今日の臨床サポート

糖尿病合併妊娠

著者: 安田重光 埼玉医科大学 内分泌内科・糖尿病内科

監修: 野田光彦 国際医療福祉大学市川病院 糖尿病・代謝・内分泌内科

著者校正/監修レビュー済:2022/01/26
参考ガイドライン:
  1. 日本産科婦人科学会,日本産婦人科医会:産婦人科診療ガイドライン産科編2020
  1. 日本糖尿病学会:糖尿病診療ガイドライン2019
患者向け説明資料

概要・推奨   

  1. 妊娠初期に糖代謝異常のスクリーニング検査をすることが勧められる(推奨度2)
  1. 全妊婦に糖代謝異常のスクリーニング検査を行うことは推奨される(推奨度2)
  1. 妊婦では、レギュラーヒトインスリンと同様に、インスリンアナログ製剤のうち超速効型インスリン製剤であるインスリンリスプロの使用が推奨される(推奨度2)
アカウントをお持ちの方はログイン
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要と
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
安田重光 : 特に申告事項無し[2022年]
監修:野田光彦 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 日本糖尿病学会の糖尿病診療ガイドライン2019に基づき、妊娠中の血糖コントロール目標について改訂を行った。

病態・疫学・診察

疾患(疫学・病態)のまとめ  
  1. 妊婦の糖代謝異常は「妊娠糖尿病」、「妊娠中の明らかな糖尿病」、「糖尿病合併妊娠」に分類される。
  1. 妊娠糖尿病とは、妊娠中に初めて発見または発症した糖尿病に至っていない糖代謝異常である。妊娠中に診断された明らかな糖尿病は含まれない。
  1. 妊娠前にすでに糖尿病と診断された場合、または妊娠中に発見された場合で確実な糖尿病網膜症があるものを糖尿病合併妊娠とする。妊娠中に発見された場合において、空腹時血糖値126mg/dL以上またはHbA1c6.5%以上のどちらかを満たせば妊娠中の明らかな糖尿病と診断する(“妊娠中の明らかな糖尿病”については、「妊娠による高血糖(糖尿病)」の項を参照)。
  1. 糖尿病合併妊娠においては、妊娠許可を受けた妊娠と、妊娠許可を受けないままに妊娠に至った場合がある。
  1. 胎児の器官形成期は妊娠4週から7週末のため、この時期の血糖コントロールが非常に重要になり、また、妊娠により合併症も悪化するため、血糖コントロール、合併症を管理した上で妊娠を許可する必要がある。
  1. 糖尿病を有する女性が挙児希望で来院した場合は計画妊娠を指導する。糖尿病治療はインスリン療法のみが認められており、経口糖尿病薬はすべて中止する。また、高血圧を合併しており、降圧剤を服用している場合は、メチルドーパ、ヒドララジン、ラベタロールが第一選択薬である。妊娠20週以降はニフェジピン徐放製剤も使用可である。ACE阻害薬やARBについては、妊娠中期以降の使用は禁忌である。
  1. 妊娠中の明らかな糖尿病のスクリーニングは妊娠糖尿病と同様に行う。(参照:妊娠による高血糖(糖尿病)
  1. 糖尿病合併妊娠の診断について、妊娠前にすでに糖尿病と診断されている場合は糖尿病の診断基準に準じて診断される(参照:2型糖尿病)。それ以外に、妊娠中に発見された場合でも確実な糖尿病網膜症が確認されれば糖尿病合併妊娠とする。
  1. 妊娠中に発症した劇症1型糖尿病は妊娠中の明らかな糖尿病に分類される。劇症1型糖尿病は妊娠と強く関連して発症し、母児の予後が悪いため、頻度は少ないが注意が必要である。
問診・診察のポイント  
  1. 糖尿病歴、糖尿病合併症歴、妊娠糖尿病歴、妊娠前BMI、過度の体重増加の有無、糖尿病家族歴、巨大児出産歴、年齢を確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

