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Insulin and Oral Agents for Management of Diabetes in Pregnancy, Part 4

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Insulin and Oral Agents for Management of Diabetes in Pregnancy, Part 4

Ucsd we actually used i be right in a targeted matter to treat postprandial as well as fasting glucose values so generally speaking where we initiate patients on glyburide based on the patient’s weight if they weigh less than 200 i usually start glyburide 1.25 milligram if they weigh greater than 200 then i start live right at two point five milligrams as i stated

Above i use it in a targeted manner to target the postprandial values so generally speaking i instruct the patient to take the glyburide about an hour before her meals and again we start anywhere from 1.5 to 2.5 milligrams and then i increase it by 1.25 to 2.5 milligram increments to a max of 10 milligrams per segment per meal i also instruct the patient to take

Library id after 10pm to target her fasting glucose values no this is different from the c-type website they actually recommend the languor on method of joseph library which is b id now with glyburide it’s important to make changes every four days you need to allow for a steady state of the medication and generally speaking as we reviewed earlier if i reach a

Maximum dose of 10 milligrams per segment or a total dose of 15 to 20 milligrams per day then i start adding insulin to control their blood glucose if needed again we add insulin more than thirty percent of the blood glucose are above the target before i move on to side effects the failure rate of khyber it is approximately twenty percent so about twenty percent of

Our patients will need to be on insulin in addition to their library to achieve glucose targets hypoglycemia is a risk factor that can occur with the use of chloride it occurs about 11 to thirty-eight percent of type 2 diabetes patients in general i see it in about twenty percent of our patients who are pregnant and it’s obviously jos dependent the higher the dose

That higher hypoglycemia and it can be seen in older patients as well there’s other rare side effects for example nausea epigastric fullness or burn and allergic skin reactions now moving on to other oral hypoglycemics the second one that we use in pregnancy is metformin which is a biguanide which is mainly its use to target hyperglycemia is to increase muscle

Uptake of glucose metformin peaks within four hours of ingestion ingestion and the plasma half-life is about two to five hours it’s primarily cleared by the kidney and there are some rare side effects that are important to note which is not to guest doses so in our patients with metformin and very cautious in instructing them that if they are to undergo a ct for

Any reason which uses ct contrast iv contrast that there can be a risk of lactic acidosis particularly if they already have underlying renal insufficiency so make sure to always advise your patients with regards to do this when they are mid foreman and also it can cause gi upset so i tend to initiate treatment with amigo either at breakfast or at that time egg

Dinner the dose of insulin outside of pregnancy can be anywhere from five hundred three hundred and fifty milligrams increments from maximum of three thousand milligrams per day l’essentiel studies showed that it does cross the placenta however we have very good data about safety use in the first trimester as you recall that foreman has been used by patients with

Plus cystic ovarian syndrome to induce ovulation and on good studies of its use in the first trimester i have shown that there is no increased risk of congenital anomalies or birth defects or adversity or nato all comes with the use of metformin in the first trimester so if our patients have pre gestational diabetes that come to pregnancy on metformin i generally

Don’t stop it and i like to instruct our patients preconception that they should not stop them in corpsman collaborate on the other hand i do counsel them to stop it in the first trimester as again safety has not been proven with a use of library in the first trimester so the trial which was performed by rolen at all randomized patients with gestational diabetes

To metformin versus insulin for the treatment of gtn and what they found again was there was no difference in glycemic control between patients treated with metformin and insulin although are also no differences in the rates of macrosomia our neonatal hyperglycemia however the failure rate for patients treated with mcfarland was forty-six percent in other word

Forty-six percent of patients needed to be started on insulin as they did not meet glucose control targets again this is in comparison to twenty percent in library treat a patient if you look closely at their outcomes however you do see that there’s a lower rate of hypoglycemia in patients treated with metformin as compared to those with insulin this is actually

Very important because you may have encountered this if patients with type 2 diabetes or gestational diabetes patients who have undergone gastric bypass they tend to be prone to hypoglycemia between meals so metformin is a good adjunct treatment as it tends to not cause hypoglycemia and his patients collaborate tends to cause hypoglycemia and his patients so i tend

To utilize metformin in these patients more often than not one interesting finding that they found in this trial was that my foreman was associated with a higher rate of preterm birth live on twelve percent versus eight percent in the insulin treated group and if you break that down further into spontaneous preterm birth it was also higher than the common treated

Group interestingly enough this finding has not been demonstrated again in subsequent studies again dr. rowan has published a lot of trials on metformin and she has not found this association again and we do not know what biologic possibility of those findings but still i always do mention this to our patients so in somebody glyburide in my form and appear to be

Effective in the treatment of gbm high bar optimal dosing at least for glyburide is still in question and we do have still have some questions regarding neonatal metabolic effects i think in a large randomized control trial needs to be performed in order to examine needs the unitive welcome but it requires collaboration between a lot of multiple centers and this

Is a the end of my talk i want to thank you all for your

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Insulin and Oral Agents for Management of Diabetes in Pregnancy, Part 4 By CDAPPSweetSuccess