Updates in Gestational Diabetes

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Presentation at the 2014 Philippine General Hospital Department of Obstetrics & Gynecology postgraduate course. 9 July 2014, SMX Convention Center.

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Updates in Gestational Diabetes

  1. 1. Updates in Gestational Diabetes Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM Associate Professor 4, UP College of Medicine Chief, UP Medical Informatics Unit 9 July 2014 Thursday, July 10, 14
  2. 2. “Diabetes, Gestational” [MeSH] Free full text on Pubmed.gov Publication date from 2012/01/01 Thursday, July 10, 14
  3. 3. Implications of using IADPSG criteria women serie 2 by asterisco http://www.freeimages.com/photo/313127 Outline Tablets vs insulin white round pills by dimshilk http://www.freeimages.com/photo/755944 Lactation after GDM Lactation2 by carin http://www.freeimages.com/photo/161052 Thursday, July 10, 14
  4. 4. Implications of using IADPSG criteria women serie 2 by asterisco http://www.freeimages.com/photo/313127 Thursday, July 10, 14
  5. 5. Philippine Diabetes CPG has partially adopted the IADPSG consensus by endorsing the HAPO-derived thresholds for the 75-g OGTT. Thursday, July 10, 14
  6. 6. Hyperglycemia Adverse Pregnancy Outcomes HAPO 25,505 pregnant 15 centers 9 countries Thailand, Hong Kong, Singapore NEJM 2008; 358:1991-2002 large diverse population single protocol Thursday, July 10, 14
  7. 7. OR for increased neonatal body fat, LGA and cord serum C-peptide Mean glucose as reference Coustan et al. AJOG 2010; 202(6):654.e1-654.e6 OR % Subjects > Threshold Positive Predictive Value for >90th %ile Positive Predictive Value for >90th %ile Positive Predictive Value for >90th %ile OR % Subjects > Threshold Birth weight C-peptide % Body fat 1.75 16.1 16.2 17.5 16.6 2.0 8.8 17.6 19.7 18.8 Thursday, July 10, 14
  8. 8. Coustan et al. AJOG 2010; 202(6):654.e1-654.e6 IADPSG recommendation for diagnosis of GDM FBS 92 mg/dL 1h 180 mg/dL 2h 153 mg/dL Diagnosis requires only one threshold value exceeded Overt diabetes FPG >7.0 mmol/L (126 mg/dL) 24-28 wks AOG Thursday, July 10, 14
  9. 9. http://www.sxc.hu/photo/358002 IADPSG ACOG recommends against IADPSG consensus 1.All pregnant women should be screened for GDM by patient history, clinical risk factors or a 50-g, 1-hour loading test to determine blood glucose levels. ACOG Committee on Obstetric Practice. Screening & Diagnosis of Gestational Diabetes Mellitus. Obstetrics & Gynecology 2011; 118(3):751-3 Thursday, July 10, 14
  10. 10. http://www.sxc.hu/photo/358002 IADPSG ACOG recommends against IADPSG consensus 2.The diagnosis of GDM can be made based on the result of the 100-g, 3h OGTT. Carpenter & Coustan or NDDG criteria ACOG Committee on Obstetric Practice. Screening & Diagnosis of Gestational Diabetes Mellitus. Obstetrics & Gynecology 2011; 118(3):751-3 Thursday, July 10, 14
  11. 11. http://www.sxc.hu/photo/358002 IADPSG ACOG recommends against IADPSG consensus 3.Diagnosis of GDM based on the 1-step screening and diagnosis test outlined in the IADPSG guidelines is not recommended at this time because there is no evidence that diagnosis using these criteria leads to clinically significant improvement in maternal or newborn outcomes, and it would lead to a significant increase in healthcare costs. ACOG Committee on Obstetric Practice. Screening & Diagnosis of Gestational Diabetes Mellitus. Obstetrics & Gynecology 2011; 118(3):751-3 Thursday, July 10, 14
