diabetestalk.net

Gestational Diabetes Management Guidelines

  1. Insulin
  2. Gestational Diabetes Management Guidelines
Guidelines For Gestational Diabetes Mellitus

Guidelines For Gestational Diabetes Mellitus

Guidelines for Gestational Diabetes Mellitus Obstet Gynecol; ePub 2017 Jul; Caughey, et al The American College of Obstetricians and Gynecologists (ACOG) has issued clinical management guidelines for the diagnosis and treatment of gestational diabetes mellitus (GDM) in pregnancy. The document provides a brief overview of the understanding of GDM, reviews management guidelines that have been validated by appropriately conducted clinical research, and identifies gaps in current knowledge. Among the recommendations offered: Women in whom GDM is diagnosed should receive nutrition and exercise counseling, and when this fails to adequately control glucose levels, medication should be used for maternal and fetal benefit. When pharmacologic treatment of GDM is indicated, insulin is considered the first-line treatment for diabetes in pregnancy. All pregnant women should be screened for GDM with a laboratory-based screening test(s) using blood glucose levels. In women who decline insulin therapy or for those women whom the obstetrician or obstetric care provider believes the patient will be unable to safely administer insulin, metformin is a reasonable second-line choice. Glyburide treatment should not be recommended as a first-line pharmacologic treatment because, in most studies, it does not yield equivalent outcomes to insulin. Health care providers should counsel women of the limitations in safety data when prescribing oral agents to women with GDM. Women with GDM should be counseled regarding the risks and benefits of a scheduled cesarean delivery when the estimated fetal weight is 4,500 g or more. Gestational diabetes mellitus. Practice Bulletin No. 180. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2017;130:e1731. Continue reading >>

Acog Issues New Guidelines For Gestational Diabetes Management

Acog Issues New Guidelines For Gestational Diabetes Management

While Gestational Diabetes Mellitus (GDM) is a less frequent reason for being prescribed Bedrest, GDM can significantly complicate pregnancy as well as maternal and fetal health. Close management of GDM and tight control of blood sugars is essential for best pregnancy outcomes. In the August issue of Obstetrics and Gynecology, researchers report that new studies comparing single step and 2 step GDM screening indicate that 2 step screening, which is the current course of screening in the US, is still the preferred method of care. Many other countries use the single step method, but ACOG researchers feel more researcher needs to be done before recommending changing screening protocols. The two step screening process requires pregnant women between 24 and 28 wks gestation drink a 50gm glucose solution followed by blood glucose levels taken one hour later. If a woman’s blood sugar levels are elevated, the test is repeated using a 100gm solution and blood levels drawn 3 hours later. If the second test comes back elevated, the woman is diagnosed with GDM and started on dietary management first, than oral medications and/or insulin injections are added if necessary to reach and maintain proper blood sugar levels. According to ACOG’s report, 4 million American women give birth annually and 7% will develop GDM. GDM complicates pregnancy by putting mamas at increased risk of pregnancy induced hypertension, pre-eclampsia, c-section delivery and developing Type II Diabetes later in life. Infants born to mothers with GDM are at risk of macrosomia (being large for gestational age), hypoglycemia, birth trauma and c-section delivery. GDM is a relatively common occurrence during pregnancy and is on the rise with the national rise in obesity and mamas delaying pregnancy until later i Continue reading >>

12. Management Of Diabetes In Pregnancy

12. Management Of Diabetes In Pregnancy

For guidelines related to the diagnosis of gestational diabetes mellitus, please refer to Section 2 “Classification and Diagnosis of Diabetes.” Pregestational Diabetes Provide preconception counseling that addresses the importance of glycemic control as close to normal as is safely possible, ideally A1C <6.5% (48 mmol/mol), to reduce the risk of congenital anomalies. B Family planning should be discussed and effective contraception should be prescribed and used until a woman is prepared and ready to become pregnant. A Women with preexisting type 1 or type 2 diabetes who are planning pregnancy or who have become pregnant should be counseled on the risk of development and/or progression of diabetic retinopathy. Eye examinations should occur before pregnancy or in the first trimester and then be monitored every trimester and for 1 year postpartum as indicated by degree of retinopathy. B Lifestyle change is an essential component of management of gestational diabetes mellitus and may suffice for treatment for many women. Medications should be added if needed to achieve glycemic targets. A Preferred medications in gestational diabetes mellitus are insulin and metformin; glyburide may be used but may have a higher rate of neonatal hypoglycemia and macrosomia than insulin or metformin. Other agents have not been adequately studied. Most oral agents cross the placenta, and all lack long-term safety data. A General Principles for Management of Diabetes in Pregnancy Potentially teratogenic medications (ACE inhibitors, statins, etc.) should be avoided in sexually active women of childbearing age who are not using reliable contraception. B Fasting, preprandial, and postprandial self-monitoring of blood glucose are recommended in both gestational diabetes mellitus and pregestati Continue reading >>

