PracticeUpdate Diabetes Best of 2018

CONFERENCE COVERAGE 24

Very Tight Control in Gestational Diabetes Not More Beneficial Tight control nearly doubles the need for insulin without providing clear benefits W omen with gestational diabetes and their offspring fare just as well with moderately tight control of their plasma glucose levels

To remedy this, the investigators randomized women in their 8th to 31st week of gestation who met the World Health Organization 2013 criteria for gestational dia- betes to very tight glycemic control (fasting plasma glucose <5.1 mmol/L and <7.0 mmol/L postprandial) or less tight glycemic control (fasting plasma glucose < .3 mmol/L and <7.8 mmol/L postprandial). All partici- pants were provided instructions on diet and lifestyle changes. When patients exceeded their plasma glucose targets in two or more measurements per week in the tight control group or more than one-third of measurements per week in the less-tight control group, insulin ther- apy was started. The primary outcome of the study was the incidence of large-for-gestational-age infants born to the mothers in the study. Secondary outcomes for the baby were the composite of neonatal death or severe morbidity (ie, nerve palsy, bone fracture, and shoulder dystocia), gestational age at birth, birthweight, macrosomia (birth weight >4000 g), small for gestational age, and hypo- glycemia. Secondary outcomes for the woman were preeclampsia, mode of birth, mean daily fasting and postprandial capillary glucose concentration during treatment, proportion of glucose values within target, and the proportion of women requiring insulin therapy. Overall, 262 women were included in the tight con- trol group and 253 in the less-tight control group. The two groups of women were similar with respect to their ages and prepregnancy body mass index. A greater proportion of the women in the tight control group met the glucose control targets for both groups. In addition, more of the women in the tight control group required insulin therapy. Despite the tighter control, there were no significant differences between the two groups with respect to having offspring who were large for gestational age. In addition, an intent-to treat analysis revealed no signifi- cant differences with regard to the composite outcome or any of the other secondary outcomes measured, except for lower mean daily values of postprandial cap- illary glucose levels in the tight control group. These results were somewhat surprising for the inves- tigators. “We expected to find some difference in pregnancy outcomes in the groups with different gly- cemic control, at least for the frequency of large- and small-for-gestational-age neonates,” said Dr. Popova. “Our data indicate that there is no need to make tighter the glycaemic targets currently recommended by the American Diabetes Association, International Fed- eration of Gynecology and Obstetrics, and the Fifth Workshop-Conference on Gestational Diabetes Mel- litus. Our data may be a reason to change Russian guidelines, which currently recommend more tight gly- cemic targets.” www.practiceupdate.com/c/74336

as those with very tight control. Moreover, very tight control is associated with far greater use of insulin. These are the main findings of a Russian study pre- sented at EASD 2018. “Currently, the most appropriate glycemic goal for the management of gestational diabetes remains a point of contention,” Polina Popova, MD, PhD, with the Alma- zov National Medical Research Centre and Pavlov First State Medical University in Saint Petersburg, Russia, told Elsevier’s PracticeUpdate. “Various medical societies suggest different glycemic goals and different approaches for glycemic profile assessment,” she noted. “This controversy persists because scant evidence on glucose data and preg- nancy outcome exists. No randomized treatment trial has defined the optimal treatment targets.”

Dr. Polina Popova

" Our data indicate that there is no need to make tighter the glycaemic targets currently recommended by the American Diabetes Association, International Federation of Gynecology and Obstetrics, and the FifthWorkshop- Conference on Gestational Diabetes Mellitus. "

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