Insulin treatment of patients with gestational diabetes: does dosage play a role?

BACKGROUND AND OBJECTIVE: In nonpregnant patients high insulin requirements are associated with hypoglycemia and weight gain but not with improvement in glucose control. The effect of insulin requirement on maternal and neonatal outcomes in gestational diabetes mellitus (GDM) is yet unknown. METHODS: We conducted a retrospective cohort study of maternal and neonatal outcomes of pregnancy according to insulin requirements in women with GDM who were followed and delivered at the Yitzhak Shamir Medical Center between 2006 and 2016. The daily insulin dose in units per body weight was divided into quartiles and analyses were performed to compare the lowest, highest, and two middle quartiles. The primary outcome was a composite of any of the following: cesarean-section (CS), preeclampsia, macrosomia and large for gestational age (LGA) birth weight, neonatal intensive care unit admission, need for phototherapy, and neonatal hypoglycemia. RESULTS: Women were divided according to their insulin requirements as follows: 79 (24.8%) women who needed <0.13 IU/kg/day of insulin (insulin-sensitive group), 160 (50%) women who needed 0.14-0.42 IU/kg/day of insulin (comparison-group), and the rest who needed >0.43 IU/kg/day of insulin (insulin resistant group). There were no differences in the composite outcome between the groups (64.6, 61.3, and 69.6% for the insulin sensitive-, comparison- and resistant- groups, respectively, p = .44). Women in the insulin-resistant group had higher fasting glucose levels in the first trimester (91, 98 and 102 mg/dL for women in the insulin sensitive-, comparison- and insulin-resistant groups, respectively; p = .01). Women in the insulin-sensitive group had significantly better glycemic control (fasting glucose levels ≤90 mg/dL and 1-hour and 2-hour postprandial glucose levels ≤140 mg/dL and ≤120 mg/dL for more than 80% of measurements) than those in the insulin-resistant group (70.3 versus 29.9%; p < .001). The rate of CS was significantly higher in the insulin-resistant group (42.3 versus 24.1%; p = .03), but the rate of LGA birth weight was surprisingly higher in the insulin-sensitive group (29.5 versus 16.7%, p = .04). After controlling for confounders, women in the insulin-sensitive group had a decreased risk for CS in relation to the comparison group (OR = 0.46, 95%CI 0.23-0.9, p = .025). CONCLUSION: We found no association between insulin requirements and adverse composite outcome in women with GDM. However, those with higher insulin requirements have poorer glucose control and higher rates of CS than those with lower insulin requirements. Larger studies are needed to inquire short- and long-term outcomes of insulin requirements on fetal and maternal outcomes.

The Use of Complementary and Alternative Medicine Among Dialysis Patients.

Context • The use of complementary and alternative medicine (CAM) has been on the rise in the last decade. Subpopulations of patients with chronic diseases are at risk for adverse events and potential drug-herb interactions, among them dialysis patients. Objective • The study aimed to evaluate the prevalence of CAM consumption among dialysis patients and to search for potential interactions. Design • The study was cross-sectional, based on questionnaires. Setting • The study occurred in the hemodialysis unit at Assaf Harofeh Medical Center (Zeriffin, Israel). Participants • Participants were patients of the hemodialysis unit. Outcome Measures • The questionnaires obtained demographic data, information about a patient's medical history and use of prescription medication, and all relevant history of CAM use, including the interest of the medical team in the patient's use of supplements. Results • Eighty-four patients participated in the study. Eight patients (9.5%) had used CAM, 5 of whom were women (62.5%). Of the CAM consumers, 4 (50%) had more than 12 y of education vs 14 (8.4%) in the nonconsumer group (P = .061). Six of the consumers were professionals (75%) in comparison with 30 (39.5%) of the nonconsumers, although that difference was not statistically significant (P = .22). The CAM users' monthly incomes were significantly better than that of the nonconsumers (P = .01). No differences were found regarding smoking, alcohol consumption, or physical activity. The study found potential drug-herb interactions in 4 (50%) of the CAM consumers. Moderate potential interactions were found between Aloe vera and diuretics; Aloe vera and insulin; pyridoxine and calcium-channel blockers and diuretics; and niacin and statins. Those interactions had the potential to result in hypoglycemia, hyperglycemia, hypokalemia, and lower blood pressure. Conclusions • The study found a lower prevalence of CAM consumption in dialysis patients than had been found in other studies of the general population. Still, the unawareness of the harm and potential interactions and the lack of data sharing between the patients and caregivers might have had disastrous consequences. Therefore, caregivers need to inquire of their patients specifically about their use of CAM, especially for populations with chronic diseases, let alone patients undergoing dialysis.

The Use of Complementary and Alternative Medicine in Hospitalized Patients with Type 2 Diabetes Mellitus in Israel.

INTRODUCTION: The use of complementary and alternative medicine (CAM) has been on the rise in recent years in the general population, as well as among patients with chronic diseases such as diabetes mellitus. The aim of this study was to add information regarding the use of CAM in patients with type 2 diabetes mellitus (DM2) in Israel and explore possible interactions between CAM and prescription medication (PM). METHODS: This is a cross-sectional study based on questionnaires. The study included type 2 diabetic patients who were hospitalized in an internal medicine department at Assaf Harofeh Medical Center, Zerifin, Israel, between December 2013 and December 2014. Possible interactions between CAM and PM were evaluated by a clinical pharmacist and a clinical pharmacologist. RESULTS: Out of 111 diabetic patients, 23.4% used CAM. There was no significant difference between the consumers and nonconsumers in terms of age, education, income, smoking, or alcohol habits. Only 11 of the 26 CAM consumers informed their physician regarding the use. We found possible drug-herb interactions in 19 of the 26 CAM consumers. A major interaction was found between omega-3 and antiaggregants and was encountered in 7 (26.9%) of the CAM consumers. Other minor and major interactions were found with vitamin E, ginkgo-biloba, co-enzyme Q10, green tea, fenugreek seeds, pyridoxine, and dandelion. CONCLUSIONS: Since CAM consumption is on the rise, it is desirable to improve our knowledge concerning their potential effects and adverse effects, especially in conjunction with PM. Given the complexity of pharmaceutics in patients with chronic diseases, among them patients with DM, the use of supplementary medicine cannot be ignored.