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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: May 13, 2015
Expiration Date: May 13, 2016

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Executive Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 13.0 contact hour(s) of continuing education by the American Association of Nurse Practitioners. Program ID 1504207. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.

Last week 653 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 173 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to inform clinical practice," one article was selected by the DynaMed Editorial Team.

Glyburide is Associated with an Increased Risk of Adverse Neonatal Outcomes Compared to Insulin in Women with Gestational Diabetes

Reference: JAMA Pediatr 2015 May 1;169(5):452 (level 2 [mid-level] evidence)

Gestational diabetes mellitus affects approximately 7% of all pregnancies and is associated with increased risk of maternal and neonatal complications (Diabetes Care 2014 Jan;37 Suppl 1:S81, Diabetes Care 2007 Jul;30 Suppl 2:S251). Identification and proper treatment of gestational diabetes, however, may decrease these risks (BMJ 2010 Apr 1;340:c1395, N Engl J Med 2009 Oct 1;361(14):1339). The American Diabetes Association recommends initial management of gestational diabetes with diet and exercise, with the addition of insulin or oral hypoglycemic agents if needed (Diabetes Care 2015 Jan;38 Suppl 1:S1 PDF). Currently, the evidence comparing insulin to oral hypoglycemic agents including glyburide is limited. A recent retrospective cohort study assessed maternal and neonatal outcomes in 9,137 privately insured women with gestational diabetes prescribed glyburide or insulin within 150 days of delivery. All included women had singleton pregnancies.

The mean duration of treatment was 50.4 days for the 4,982 women (54.3%) prescribed glyburide and 54.1 days for the 4,191 women (45.7%) prescribed insulin. In an analysis adjusted for age and other covariates, use of glyburide was associated with increased risk of neonatal complications compared to insulin, including neonatal intensive care unit admission (adjusted relative risk [RR] 1.41, 95% CI 1.23-1.62, NNH 25-60), respiratory distress (adjusted RR 1.63, 95% CI 1.23-2.15, NNH 61-233), and large for gestational age (adjusted RR 1.43, 95% CI 1.16-1.76, NNH 46-164). Glyburide was also nonsignificantly associated with an increased risk of hypoglycemia and birth injury, but there were no significant differences in the risk of obstetric trauma, cesarean delivery, jaundice, or prematurity.

Although limited by its retrospective cohort design, this study allows for the examination of a much larger group of women than reported in previous observational studies or randomized trials. The largest randomized trial comparing glyburide vs. insulin included 404 women and found no significant differences in neonatal outcomes (N Engl J Med 2000 Oct 19;343(16):1134), but the trial was likely underpowered to detect differences in these outcomes. The results of the current study are consistent with the direction of outcomes in the prior trial, but the 20-fold larger patient population increased the ability of this study to detect differences in neonatal outcomes affecting a small percentage of patients. The study also reflects real world conditions rather than the tightly controlled protocols found in many randomized trials. Overall, the results of this study suggest that glyburide may be associated with a greater risk of complications than insulin in women with gestational diabetes requiring medication.

For more information, see the Gestational diabetes mellitus (GDM) topic in DynaMed.

Quick Access to Clinical Answers with the DynaMed App

DynaMed users can access valuable evidence-based content anywhere with the updated DynaMed mobile app. The app has been redesigned to make it easier and faster for physicians to find answers to clinical questions. The app features an improved user experience, seamless authentication, and easy access to the latest clinical content. It provides offline access and the ability to denote favorites, email topics, and write and save notes about particular topics. Users download the complete DynaMed content set and periodically receive notifications to update the content.

The DynaMed app is complimentary for all personal and institutional DynaMed subscriptions. The app has also been designed for easy one-time authentication via email, making the process as convenient as possible.

The app can be downloaded from the iTunes Store or Google Play. For more information, please visit the DynaMed Mobile Access page.

Critical Appraisal of the Medical Literature: A Simplified Approach

July 8 9, 2015 Portland State University - Portland, Oregon.

Join our Editorial Board members Sheri Strite and Michael Stuart and improve your critical appraisal skills. We aim to make critical appraisal of the medical literature meaningful, useful, simple, and doable. This program will be particularly helpful to those who routinely evaluate the medical literature.

Visit the Seminar page for more details.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: Gastroenterology, Nephrology, Oncology (especially Breast cancer and Pancreatic cancer), Ophthalmology, and Pediatric Neurology.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.

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