Acog Releases Updated Guidance On Gestational Diabetes

Acog Releases Updated Guidance On Gestational Diabetes

SUMMARY: ACOG has released updated guidance on gestational diabetes (GDM), which has become increasingly prevalent worldwide. Highlights and changes from the previous practice bulletin include the following: Fetal Monitoring Screening for GDM – One or Two Step? ACOG (based on NIH consensus panel findings) still supports the ‘2 step’ approach (24 – 28 week 1 hour venous glucose measurement following 50g oral glucose solution), followed by a 3 hour oral glucose tolerance test (OGTT) if positive Note: While the diagnosis of GDM is based on 2 abnormal values on the 3 hour OGTT, ACOG states, due to known adverse events, one abnormal value may be sufficient to make the diagnosis 1 step approach (75 g OGTT) on all women will increase the diagnosis of GDM but sufficient prospective studies demonstrating improved outcomes still lacking ACOG does acknowledge that some centers may opt for ‘1 step’ if warranted based on their population Who Should be Screened Early? ACOG has adopted the NIDDK / ADA guidance on screening for diabetes and prediabetes which takes in to account not only previous pregnancy history but also risk factors associated with type 2 diabetes. Screen early in pregnancy if: Patient is overweight with BMI of 25 (23 in Asian Americans), and one of the following: Physical inactivity Known impaired glucose metabolism Previous pregnancy history of: GDM Macrosomia (≥ 4000 g) Stillbirth Hypertension (140/90 mm Hg or being treated for hypertension) HDL cholesterol ≤ 35 mg/dl (0.90 mmol/L) Fasting triglyceride ≥ 250 mg/dL (2.82 mmol/L) PCOS, acanthosis nigricans, nonalcoholic steatohepatitis, morbid obesity and other conditions associated with insulin resistance Hgb A1C ≥ 5.7%, impaired glucose tolerance or impaired fasting glucose Cardiovascular disea Continue reading >>

Screening, Diagnosis, And Management Of Gestational Diabetes Mellitus

Screening, Diagnosis, And Management Of Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) affects approximately 6% of pregnancies in the United States, and it is increasing in prevalence. Pregnant women without known diabetes mellitus should be screened for GDM after 24 weeks of gestation. Treatment of GDM results in a statistically significant decrease in the incidence of preeclampsia, shoulder dystocia, and macrosomia. Initial management includes glucose monitoring and lifestyle modifications. If glucose levels remain above target values, pharmacologic therapy with metformin, glyburide, or insulin should begin. Antenatal testing is customary for women requiring medications. Induction of labor should not occur before 39 weeks in women with GDM, unless glycemic control is poor or another indication for delivery is present. Unless otherwise indicated, scheduled cesarean delivery should be considered only in women with an estimated fetal weight greater than 4,500 g. Women with a history of GDM are at high risk of subsequently developing diabetes. These patients should be screened six to 12 weeks postpartum for persistently abnormal glucose metabolism, and should undergo screening for diabetes every three years thereafter. Gestational diabetes mellitus (GDM) is a condition of glucose intolerance with onset or first recognition in pregnancy that is not clearly overt diabetes.1,2 Normal pregnancy is characterized by pancreatic β-cell hyperplasia resulting in higher fasting and postprandial insulin levels. Increased secretion of placental hormones leads to increasing insulin resistance, especially throughout the third trimester. GDM occurs when β-cell function is insufficient to overcome this insulin resistance.3 Clinical recommendation Evidence rating References Comments Screening for GDM should occur after 24 weeks of gestat Continue reading >>

