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Management of diabetes

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마더리스크라운드 발표자료

마더리스크라운드 발표자료

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  • Gestational Diabetes Mellitus2013
  • Gestational Diabetes Mellitus2013
    International Association of Diabetes and Pregnancy Study Groups Consensus Panel, Metzger BE, Gabbe SG, Persson B, Buchanan TA, Catalano PA, et al. IADPSG recommendations on the diagnosis and classification of hyperglycemia in pregnancy. Diabetes Care 2010;33:676–81.
  • The fetal and maternal consequences of gestational diabetes mellitus
  • Insulin Therapy
    in Pregnancy
  • Diabetes in pregnancy: health risks and management
  • Diabetes in pregnancy: health risks and management
  • Transcript

    • 1. Management of diabetes in pregnancy So Young Park, M.D.
    • 2. 용어 정의 • 임신성 당뇨병 (gestational diabetes, GDM) : 기존에 당뇨병이 없는 상태에서 임신 기간중에 진단된 당뇨병 • 임신전 당뇨병 (preexisting diabetes, PGDM) : 임신전에 당뇨병이 진단되어 있는 경우
    • 3. GDM • 임신과 관련한 위험 - 태아의 고인슐린혈증 - 거대아 - 사산 - 양수과다증 - 임신중 고혈압 - 분만후 당뇨병의 위험 성 증가 vs. PGDM • 당뇨병 종류 - 제 1 형 당뇨병 - 제 2 형 당뇨병 • 임신과 관련한 위험 - 임신초기 ; 선천성 기형 , 자연유산 - 임신후기 ; 고인슐린혈증 , 거대아 , 사산 , 호흡곤란 증
    • 4. Background • In 1939, ‘‘benign glycosurics are more likely to give birth to larger babies than do normal women’’ • In 1952, a link between higher maternal glucose during pregnancy and neonatal hypoglycemia hypothesizing the involvement of fetal hyperinsulinemia • In 1957, ‘‘gestational diabetes’’ by Carrington • O’Sullivan focused on the long-term risk of diabetes developing in high risk women and using the pregnancy OGTT proposed using an upper cutoff of 2SD above the mean.
    • 5. O’Sullivan criteria for diagnosing GDM with subsequently derived values
    • 6. Pathophysiology of GDM Gestational Diabetes: Caring for Yourself and Your Baby, IDC Publishing
    • 7. Diagnosis of GDM • Two step approach - Perform screen using 50 g oral glucose load and check blood glucose at 1 hour
    • 8. Diagnosis of GDM * Two or more values meeting or exceeding the cut points are required for diagnosis.
    • 9. • An observational study • 23,316 pregnant women • A 75 g OGTT with sampling at 0, 1, and 2 hours • Primary outcomes : large for gestational age (LGA), clinical neonatal hypoglycemia, cord blood C-peptide > the 90th percentile, primary cesarean section delivery rate
    • 10. Frequency of primary outcomes across the glucose categories (HAPO study) N Engl J Med 2008;358:1991-2002
    • 11. International Association of Diabetes in Pregnancy Study Groups (IADPSG) Recommendations Diabetes Care 2010;33:676–81
    • 12. Screening for and diagnosis of GDM Diabetes Care. 2013;36 (suppl 1):S67–S74.
    • 13. ACOG position • • • • • vs. IADPSG/ADA position Two-step approaches screening 50g → 100g 3-hour OGTT Based on the likelihood that a woman would develop DM several years subsequent to pregnancy Evidence has accumulated ; the association of GDM with an increased risk of adverse maternal and perinatal outcomes. GDM diagnosis ; 5 ~ 6% of the population • • Single-step approaches 75g 2-hour OGTT • Based on demonstrated associations between glycemic levels and an increased risk of obstetric and perinatal morbidities. • GDM diagnosis ; 15 ~ 20% of the population It is not well understood whether additional GDM women will benefit from treatment. •
    • 14. • The panel believes that there is not sufficient evidence to adopt a one-step approach, such as that proposed by the IADPSG. • The panel is particularly concerned about the adoption of new criteria that would increase the prevalence of GDM, and the corresponding costs and interventions, without clear demonstration of improvements in the most clinically important health and patient-centered outcomes. • Thus, the panel recommends that the two-step approach be continued.
