Effect of Glyburide vs Subcutaneous Insulin on Perinatal Complications Among Women With Gestational Diabetes: A Randomized Clinical Trial

• Published in: JAMA : the journal of the American Medical Association Vol. 319; no. 17; pp. 1773 - 1780
• Main Authors: Sénat, Marie-Victoire, Affres, Helene, Letourneau, Alexandra, Coustols-Valat, Magali, Cazaubiel, Marie, Legardeur, Helene, Jacquier, Julie Fort, Bourcigaux, Nathalie, Simon, Emmanuel, Rod, Anne, Héron, Isabelle, Castera, Virginie, Sentilhes, Loic, Bretelle, Florence, Rolland, Catherine, Morin, Mathieu, Deruelle, Philippe, De Carne, Celine, Maillot, François, Beucher, Gael, Verspyck, Eric, Desbriere, Raoul, Laboureau, Sandrine, Mitanchez, Delphine, Bouyer, Jean
• Format: Journal Article
• Language: English
• Published: United States American Medical Association 01.05.2018; American Medical Association (AMA)
• Subjects: Administration, Oral; Adult; Blood glucose; Blood Glucose - analysis; Clinical trials; Complications; Confidence intervals; Diabetes; Diabetes mellitus; Diabetes, Gestational - blood; Diabetes, Gestational - drug therapy; Diet; Disease prevention; Dosage; Female; Fetal Macrosomia - etiology; Fetal Macrosomia - prevention & control; Gestation; Gestational diabetes; Glyburide - adverse effects; Glyburide - therapeutic use; Human health and pathology; Humans; Hyperbilirubinemia; Hyperbilirubinemia - etiology; Hyperbilirubinemia - prevention & control; Hypoglycemia; Hypoglycemia - chemically induced; Hypoglycemia - etiology; Hypoglycemia - prevention & control; Hypoglycemic Agents - adverse effects; Hypoglycemic Agents - therapeutic use; Infant, Newborn; Infant, Newborn, Diseases - epidemiology; Infectious diseases; Injections, Subcutaneous; Insulin; Insulin - adverse effects; Insulin - therapeutic use; Life Sciences; Neonates; Original Investigation; Pharmacology; Pregnancy; Pregnancy Outcome; Womens health
• ISSN: 0098-7484; 1538-3598; 1538-3598
• DOI: 10.1001/jama.2018.4072

IMPORTANCE: Randomized trials have not focused on neonatal complications of glyburide for women with gestational diabetes. OBJECTIVE: To compare oral glyburide vs subcutaneous insulin in prevention of perinatal complications in newborns of women with gestational diabetes. DESIGN, SETTINGS, AND PARTICIPANTS: The Insulin Daonil trial (INDAO), a multicenter noninferiority randomized trial conducted between May 2012 and November 2016 (end of participant follow-up) in 13 tertiary care university hospitals in France including 914 women with singleton pregnancies and gestational diabetes diagnosed between 24 and 34 weeks of gestation. INTERVENTIONS: Women who required pharmacologic treatment after 10 days of dietary intervention were randomly assigned to receive glyburide (n=460) or insulin (n=454). The starting dosage for glyburide was 2.5 mg orally once per day and could be increased if necessary 4 days later by 2.5 mg and thereafter by 5 mg every 4 days in 2 morning and evening doses, up to a maximum of 20 mg/d. The starting dosage for insulin was 4 IU to 20 IU given subcutaneously 1 to 4 times per day as necessary and increased according to self-measured blood glucose concentrations. MAIN OUTCOMES AND MEASURES: The primary outcome was a composite criterion including macrosomia, neonatal hypoglycemia, and hyperbilirubinemia. The noninferiority margin was set at 7% based on a 1-sided 97.5% confidence interval. RESULTS: Among the 914 patients who were randomized (mean age, 32.8 [SD, 5.2] years), 98% completed the trial. In a per-protocol analysis, 367 and 442 women and their neonates were analyzed in the glyburide and insulin groups, respectively. The frequency of the primary outcome was 27.6% in the glyburide group and 23.4% in the insulin group, a difference of 4.2% (1-sided 97.5% CI, −∞ to 10.5%; P=.19). CONCLUSION AND RELEVANCE: This study of women with gestational diabetes failed to show that use of glyburide compared with subcutaneous insulin does not result in a greater frequency of perinatal complications. These findings do not justify the use of glyburide as a first-line treatment. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01731431