  12. 12. The ACOG... recommends that before the testing approach and diagnostic criteria are changed, implications of such changes should be studied. “ Thursday, July 10, 14
  13. 13. Thursday, July 10, 14
  14. 14. Diabetes Care 35:526-528, 2012 Although the new diagnostic criteria for GDM apply globally, center-to-center differences occur in GDM frequency and relative diagnostic importance of fasting, 1-h and 2-h glucose levels. “Thursday, July 10, 14
  15. 15. Bellflower, CA Singapore, Singapore Cleveland, OH Manchester, UK Bangkok, Thailand Chicago, IL Belfast, UK Toronto, Canada Providence, RI Newcastle, Australia Hongkong, PRC Brisbane, Australia Bridgetown, Barbados Petah-Tiqva, Israel Beersheba, Israel 0 750 1500 2250 3000 Normal GDM Frequency of GDM by HAPO Center using IADPSG criteria Sacks DA et al Diabetes Care 2012;35:526-8 25.1% 23% 14.4% Thursday, July 10, 14
  16. 16. HAPO Bellflower, CA Singapore, Singapore Cleveland, OH Manchester, UK Bangkok, Thailand Chicago, IL Belfast, UK Toronto, Canada Providence, RI Newcastle, Australia Hongkong, PRC Brisbane, Australia Bridgetown, Barbados Petah-Tiqva, Israel Beersheba, Israel 0 50 100 150 200 FPG 1h 2h Percent of GDM women: values above OGTT threshold Sacks DA et al Diabetes Care 2012;35:526-8 47 65 47 24 76 43 26 62 65 55 33 12 Thursday, July 10, 14
  17. 17. HAPO Bellflower, CA Singapore, Singapore Cleveland, OH Manchester, UK Bangkok, Thailand Chicago, IL Belfast, UK Toronto, Canada Providence, RI Newcastle, Australia Hongkong, PRC Brisbane, Australia Bridgetown, Barbados Petah-Tiqva, Israel Beersheba, Israel 0 24 48 72 96 120 FPG 1h 2h Percent of GDM diagnosed by each glucose measure Sacks DA et al Diabetes Care 2012;35:526-8 47 39 14 24 64 12 26 45 29 55 33 12 Thursday, July 10, 14
  18. 18. Given that there is a continuum of risk, no criteria will ever be comprehensive. Given that the criteria are based on a consensus, there will always be an opportunity for divergent opinions. Moses RG. Diabetes Care 2012;35:461-2 “ Thursday, July 10, 14
  19. 19. Diabetes Care 35:1894-6, 2012 Israeli HAPO participants n=3,345 1 3 2 Adverse outcomes compared IADPSG criteria IADPSG criteria with risk stratification Screening with BMI or fasting plasma glucose Thursday, July 10, 14
  20. 20. Adopting IADPSG increases GDM diagnosis by ~50% 1/3 of IADPSG(+) women at low risk for adverse outcomes Kalter-Leibovici et al. Diabetes Care 2012;35:1894-6. Thursday, July 10, 14
  21. 21. Association of GDM diagnosed using IADPSG & POGS 75-g OGTT cut-off values with adverse perinatal outcomes in PGH Urbanozo H & Isip Tan, IT In press, JAFES Sept-Dec 2013 PGH OB Charity ward report 885 deliveries GDM n=104 not GDM n=132 EXCLUDED 100g OGTT done n=88 only FBS done n=52 No OGTT done n=365 OGTT results not available n=48 Chart not available n=52 Multiple gestation n=16 Maternal age <18 y.o. n=20 Pregestational DM n=8 Chart review 75-g OGTT Thursday, July 10, 14