Diagnosis And Management Of Gestational Diabetes Mellitus

Diagnosis And Management Of Gestational Diabetes Mellitus

Gestational diabetes occurs in 5 to 9 percent of pregnancies in the United States and is growing in prevalence. It is a controversial entity, with conflicting guidelines and treatment protocols. Recent studies show that diagnosis and management of this disorder have beneficial effects on maternal and neonatal outcomes, including reduced rates of shoulder dystocia, fractures, nerve palsies, and neonatal hypoglycemia. Diagnosis is made using a sequential model of universal screening with a 50-g one-hour glucose challenge test, followed by a diagnostic 100-g three-hour oral glucose tolerance test for women with a positive screening test. Treatment consists of glucose monitoring, dietary modification, exercise, and, when necessary, pharmacotherapy to maintain euglycemia. Insulin therapy is the mainstay of treatment, although glyburide and metformin may become more widely used. In women receiving pharmacotherapy, antenatal testing with nonstress tests and amniotic fluid indices beginning in the third trimester is generally used to monitor fetal well-being. The method and timing of delivery are controversial. Women with gestational diabetes are at high risk of subsequent development of type 2 diabetes. Lifestyle modification should therefore be encouraged, along with regular screening for diabetes. Evidence for screening, diagnosing, and managing gestational diabetes mellitus has continued to accrue over the past several years. In 2003, the U.S. Preventive Services Task Force1 (USPSTF) and the Cochrane Collaboration2 found insufficient evidence to recommend for or against screening for or treating gestational diabetes. However, a subsequent randomized controlled trial (RCT) found that screening and intervention for gestational diabetes were beneficial.3 Nonetheless, in 2008, Continue reading >>

Updated Guidelines On Screening For Gestational Diabetes

Updated Guidelines On Screening For Gestational Diabetes

Go to: Introduction Gestational diabetes mellitus (GDM) has classically been defined as any glucose intolerance first identified during pregnancy.1 Recently, the American Diabetes Association (ADA) defined it as “Diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes”.2 However, as per IADPSG (International association of diabetes and pregnancy study groups) criteria, women can be diagnosed to have GDM even in the first trimester, if fasting plasma glucose (FPG) is ≥5.1 mmol/L (92 mg/dL), but <7 mmol/L (126 mg/dL).3 GDM is associated with an increased risk of complications for both mother and baby, during pregnancy as well as in the postpartum period. Screening and identifying these high-risk women is important to improve short and long-term maternal and fetal outcomes.4 However, there is lack of international uniformity in the approach to the screening and diagnosis of GDM.5 This is surprising, given that the strategies for making a diagnosis of diabetes mellitus are uniform across the world.2 The main reason for the diagnostic dilemma of GDM is the large number of procedures and glucose cutoffs proposed for the diagnosis of glucose intolerance in pregnancy.6 The first diagnostic criteria proposed by O’Sullivan in 1964 and its subsequent modifications (Carpenter and Coustan) were based on the maternal risk of developing type 2 diabetes, rather than on pregnancy outcomes. Recently, the recommendations from IADPSG attempt to redefine GDM in terms of adverse pregnancy outcomes, based on Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study results.6 But, we are still far from attaining a holistic criteria which is based on both short and long-term outcomes. The main purpose of this review is to provide an update on s Continue reading >>

Guidelines

Guidelines

There is now extensive evidence on the optimal management of diabetes, offering the opportunity of improving the immediate and long-term quality of life of those living with the condition. Unfortunately such optimal management is not reaching many, perhaps the majority, of the people who could benefit. Reasons include the size and complexity of the evidence-base, and the complexity of diabetes care itself. One result is a lack of proven cost-effective resources for diabetes care. Another result is diversity of standards of clinical practice. Guidelines are part of the process which seeks to address those problems. IDF has produced a series of guidelines on different aspects of diabetes management, prevention and care. The new IDF Clinical Practice Recommendations for managing Type 2 Diabetes in Primary Care seek to summarise current evidence around optimal management of people with type 2 diabetes. It is intended to be a decision support tool for general practitioners, hospital based clinicians and other primary health care clinicians working in diabetes. Pocket chart in the format of a Z-card with information for health professionals to identify, assess and treat diabetic foot patients earlier in the "window of presentation" between when neuropathy is diagnosed and prior to developing an ulcer. The content is derived from the IDF Clinical Practice Recommendations on the Diabetic Foot 2017. Available to download and to order in print format. The IDF Clinical Practice Recommendations on the Diabetic Foot are simplified, easy to digest guidelines to prioritize health care practitioner's early intervention of the diabetic foot with a sense of urgency through education. The main aims of the guidelines are to promote early detection and intervention; provide the criteria for Continue reading >>

