The Correct Answer is C!

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Question:

A 37 year-old woman with a history of obesity, hypertension and type 2 diabetes presents to the office for nausea, vomiting, and fatigue for the last 2 weeks. A beta-HCG test confirms pregnancy, and based on her last menstrual period, she is estimated at 6 weeks gestation. She takes metformin 1000 mg twice daily, glyburide 2.5 mg twice daily, and lisinopril 2.5 mg daily. Her blood pressure today is 145/81 mm Hg. Her most recent hemoglobin A1C is 7.2%.

Besides stopping lisinopril and starting alternative antihypertensive therapy, which of the following is the most appropriate recommendation for this patient?

  1. Stop metformin and glyburide immediately
  2. Continue both metformin and glyburide and target pre-prandial blood glucose to <120 mg/dL
  3. Transition oral hypoglycemics to an insulin regimen
  4. Continue metformin but stop glyburide

Rationale:

Diabetes is one of the most important chronic diseases to monitor and control during pregnancy, as it increases the risk of miscarriage, congenital fetal anomalies, preterm labor, pre-eclampsia, and perinatal death. Thus tight glycemic control is important during pregnancy. The preferred treatment of diabetes in pregnancy is using a basal-prandial insulin regimen as insulin does not cross the placenta, and noninsulin hypoglycemic agents mostly lack long-term safety data in pregnancy. Although there is emerging data that they are probably safe and have been used in pregnancy.

The most reasonable recommendation here is to suggest transition of this patient to an insulin regimen for diabetes treatment. Neither metformin nor glyburide should not be stopped immediately without alternative glucose control as hyperglycemia can inhibit proper organogenesis in the fetus. It is probably reasonable to continue metformin and glyburide, but the target pre-prandial blood glucose according to the ADA recommendations is 60-99 mg/dL with peak postprandial glucose 100-129 mg/dL and A1C target <6%.

1.  Source: "Comparative Analysis of Pre/Post Assessments of Live/Didactic Course Attendees when compared to Mico-Learning/Online Course Users., "Knowledge to Practice, 2017.