  22. 22. Association of GDM diagnosed using IADPSG & POGS 75-g OGTT cut-off values with adverse perinatal outcomes in PGH Urbanozo H & Isip Tan, IT In press, JAFES GDM: increased risk of primary CS (OR 1.79 [1.02–3.16], p=0.041) and NICU admission (OR 2.66 [1.3–5.44], p=0.007) FBS >92 mg/dL: increased risk of LGA infant (OR 20.97 [2.27–192.97]) 1h OGTT >180 mg/dL: increased risk primary CS (OR 1.97 [1.08–3.55]) Elevated FBS, 1h and 2h OGTT: increase risk of NICU admission (OR 2.18, 2.39 and 2.34 respectively) No difference in adverse outcomes in women diagnosed using IADPSG vs POGS criteria 1 3 2 Thursday, July 10, 14
  23. 23. Diabetes Care 35:529-535, 2012 Decision Analysis Model No screening 50-g GCT then 100-g OGTT at 24-28 wks when indicated IADPSG screening 1 3 2 Thursday, July 10, 14
  24. 24. No history of DM or GDM Strategy 1 No Screening Strategy 2 Current Screening Strategy 3 IADPSG Recommendations 50-g 1 h GCT at 24-28 weeks >7.2 mmol/L (130 mg/dL) All others insulin sensitive 100-g 3 hour OGTT Two of the following: Fasting >5.2 mmol/L (95 mg/dL), 1h >10 mmol/L (180 mg/dL), 2h >8.6 mmol or 3h >7.8 mmol/L (140 mg/dL) Overt DM or GDM All others insulin sensitive Fasting plasma glucose at first prenatal visit >7.0 mmol/L (126 mg/dL) Overt DM >5.1mmol/L (92 mg/dL) GDM <5.1mmol/L (92 mg/dL) 75-g 2h-OGTT at 24-28 weeks Fasting >7.0 mmol/L (126 mg/dL) Overt DM Fasting >5.1 mmol/L (92 mg/dL) 1h >10.0 mmol/L (180 mg/dL) 2h >8.5 mmol/L (153 mg/dL) GDM All others insulin sensitive Werner EF et al Diabetes Care 2012;35:529-35 Thursday, July 10, 14
  25. 25. Assumptions Additional prenatal monitoring, mitigating risks of preeclampsia, shoulder dystocia and birth injury 1 2 Werner EF et al Diabetes Care 2012;35:529-35 money matters by sufinawaz http://www.freeimages.com/photo/865433 Intensive post delivery counseling and behavior modification to reduce future diabetes risks ICER = cost A - cost B efficacy A - efficacy B Thursday, July 10, 14
  26. 26. Figure from Nelson AL et al. Ann Intern Med 2009;151(9):662-7 $20,336 per QALY gained for IADPSG screening Cost-effective only when post delivery care reduces diabetes incidence. Werner EF et al Diabetes Care 2012;35:529-35 Thursday, July 10, 14
  27. 27. Diabetes Care 35:529-535, 2012 ... neither the current screening strategies nor the IASDPG are cost-effective strategies unless long-term maternal benefits are achieved. “ Thursday, July 10, 14
  28. 28. Tablets vs insulin white round pills by dimshilk http://www.freeimages.com/photo/755944 Thursday, July 10, 14
  29. 29. Treatment of GDM: Glyburide compared to SC insulin therapy and associated perinatal outcomes Cheng YW et al. J Matern Fetal Neonatal Med 2012 Apr;25(4):379–384 I M O P Retrospective cohort study GDM women (n=10,682) who required pharmaceutical therapy and enrolled in Sweet Success California Diabetes & Pregnancy Program 2001–2004 Glyburide (n=2073, 19.4%) vs subcutaneous insulin (n=8609, 80.6%) Neonates born to mothers on glyburide more likely to be macrosomic and to be admitted to NICU Thursday, July 10, 14
  30. 30. I M O P 5 RCTs using “gestational diabetes” and “Metformin” Effects of metformin vs insulin on glycemic control, maternal and neonatal outcomes in GDM Maternal: glycemic control, CS incidence, weight gain after enrollment, pregnancy-induced hypertension, preeclampsia, preterm delivery, gestational age at delivery, shoulder dystocia etc Fetal: hypoglycemia, birth weight, NICU admission, LGA, SGA, respiratory distress syndrome, hyperbilirubinemia etc Meta-analysis using random effects model PLoS One 8(5):e64585 Thursday, July 10, 14
