Benefits and risks of oral diabetes agents compared with insulin in women with gestational diabetes: a systematic review. Export

@article{citeulike:4166363, abstract = {OBJECTIVE: Little is known about the comparative risks and benefits of medical treatments for gestational diabetes mellitus (GDM). We conducted a systematic review of randomized controlled trials and observational studies of maternal and neonatal outcomes in women with GDM treated with oral diabetes agents compared with all types of insulin. DATA SOURCES: We searched four electronic databases from inception through January 2007. Terms for GDM, insulins, and oral hypoglycemic agents were used in the search. Two investigators independently reviewed titles and abstracts, performed data abstraction on full articles, and assessed study quality. METHOD OF STUDY SELECTION: Articles were excluded if they had no comparison group or did not use a standard diagnosis of GDM (3-hour, 100-g oral glucose tolerance test or 2-hour, 75-g oral glucose tolerance test). Nine studies met our inclusion criteria, four randomized controlled trials (n=1,229 participants) and five observational studies (n=831 participants). Data were abstracted on study characteristics, gestational age at treatment, medication dosage, and length of follow-up. Outcomes included glycemic control, infant birth weight, neonatal hypoglycemia, and congenital anomalies. TABULATION, INTEGRATION, AND RESULTS: Two trials compared insulin to glyburide; one trial compared insulin, glyburide, and acarbose; and one trial compared insulin to metformin. No significant differences were found in maternal glycemic control or cesarean delivery rates between the insulin and glyburide groups. A meta-analysis showed similar infant birth weights between women treated with glyburide and women treated with insulin (mean difference -93 g) (95\% confidence interval -191 to 5 g). There was a higher proportion of infants with neonatal hypoglycemia in the insulin group (8.1\%) compared with the metformin group (3.3\%) (P=.008). The rate of congenital malformations did not differ between pregnancies treated with insulin and those treated with oral agents. Observational studies were limited by selection bias and confounding. CONCLUSION: No substantial maternal or neonatal outcome differences were found with the use of glyburide or metformin compared with use of insulin in women with GDM.}, author = {Nicholson, W. and Bolen, S. and Witkop, C. T. and Neale, D. and Wilson, L. and Bass, E.}, citeulike-article-id = {4166363}, citeulike-linkout-0 = {http://dx.doi.org/10.1097/AOG.0b013e318190a459}, citeulike-linkout-1 = {http://view.ncbi.nlm.nih.gov/pubmed/19104375}, citeulike-linkout-2 = {http://www.hubmed.org/display.cgi?uids=19104375}, comment = { Comment 1: The is a very positive negative finding; accepting the null hypothesis here is quite valuable. We can be much more confident in treating GDM without insulin when feasible. Comment 1: This review should be required reading. I would never have guessed that 1.) no trials addressing the TREATMENT of impaired glucose tolerance in pregnancy met inclusion criteria for the Cochrane Collaboration and that 2.) this publication began with 14,064 papers, but went to press including only 9 that passed scientific muster! Despite the paucity of good data, there are no substantial maternal or neonatal differences comparing treatment for gestational diabetes with glyburide and metformin versus insulin as a result of the review. Looks like we need some good trials for a disease that is crying out for attention. border Comments Comment 1: There is an issue here about whether the data rules out an important incidence of problems - this is not clear. Comment 2: Not enough data yet to change practice. Comment 3: This article suggests that either oral anti-diabetes therapy or insulin may be safely used for DM. However, the standard therapy has been insulin and is likely to remain so. One systematic review can`t change established medical practice. Comment 1: Many centres have dedicated clinics where these woman are seen, but NICE guidelines in the UK will increase the numbers diagnosed and treated. An alternative to insulin may be beneficial. }, doi = {10.1097/AOG.0b013e318190a459}, issn = {0029-7844}, journal = {Obstetrics and gynecology}, keywords = {diabetes, gdm, pregnancy}, month = {January}, number = {1}, pages = {193--205}, posted-at = {2009-03-11 22:15:27}, priority = {3}, title = {Benefits and risks of oral diabetes agents compared with insulin in women with gestational diabetes: a systematic review.}, url = {http://dx.doi.org/10.1097/AOG.0b013e318190a459}, volume = {113}, year = {2009} }