Diabetes Management Guidelines

Diabetes Management Guidelines

Source: American Diabetes Association. Standards of medical care in diabetes—2016. Diabetes Care. 2016;39(suppl 1):S1-S106. Available here. Refer to source document for full recommendations, including class of recommendation and level of evidence. Jump to a topic or click back/next at the bottom of each page Diabetes in Pregnancy (Gestational Diabetes) Glycemic Targets in Pregnancy Pregestational diabetes Gestational diabetes mellitus (GDM) Fasting ≤90 mg/dL (5.0 mmol/L) ≤95 mg/dL (5.3 mmol/L) 1-hr postprandial ≤130-140 mg/dL (7.2-7.8 mmol/L) ≤140 mg/dL (7.8 mmol/L) 2-hr postprandial ≤120 mg/dL (6.7 mmol/L) ≤120 mg/dL (6.7 mmol/L) A1C 6.0-6.5% (42-48 mmol/L) recommended <6.0% may be optimal as pregnancy progresses Achieve without hypoglycemia Recommendations for Pregestational Diabetes Pregestational type 1 and type 2 diabetes confer greater maternal and fetal risk than GDM Spontaneous abortion Fetal anomalies Preeclampsia Intrauterine fetal demise Macrosomia Neonatal hypoglycemia Neonatal hyperbilirubinemia Diabetes in pregnancy may increase the risk of obesity and type 2 diabetes in offspring later in life Maintain A1C levels as close to normal as is safely possible Ideally, A1C <6.5% (48 mmol/L) without hypoglycemia Discuss family planning Prescribe effective contraception until woman is prepared to become pregnant Women with preexisting type 1 or type 2 diabetes Counsel on the risk of development and/or progression of diabetic retinopathy Perform eye exams before pregnancy or in first trimester; monitor every trimester and for 1 year postpartum Management of Pregestational Diabetes Insulin is the preferred medication for pregestational type 1 and type 2 diabetes not adequately controlled with diet, exercise, and metformin Insulin* management during pre Continue reading >>

Acog Guidelines At A Glance: Gestational Diabetes Mellitus

Acog Guidelines At A Glance: Gestational Diabetes Mellitus

Committee on Practice Bulletins—Obstetrics ACOG Practice Bulletin 137: Gestational Diabetes Mellitus, August 2013 (Replaces Practice Bulletin Number 30, September 2001, Committee Opinion Number 435, June 2009, and Committee Opinion Number 504, September 2011). Obstet Gynecol. 2013;122:406-16. Full text of ACOG Practice Bulletins is available to ACOG members at _Bulletins_--_Obstetrics/Gestational_Diabetes_Mellitus. Gestational diabetes mellitus Gestational diabetes mellitus (GDM) is one of the most common medical complications of pregnancy. Debate continues to surround both the diagnosis and treatment of GDM despite several recent large-scale studies addressing these issues. The purpose of this document is to 1) provide a brief overview of the understanding of GDM, 2) provide management guidelines that have been validated by appropriately conducted clinical research, and 3) identify gaps in current knowledge toward which future research can be directed. Used with permission. Copyright the American College of Obstetricians and Gynecologists. By Haywood L. Brown, MD Dr. Brown is Roy T. Parker Professor and Chair, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Duke Medicine, Durham, NC. He is also a member of the Contemporary OB/GYN Editorial Board. Practice Bulletin 137 on gestational diabetes mellitus provides a rationale for current screening guidelines for a pregnancy population in which prevalence of obesity and Type 2 diabetes has increased over the past several decades. Review of the bulletin underscores several questions pertinent to diagnosis and management, which are reflected by and addressed similarly in the evidence-based recommendations in the document.1 Is GDM overdiagnosed or underdiagnosed? Obviously, the prevalence of gest Continue reading >>