  31. 31. PLoS One 8(5):e64585 Weight gain after enrollment Gestational age at delivery Thursday, July 10, 14
  32. 32. PLoS One 8(5):e64585 Incidence of preterm birth Incidence of PIH Thursday, July 10, 14
  33. 33. PLoS One 8(5):e64585 Incidence of preeclampsia Lower in Metformin: average weight gain & gestational age at delivery, rate of PIH Higher in Metformin: preterm birth rate No significant difference in preeclampsia MATERNAL Thursday, July 10, 14
  34. 34. PLoS One 8(5):e64585 Birthweight Incidence of LGA infants Thursday, July 10, 14
  35. 35. PLoS One 8(5):e64585 Incidence of SGA infants Incidence of hypoglycemia Thursday, July 10, 14
  36. 36. Metformin is comparable to insulin in glycemic control and neonatal outcomes. May be more suitable for mild GDM. Weigh ?risk of preterm birth PLoS One 8(5):e64585 Thursday, July 10, 14
  37. 37. Lactation after GDM Lactation2 by carin http://www.freeimages.com/photo/161052 Thursday, July 10, 14
  38. 38. Diabetes Care 35:50-56, 2012 I M OP 522 GDM women diagnosed by 100-g OGTT enrolled in Study of Women, Infant Feeding & Type 2 Diabetes (SWIFT) Exclusive or mostly breastfeeding vs formula feeding Fasting plasma glucose, fasting and 2h insulin Prospective observational cohort study Thursday, July 10, 14
  39. 39. Gunderson EP et al. Diabetes Care 2012;35:50–56 Glucose tolerance categories among infant-feeding groups at 6-9 weeks’ postpartum Entire cohort n=522 Normal PreDM DM Thursday, July 10, 14
  40. 40. Gunderson EP et al. Diabetes Care 2012;35:50–56 Obese women only n=241 Normal PreDM DM Glucose tolerance categories among infant-feeding groups at 6-9 weeks’ postpartum Thursday, July 10, 14
  41. 41. Lactation may have favorable effects on glucose metabolism and insulin sensitivity that may reduce diabetes risk after GDM pregnancy. “ Thursday, July 10, 14
  42. 42. I M O P Diabetes 2012;61:3167–3171 GDM women (n=304) participating in prospective German GDM study recruited 1989–1999 & followed for up to 19 y postpartum OGTT postpartum at 2 and 9 months; 2, 5, 8, 11, 15 and 19 y or until diagnosis of diabetes Development of diabetes Prospective, observational Thursday, July 10, 14
  43. 43. Ziegler et al. Diabetes 2012;61:3167–3171 Cumulative life-table risk of postpartum diabetes in islet autoantibody-negative GDM who breastfed No breastfeeding Breastfeeding <3 mos. Breastfeeding >3 mos. Thursday, July 10, 14
  44. 44. Diabetes 2012;61:3167–3171 Median time to diabetes in autoantibody-negative breastfeeding women is 12.3 y vs 2.3 y in women who did not breastfeed. Breastfeeding should be encouraged among these women because it offers a safe and feasible low-cost intervention to reduce the risk of subsequent diabetes in this high-risk population. “ Thursday, July 10, 14
  45. 45. Implications of using IADPSG criteria women serie 2 by asterisco http://www.freeimages.com/photo/313127 www.slideshare.net/isiptan Tablets vs insulin white round pills by dimshilk http://www.freeimages.com/photo/755944 Lactation after GDM Lactation2 by carin http://www.freeimages.com/photo/161052 Thursday, July 10, 14

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