    • 15. Fetal outcomes related to GDM
    • 16. Potential maternal complications of GDM J Matern Fetal Neonatal Med 2010;23(3):199-203
    • 17. Effects of treating GDM ; Meta-analysis of RCT Outcome Risk Ratio (95% CI) Fetal Shoulder dystocia 0.42 (0.23–0.77) Neonatal hypoglycemia 1.18 (0.92–1.52) Macrosomia (birthweight >4000 g) 0.50 (0.35–0.71) Admission to the NICU 0.96 (0.67–1.37) Maternal Cesarean delivery 0.90 (0.79–1.01) Preeclampsia 0.62 (0.43–0.89) Ann Intern Med. 2013;159:123-129
    • 18. Recommended targets for home-monitored glucose levels during pregnancy (95) (60-99) (100-129) (99) (63-106) (140) (99) (144) (72-108) 본원 120a (120) (140) 70-100 (144) (126) (126) (140) 100-140 90-120 90- Endocrinol Metab Clin N Am 2012;41:161–173
    • 19. Medical management • Self-glucose monitoring • Diet/Exercise • Oral agents • Insulin
    • 20. Self-glucose monitoring • The cornerstone of diabetes management in GDM • Glucose monitoring ≥3 times daily - Morning fasting - 2-hour postprandial (breakfast, lunch, and dinner) - Before bed
    • 21. Medical nutrition therapy (MNT) • Medical nutrition therapy (MNT) and lifestyle changes can effectively manage 80% to 90% of mild GDM cases. • MNT nutritional goals and recommendations: – Choose healthy low-carbohydrate, high-fiber sources of nutrition, with fresh vegetables as the preferred carbohydrate sources – Avoid sugars, simple carbohydrates, highly processed foods, dairy, juices, and most fruits – Eat frequent small meals to reduce risk of postprandial hyperglycemia and preprandial starvation ketosis • As pregnancy progresses, glucose intolerance typically worsens; patients may ultimately require insulin therapy. 1. Chitayat, L, et al. Diabetes Technology & Therapeutics. 2009;11:S105-111. 2. ADA. Diabetes Care. 2013;36(suppl 1):S11-66. 3. ADA. Diabetes Care. 2004;27(suppl 1):S88-90. 4. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 5. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 6. Mathiesen ER, et al. Endocrinol Metab Clin N Am. 2011;40:727-738.
    • 22. 식사요법의 실제 • 3 식 + 2~4 간식 • 표준체중 계산 : (kg)=( 키 cm-100)x0.9 • 총열량 (kcal)= 표준체중 x25~30kcal + 300~350kcal • 영양소 배분 : 탄수화물 50%, 단백질 20%, 지방 25-30% • 식품군 1 단위당 칼로리 : 곡류군 (100 칼로리 ), 어육류군 (50~100 칼로리 ), 채소군 (20 칼로리 ), 지방군 (45 칼로리 ), 우유군 (125 칼로리 ), 과일군 (50 칼로리 )
    • 23. 식품 교환표 Ex) 1900kcal = 곡류군 8 단위 + 어육류군 ( 저지방 2 + 중지방 4) + 채소군 7 단위 + 지방군 5 단위 + 우유군 2 단위 + 과일군 2 단위
    • 24. Physical activity • Unless contraindicated, physical activity should be included in a pregnant woman’s daily regimen. • Regular moderate-intensity physical activity (eg, walking) can help to reduce glucose levels in patients with GDM. 1. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 2. ADA. Diabetes Care. 2004;27(suppl 1):S88-90. 3. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80.
    • 25. Oral agents for the management of GDM • When MNT alone fails, pharmacologic therapy is indicated – • AACE guidelines recommend insulin as the optimal approach Metformin and glyburide (sulfonylurea) are the 2 most commonly prescribed oral antihyperglycemic agents during pregnancy. Medication Crosses Placenta FDA Classification Notes Metformin Yes Category B Glyburide Minimal transfer Some formulations category B, others category C Metformin and glyburide may be insufficient to maintain normoglycemia at all times, particularly during postprandial periods • Due to efficacy and safety concerns, the ADA does not recommend 1. AACE. Endocr Pract. 2011;17(2):1-53. 2. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 3. ADA. Diabetes gestational diabetes mellitus (GDM) 2004;27(suppl 1):S88-90. Jovanovic J Med. 2009;76(3):269-80. oral antihyperglycemic agents forCare. of Pifizer, NY, NY, 2010. 6.4.Diabeta PI. L, et al. Mt SinaiU.S. Bridgewater, NJ, 2009. 5. Micronase PI. Pifizer. Division Sanofi-Aventis
