Factors Associated with the Need for Insulin as a Complementary Treatment to Metformin in Gestational Diabetes Mellitus

Souza, Matheus Leite Ramos de; Silva, Rodrigo Ribeiro e; Silva, Thiago Ribeiro e; Oliveira, Larissa Cano de; Dienstmann, Guilherme; Nascimento, Iramar Baptistella do; Silva, Jean Carl

doi:10.1055/s-0039-1700796

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Original Articles • Rev. Bras. Ginecol. Obstet. 41 (12) • Dec 2019 • https://doi.org/10.1055/s-0039-1700796 copy

Factors Associated with the Need for Insulin as a Complementary Treatment to Metformin in Gestational Diabetes Mellitus

Fatores associados à necessidade de insulina como tratamento complementar à metformina na diabetes mellitus gestacional

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective

To evaluate the factors associated with the need for insulin as a complementary treatment to metformin in pregnant women with gestational diabetes mellitus (GDM).

Methods

A case-control study was performed from April 2011 to February 2016 with pregnant women with GDM who needed complementary treatments besides diet and physical exercise. Those treated with metformin were compared with those who, in addition to metformin, also needed the combination with insulin. Maternal characteristics and glycemic control were evaluated. Multinomial logistic regression models were developed to evaluate the influence of different therapies on neonatal outcomes.

Results

A total of 475 pregnant women who needed pharmacological therapy were evaluated. Of these, 366 (77.05%) were submitted to single therapy with metformin, and 109 (22.94%) needed insulin as a complementary treatment. In the analysis of the odds ratio (OR), fasting glucose (FG)<90 mg/dL reduced the odds of needing the combination (OR: 0.438 [0.235-0.815]; p=0.009], as well as primiparity (OR: 0.280 [0.111-0.704]; p=0.007]. In obese pregnant women, an increased chance of needing the combination was observed (OR: 2,072 [1,063-4,039]; p=0,032).

Conclusion

Obesity resulted in an increased chance of the mother needing insulin as a complementary treatment to metformin, while FG<90 mg/dL and primiparity were protective factors.

Keywords:
gestational diabetes; metformin; insulin; combined treatment

	Metformin(n= 366)	Combination(n= 109)	p-value
Age	31.48 (6.88)	34.40 (6.33)	0.020^c
Previous pregnancies	3.00 (2.08)	3.50 (1.73)	0.008^c
BMI	29.48 (5.96)	32.13 (6.99)	0.009^c
BMI class
Low weight	28 (7.65%)	1 (0.91%)	0.006^b
Adequate	78 (21.31%)	17 (15.59%)	0.190^a
Overweight	116 (31.69%)	29 (26.60%)	0.311^a
Obese	139 (37.97%)	60 (55.04%)	0.002^a
Weight gain	1.31 (3.16)	3.48 (3.72)	0.009^c
GA at diagnosis	28.76 (5.83)	25.95 (5.76)	< 0.001^c
SHGS	21 (5.73%)	9 (8.25%)	0.346^a
Previous SAH	55 (15.02%)	17 (15.59%)	0.864^a

	Metformin(n= 366)	Combination(n= 109)	p-value
OGTT
Fasting	92.77 (11.90)	98.30 (7.42)	< 0.001^c
1 hour	172.16 (33.90)	178.50 (32.58)	0.769^c
2 hours	147.33 (36.58)	151.35 (30.67)	0.403^c
Glycemic control
Fasting	88.90 (9.81)	98.29 (10.58)	<0.001^c
Postprandial	120.28 (14.16)	124.03 (15.97)	<0.001^c
HBA1C	5.35 (0.34)	5.60 (0.38)	0.018^c

	Metformin(n= 366)	Combination(n= 109)	p-value
GA at birth	38.67 (1.36)	38.55 (1.57)	0.228^c
Premature	17 (4.64%)	4 (3.66%)	0.664^b
Delivery route
Normal	174 (47.54%)	41 (37.61%)	0.068^a
Caesarean	192 (52.46%)	68 (62.38%)	0.068^a
Weight	3334.18 (357.52)	3461.25 (448.55)	0.001^c
Weight Classification
SGA	9 (2.45%)	1 (0.91%)	0.467^b
AGA	292 (79.78%)	75 (68.80%)	0.016^a
LGA	65 (17.75%)	33 (30.29%)	0.005^a
Apgar
1 minute	8.03 (1.20)	7.75 (1.37)	0.227^c
1 minute low	28 (7.65%)	7 (6.42%)	0.806^a
5 minutes	9.01 (0.69)	8.75 (0.78)	0.477^c
5 minutes low	2 (0.54%)	2 (1.83%)	0.196^b
Need for ICU	15 (4.09%)	15 (13.76%)	< 0.001^a
Malformation	13 (3.55%)	2 (1.83%)	0.537^b
Death	2 (0.54%)	0	1.000^b

	MTF/MTF + insulin	OR^a	95%CI	p-value
Age > 30 years	164/197	0.879	0.508–1.521	0.645
Primiparity	285/76	0.280	0.111–0.704	0.007
GA diagnosis before the 28^th week	213/148	1.331	0.654–2.708	0.430
Low weight	338/23	0.300	0.038–2.396	0.256
Obese	208/153	2.072	1.063–4.039	0.032
FG < 90 mg/dL	225/136	0.438	0.235–0.815	0.009

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[1] Address for correspondence Matheus Leite Ramos de Souza, Universidade da Região de Joinville, Rua Ministro Calógeras 439, 89202-207, Centro, Joinville, SC, Brazil (e-mail: matheus.leite.souza@gmail.com).