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Table 4 Pharmacological therapy recommendations among different guidelines

From: Current guidelines on the management of gestational diabetes mellitus: a content analysis and appraisal

Guidelines Recommendation
NICE, 2015 Offer metformin to women with gestational diabetes if blood glucose targets are not met using changes in diet and exercise within 1–2 weeks;
Offer insulin instead of metformin to women with gestational diabetes if metformin is contraindicated or unacceptable to the woman;
Consider glibenclamide for women with gestational diabetes: in whom blood glucose targets are not achieved with metformin but who decline insulin therapy or who cannot tolerate metformin.
NZGG, 2014 Where women who have gestational diabetes and poor glycaemic control (above treatment targets) in spite of dietary and lifestyle interventions, offer oral hypoglycaemics (metformin or glibenclamide) and/or insulin therapy. In deciding whether to use oral therapy or insulin, take account of the clinical assessment and advice, and the woman’s preferences and her ability to adhere to medication and self-monitoring.
SIGN, 2013 Metformin or glibenclamide may be considered as initial pharmacological, glucose-lowering treatment in women with gestational diabetes.
ADA, 2018 Insulin is the preferred medication or treating hyperglycemia in gestational diabetes mellitus as it does not cross the placenta to a measurable extent. Metformin and glyburide may be used, but both cross the placenta to the fetus, with metformin likely crossing to a greater extent than glyburide. All oral agents lack long-term safety data.
FIGO, 2015 Insulin, glyburide, and metformin are safe and effective therapies for GDM during the second and third trimesters, and may be initiated as first-line treatment after failing to achieve glucose control with lifestyle modification. Among OADs, metformin may be a better choice than glyburide;
High resource: Insulin should be considered as the first-line treatment in women with GDM who are at high risk of failing on OAD therapy, including some of the following factors:
• Diagnosis of diabetes < 20 weeks of gestation
• Need for pharmacologic therapy > 30 weeks
• Fasting plasma glucose levels > 110 mg/dL
• 1-h postprandial glucose > 140 mg/dL
• Pregnancy weight gain > 12 kg
Endocrine Society, 2013 We suggest that glyburide (glibenclamide) is a suitable alternative to insulin therapy for glycemic control in women with gestational diabetes who fail to achieve sufficient glycemic control after a 1-week trial of medical nutrition therapy and exercise except for those women with a diagnosis of gestational diabetes before 25 weeks gestation and for those women with fasting plasma glucose levels > 110 mg/dl (6.1 mmol/l), in which case insulin therapy is preferred;
We suggest that metformin therapy be used for glycemic control only for those women with gestational diabetes who do not have satisfactory glycemic control despite medical nutrition therapy and who refuse or cannot use insulin or glyburide and are not in the first trimester.
CDA, 2013 If women with GDM do not achieve glycemic targets within 2 weeks from nutritional therapy alone, insulin therapy should be initiated;
For women who are nonadherent to or who refuse insulin, glyburide or metformin may be used as alternative agents for glycemic control. Use of oral agents in pregnancy is off-label and should be discussed with the patient.
API, 2014 The use of OADs is currently not recommended for glycaemic management during pregnancy.
IDF, 2009 Insulin has been, and is likely to remain, the treatment of choice but there is now adequate evidence to consider the use of metformin and glibenclamide (glyburide) as treatment options for women who have been informed of the possible risks. Combination therapy has not been specifically studied.
Queensland, 2015 Metformin when compared to Insulin is effective at lowering blood glucose and is safe for pregnant women and their fetuses;
I nsulin is safe to use in pregnancy.
HKCOG, 2016 Offer metformin if blood glucose targets are not met after diet and exercise therapy within 1–2 weeks;
Offer addition of insulin to diet therapy, exercise and metformin if blood glucose targets are not met.
Consider glibenclamide for women in whom blood glucose targets are not achieved with metformin but who decline insulin therapy or who cannot tolerate metformin.
CMA, 2014 Insulin should be considered as the first-line treatment in women with GDM, and OADs is currently not recommended for glycaemic management during pregnancy.
DDG, 2018 The indication for insulin should first be considered within 1–2 weeks after the start of basic therapy (diet, exercise);
For pregnant women with GDM and suspected severe insulin resistance and when individually indicated, use of metformin can be considered following explanation of the off-label use.