Management Of Pregnancy Complicated By Diabetes

Management Of Pregnancy Complicated By Diabetes

Preconception Care AACE guidelines specify that preconception care is important for all women with preexisting type 1 diabetes mellitus (T1DM) or type 2 diabetes mellitus (T2DM) or previous gestational diabetes mellitus (GDM). One of the primary goals of preconception care is to educate patients about strategies to maintain adequate nutrition and glucose control before conception, during pregnancy, and in the postpartum period.1 Intensive glycemic management of women with diabetes prior to conception and throughout pregnancy has been shown to confer significant health benefits to both mother and child.2 When women with diabetes establish normoglycemia before pregnancy and maintain it through the first trimester, the risk of complications (eg, congenital anomalies and spontaneous abortion) is comparable to levels for women without diabetes.3 Glycemic Targets Glycemic targets during pregnancy are defined in the 2011 AACE guidelines, shown in the table below. For all glucose management protocols, AACE recommendations stress that patient safety must be the first priority.1,4 Table 1. AACE and ADA Glycemic Target Guidelines for Pregnant Women With GMD, T1DM, or T2DM1,5 Glucose Increment Patients With GDM Patients With Preexisting T1DM or T2DM Preprandial, premeal ≤95 mg/dL (5.3 mmol/L) Premeal, bedtime, and overnight glucose: 60-99 mg/dL (3.4-5.5 mmol/L) Postprandial, post-meal 1-hour post-meal: ≤140 mg/dL (7.8 mmol/L) or 2-hour post-meal: ≤120 mg/dL (6.7 mmol/L) Peak postprandial glucose 100-129 mg/dL (5.5-7.1 mmol/L) A1C ≤6.0% ≤6.0% Table 2. Expert Recommendations for Glycemic Target Guidelines for Pregnant Women With GMD, T1DM, or T2DM*1,5,6 Some experts recommend more stringent goals, in particular, for patients on insulin therapy, to prevent maternal and fetal Continue reading >>

13.3 Gestational Diabetes Mellitus

13.3 Gestational Diabetes Mellitus

Clinical context Gestational diabetes, or GDM, is defined as glucose intolerance that begins or is first diagnosed during pregnancy. It may appear earlier, particularly in women with a high level of risk for GDM. GDM generally develops and is diagnosed in the late second or early third trimester of the pregnancy. GDM affects about 9.6–13.6% of pregnancies in Australia.245,246 The reported prevalence of GDM varies for a number of reasons. One reason is the use of different screening and diagnostic criteria. The prevalence is also affected by maternal factors such as history of previous gestational diabetes, ethnicity, advanced maternal age, family history of diabetes, pre-pregnancy weight and high gestational weight gain. Mothers of different ethnicity born in areas with high diabetes prevalence such as Polynesia, Asia and the Middle East, are three times as likely to have GDM as mothers born in Australia. Among Aboriginal and Torres Strait Islander mothers, GDM is twice as common, and pre-gestational diabetes affecting pregnancy is three to four times as common as in non-Indigenous mothers.245 In pregnancy, there is a natural increase in levels of hormones including cortisol, growth hormone, human placental lactogen, and progesterone and prolactin levels, causing two to three fold increases in insulin resistance. The action of these hormones is usually compensated by increased insulin release. In pregnant women with abnormal glucose tolerance or impaired β-cell reserve, the pancreas is unable to sufficiently increase insulin secretion in order to control BGLs. Potential maternal complications during pregnancy and delivery include pre-eclampsia and higher rates of caesarean delivery, maternal birth injury, postpartum haemorrhage. For the neonate, complications can inc Continue reading >>

