In gestational diabetes (GDM), the initial management centres on an individualised medical nutrition plan, regular moderate-intensity physical activity, and appropriate weight management. When these measures prove insufficient to bring blood glucose into the required range, an evidence-based next-line protocol guides further management.

First-Line Approach — and When It Is Not Enough

Medical nutrition therapy (an individualised plan developed with a registered dietitian nutritionist), physical activity of at least 150 minutes of moderate-intensity aerobic exercise per week, and weight management form the first treatment line. Escalation to pharmacologic therapy is triggered when glycemic targets are not met: fasting plasma glucose at or above 95 mg/dL, 1-hour postprandial glucose at or above 140 mg/dL, or 2-hour postprandial glucose at or above 120 mg/dL.

Next-Line Treatment — Partial Overview

When lifestyle measures fall short of glycemic targets, pharmacologic therapy is added. Insulin is the preferred first-line pharmacologic agent for GDM; in selected situations where insulin cannot be used safely or effectively, oral pharmacologic agents may be considered as an alternative after discussing the relevant considerations.

Fasting <95 mg/dL 1-h post-meal <140 mg/dL 2-h post-meal <120 mg/dL

References

DOI: 10.2337/dc26-S015

Insulin should be added if needed to achieve glycemic goals.
Insulin is the first-line agent recommended for the treatment of GDM in the U.S.
Glucose goals are fasting plasma glucose <95 mg/dL (<5.3 mmol/L) and either 1-h postprandial glucose <140 mg/dL (<7.8 mmol/L) or 2-h postprandial glucose <120 mg/dL (<6.7 mmol/L).

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Gestational Diabetes When Medical Nutrition Therapy and Lifestyle Changes Fail to Achieve Glycemic Goals

References