    • 26. When to add insulin • If medical nutritional therapy (MNT) fails then add insulin when glucose are: ADA ACOG Fasting ≥ 105 mg/dL ≥ 95 mg/dL 1-H postprandial ≥ 155 mg/dL ≥ 130-140 mg/dL 2-H postprandial ≥ 130 mg/dL ≥ 120 mg/dL
    • 27. Insulin use during pregnancy Patient Education • Insulin administration, dietary modifications in response to self-monitoring of blood glucose (SMBG), hypoglycemia awareness and management Basal Insulin • Intermediate- or long-acting insulin administered by injection, or • Rapid-acting insulin administered by insulin pump Postprandial hyperglycemia • Recommended approach: rapid-acting insulin analogues 1. Jovanovic L, et al. Mt Sinai J Med. 2009;76(3):269-80. 2. AACE. Endocr Pract. 2011;17(2):1-53. 3. Castorino K, Jovanovic L. Clin Chem. 2011;57(2):221-30. 4. ADA. Diabetes Care. 2004;27(suppl 1):S88-90.
    • 28. Characteristics of various insulin preparations Onset, h Peak, h Duration, h FDA category 0.25~0.5 0.5~2.5 3~5 B <0.25 1~3 3~5 B 2~4 4~10 10~16 B Detemir (Levemir®) 2 No peak 7.6~24 B Glargine (Lantus®) 2 No peak 11~24 C Rapid-acting analogs Lispro (Humalog®) Aspart (Novorapid®) Intermediate-acting NPH, isophane Long-acting analogs Premixed 75% lispro protamine/25% lispro B 70% aspart protamine/30% aspart B 50% aspart protamine/50% aspart B
    • 29. Management during labor During labor : • • • Maternal hyperglycaemia during labour ∝neonatal hypoglycaemia → target glycaemic control ; 72 ~ 144 mg/dl For women with PGDM, an insulin infusion is usually required to achieve normoglycaemia. Women with GDM are usually able to maintain the required blood glucose targets without requiring an intravenous insulin or with reduced insulin dose. After delivery : • • • PGDM; Insulin requirements fall to pre-pregnancy levels. GDM: Hypoglycaemic agents can be discontinued following birth. Breastfeeding is encouraged. Postgrad Med J 2011; 87: 417-427
    • 30. Risks factors for diabetes following a gestational diabetes pregnancy • Family origin with high prevalence of diabetes ; South Asian, black Caribbean, Middle Eastern • Insulin treatment in pregnancy • Maternal obesity • Weight gain postpartum • Family history of diabetes Postgrad Med J 2011; 87: 417-427
    • 31. Suggested management of women with prior GDM At 1–4 months postpartum (6-8 wk) Nat Rev Endocrinol 2012;8:639–649
    • 32. Take home messages • Gestational diabetes mellitus (GDM) is caused by reduced pancreatic β‑cell function, which results from the full spectrum of causes of β‑cell dysfunction. • GDM is associated with a modest increase in adverse perinatal outcomes, an increased risk of obesity in offspring and a high risk of subsequent development of DM in mothers. • GDM is treated nutritionally; insulin or oral antidiabetic agents can be added if maternal glucose levels and/or fetal growth parameters indicate a sufficiently high risk of perinatal complications. • Long-term management of mothers includes assessment of diabetes risk, and lifestyle and/or pharmacological approaches for women at risk of type 2 diabetes mellitus.
    • 33. Thank you for your attention…

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