Current Management Of Gestational Diabetes Mellitus

Current Management Of Gestational Diabetes Mellitus

Current Management of Gestational Diabetes Mellitus Guido Menato; Simona Bo; Anna Signorile; Marie-Laure Gallo; Ilenia Cotrino; Chiara Botto Poala; Marco Massobrio Expert Rev of Obstet Gynecol.2008;3(1):73-91. Treatment of Gestational Diabetes Mellitus Diet is the mainstay of treatment in GDM whether or not pharmacologic therapy is introduced. Dietary control with a reduction in fat intake and the substitution of complex carbohydrates for refined carbohydrates seeks to achieve and maintain the maternal blood glucose profile essential during gestation. Two approaches are recommended: decreasing the proportion of carbohydrates to 40% in a daily regimen of three meals and three or four snacks, or lowering the glycemic index so that carbohydrates make up approximately 60% of the daily intake.[ 9 , 10 , 11 , 12 ] The ADA also recommends nutritional counseling, if possible by a registered dietitian, with individualization of the nutrition plan based on height and weight.[ 13 ] For normal-weight women (BMI: 20-25 kg/m2) 30 kcal/kg should be prescribed; for overweight and obese women (BMI > 24-34 kg/m2) calories should be restricted to 25 kcal/kg, and for morbidly obese women (BMI > 34 kg/m2) calories should be restricted to 20 kcal/kg or less.[ 12 ] In normal pregnancy expected weight gain varies according to the prepregnancy weight. The Fifth International Workshop-Conference on GDM recommends a relatively small gain during pregnancy of 7 kg (15 lb) or more for obese women (BMI 30 kg/m2) and a proportionally greater weight gain (up to 18 kg or 40 lb) for underweight women (BMI < 18.5 kg/m2) at the onset of pregnancy. However, there are no data on optimal weight gain for women with GDM.[ 14 ] Caloric composition includes 40-50% from complex, high-fiber carbohydrates, 20% from Continue reading >>

Final Recommendation Statement

Final Recommendation Statement

Importance Gestational diabetes mellitus is glucose intolerance discovered during pregnancy. The prevalence of GDM in the United States is 1% to 25%, depending on patient demographics and diagnostic thresholds (1). Pregnant women with gestational diabetes are at increased risk for maternal and fetal complications, including preeclampsia, fetal macrosomia (which can cause shoulder dystocia and birth injury), and neonatal hypoglycemia. Women with GDM are also at increased risk for developing type 2 diabetes mellitus; approximately 15% to 60% of women develop type 2 diabetes within 5 to 15 years of delivery (2). Screening for GDM generally occurs after the 24th week of pregnancy. Screening before 24 weeks may identify women with glucose intolerance earlier in pregnancy. The USPSTF found adequate evidence that primary care providers can accurately detect GDM in asymptomatic pregnant women after 24 weeks of gestation. The most commonly used screening test in the United States is the 50-g oral glucose challenge test (OGCT). Other methods of screening include the fasting plasma glucose test and screening based on risk factors. However, there is limited evidence on these alternative screening approaches. The USPSTF found inadequate evidence to compare the effectiveness of different screening tests or thresholds for a positive screen result. Benefits of Detection and Early Treatment The USPSTF found adequate evidence that treatment of screen-detected GDM with dietary modifications, glucose monitoring, and insulin (if needed) can significantly reduce the risk of preeclampsia, fetal macrosomia, and shoulder dystocia. When these outcomes are considered collectively, there is a moderate net benefit for both mother and infant. The benefit of treatment on long-term metabolic outcomes Continue reading >>

Gestational Diabetes Management: Guidelines To A Healthy Pregnancy

Gestational Diabetes Management: Guidelines To A Healthy Pregnancy

Gestational diabetes mellitus is a common disease, affecting 7% of pregnant women annually (200,000 cases are diagnosed each year). While insulin has been the accepted treatment for gestational diabetes when diet and exercise are not effective at controlling blood glucose, attention is now focused on the safety and effectiveness of oral agents. Melissa Scollan-Koliopoulos is an Assistant Professor and Coordinator of the Family Nurse Practitioner Program at the University of Medicine and Dentistry of New Jersey School of Nursing, Newark. Sharon Guadagno is the Founder and Director of an advanced practice nurse-coordinated center, the Diabetes Center at Pascack Valley Hospital, Westwood, N.J. Elizabeth A. Walker is a Professor of Medicine and Director of the Prevention and Control Division of the Diabetes Research and Training Center at the Albert Einstein College of Medicine, Bronx, N.Y. The authors have disclosed that they have no significant relationship or financial relationship with any commercial companies mentioned in this continuing education activity. 2006 Lippincott Williams & Wilkins, Inc. Thought you might appreciate this item(s) I saw at The Nurse Practitioner. Your message has been successfully sent to your friend. Some error has occurred while processing your request. Please try after some time. Continue reading >>

More in insulin