TY - JOUR ID - citeulike:4166363 L3 - citeulike-article-id:4166363 N2 - OBJECTIVE: Little is known about the comparative risks and benefits of medical treatments for gestational diabetes mellitus (GDM). We conducted a systematic review of randomized controlled trials and observational studies of maternal and neonatal outcomes in women with GDM treated with oral diabetes agents compared with all types of insulin. DATA SOURCES: We searched four electronic databases from inception through January 2007. Terms for GDM, insulins, and oral hypoglycemic agents were used in the search. Two investigators independently reviewed titles and abstracts, performed data abstraction on full articles, and assessed study quality. METHOD OF STUDY SELECTION: Articles were excluded if they had no comparison group or did not use a standard diagnosis of GDM (3-hour, 100-g oral glucose tolerance test or 2-hour, 75-g oral glucose tolerance test). Nine studies met our inclusion criteria, four randomized controlled trials (n=1,229 participants) and five observational studies (n=831 participants). Data were abstracted on study characteristics, gestational age at treatment, medication dosage, and length of follow-up. Outcomes included glycemic control, infant birth weight, neonatal hypoglycemia, and congenital anomalies. TABULATION, INTEGRATION, AND RESULTS: Two trials compared insulin to glyburide; one trial compared insulin, glyburide, and acarbose; and one trial compared insulin to metformin. No significant differences were found in maternal glycemic control or cesarean delivery rates between the insulin and glyburide groups. A meta-analysis showed similar infant birth weights between women treated with glyburide and women treated with insulin (mean difference -93 g) (95% confidence interval -191 to 5 g). There was a higher proportion of infants with neonatal hypoglycemia in the insulin group (8.1%) compared with the metformin group (3.3%) (P=.008). The rate of congenital malformations did not differ between pregnancies treated with insulin and those treated with oral agents. Observational studies were limited by selection bias and confounding. CONCLUSION: No substantial maternal or neonatal outcome differences were found with the use of glyburide or metformin compared with use of insulin in women with GDM. IS - 1 JF - Obstetrics and gynecology SN - 0029-7844 EP - 205 TI - Benefits and risks of oral diabetes agents compared with insulin in women with gestational diabetes: a systematic review. VL - 113 SP - 193 KW - diabetes KW - gdm KW - pregnancy N1 - Comment 1: The is a very positive negative finding; accepting the null hypothesis here is quite valuable. We can be much more confident in treating GDM without insulin when feasible. Comment 1: This review should be required reading. I would never have guessed that 1.) no trials addressing the TREATMENT of impaired glucose tolerance in pregnancy met inclusion criteria for the Cochrane Collaboration and that 2.) this publication began with 14,064 papers, but went to press including only 9 that passed scientific muster! Despite the paucity of good data, there are no substantial maternal or neonatal differences comparing treatment for gestational diabetes with glyburide and metformin versus insulin as a result of the review. Looks like we need some good trials for a disease that is crying out for attention. border Comments Comment 1: There is an issue here about whether the data rules out an important incidence of problems - this is not clear. Comment 2: Not enough data yet to change practice. Comment 3: This article suggests that either oral anti-diabetes therapy or insulin may be safely used for DM. However, the standard therapy has been insulin and is likely to remain so. One systematic review can`t change established medical practice. Comment 1: Many centres have dedicated clinics where these woman are seen, but NICE guidelines in the UK will increase the numbers diagnosed and treated. An alternative to insulin may be beneficial. AU - Nicholson, W AU - Bolen, S AU - Witkop, CT AU - Neale, D AU - Wilson, L AU - Bass, E PY - 2009/01// UR - http://dx.doi.org/10.1097/AOG.0b013e318190a459 ER -