian Diabetes in Pregnancy Society guidelines in the section 'for further research' and are followed by many, but by no means all, maternity centres: 4,25 • Fasting capillary blood glucose:…”