まずは15日間無料トライアル
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

Shlomit Riskin-Mashiah, Grace Younes, Amit Damti, Ron Auslender
First-trimester fasting hyperglycemia and adverse pregnancy outcomes.
Diabetes Care. 2009 Sep;32(9):1639-43. doi: 10.2337/dc09-0688. Epub 2009 Jun 23.
Abstract/Text OBJECTIVE: The Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study found strong associations between higher levels of maternal glucose at 24-32 weeks, within what is currently considered normoglycemia and adverse pregnancy outcomes. Our aim was to evaluate the associations between first-trimester fasting plasma glucose level and adverse pregnancy outcomes.
RESEARCH DESIGN AND METHODS: Charts of all patients who delivered at our hospital between June 2001 and June 2006 were reviewed. Only subjects with singleton pregnancy and a recorded first-trimester fasting glucose level were included. Women with pregestational diabetes, fasting glucose level >105 mg/dl, or delivery <24 weeks were excluded. Fasting glucose levels were analyzed in seven categories, similar to the HAPO study. The main outcomes were development of gestational diabetes mellitus (GDM), large-for-gestational-age (LGA) neonates and/or macrosomia, and primary cesarean section. Multivariate logistic regression analysis was used; significance was <0.05.
RESULTS: A total of 6,129 women had a fasting glucose test at median of 9.5 weeks. There were strong, graded associations between fasting glucose level and primary outcomes. The frequency of GDM development increased from 1.0% in the lowest glucose category to 11.7% in the highest (adjusted odds ratio 11.92 [95% CI 5.39-26.37]). The frequency of LGA neonates and/or macrosomia increased from 7.9 to 19.4% (2.82 [1.67-4.76]). Primary cesarean section rate increased from 12.7 to 20.0% (1.94 [1.11-3.41]).
CONCLUSIONS: Higher first-trimester fasting glucose levels, within what is currently considered a nondiabetic range, increase the risk of adverse pregnancy outcomes. Early detection and treatment of women at high risk for these complications might improve pregnancy outcome.

PMID 19549728
M E Griffin, M Coffey, H Johnson, P Scanlon, M Foley, J Stronge, N M O'Meara, R G Firth
Universal vs. risk factor-based screening for gestational diabetes mellitus: detection rates, gestation at diagnosis and outcome.
Diabet Med. 2000 Jan;17(1):26-32.
Abstract/Text AIMS: Gestational diabetes mellitus (GDM) is associated with adverse maternal and fetal outcome. Screening for GDM is therefore recommended but the best screening method remains controversial. This prospective, randomized study compared a risk factor-based screening programme with a universally based one.
METHODS: Subjects were randomized at booking to one of two groups: the risk factor group had a 3-h 100-g oral glucose tolerance test (OGTT) at 32 weeks if any risk factor for GDM was present; the universal group had a 50-g glucose challenge test performed and if their plasma glucose at 1 h was > or = 7.8 mmol/l, a formal 3-h 100-g OGTT was then performed.
RESULTS: Universal screening detected a prevalence of GDM of 2.7%, significantly more than the 1.45% detected in the risk factor screened group (P<0.03). Universal screening facilitated earlier diagnosis than risk factor screening - mean gestation 30 +/- 2.6 weeks vs. 33 +/- 3.7 weeks (P<0.05). A higher rate of spontaneous vaginal delivery at term, and lower rates of macrosomia, Caesarean section, prematurity, pre-eclampsia and admission to neonatal intensive care unit were observed in the universally screened, early diagnosis group.
CONCLUSIONS: Universal screening for GDM is superior to risk factor based screening-detecting more cases, facilitating early diagnosis and is associated with improved pregnancy outcome.

PMID 10691156
Abstract/Text This prospective nationwide study examined the relationship between diabetic control in early pregnancy as assessed by HbA1C and the incidence of spontaneous abortion and fetal malformation. HbA1C and plasma C-peptide were determined in 532 women with Type 1 (insulin-dependent) diabetes mellitus, corresponding to approximately 80% of all the diabetic pregnancies in the country during the study period 1982-1985, and 222 non-diabetic control women. Median gestational week for sampling was 9.0 in the Type 1 diabetic and 10.0 in the control group. The median value of HbA1C was 7.7% in the diabetic and 5.3% in the control group (p less than 0.001). The rates of spontaneous abortion, 7.7% vs 7.2%, and malformation, 4.3% (major 2.0%) and 2.4% (major 1.0%), were not significantly different between the diabetic and control group, respectively. These rates of malformation were not significantly different from the national figures of 4.55% (major 1.75%). Much elevated HbA1C, i.e., greater than 10.1% equal to 8 SD above the normal mean control value, was significantly associated with the occurrence of spontaneous abortion (p less than 0.001) and malformation (p less than 0.01). Discriminant analysis revealed that after correction had been made for the significant value of HbA1C to predict the occurrence of spontaneous abortion and malformation, no further predictive power was displayed by measurable plasma C-peptide, maternal age or duration of diabetes or presence of diabetic microangiopathy. We conclude that poor metabolic control in early pregnancy contributes to an increased risk of both spontaneous abortion and fetal malformation.

PMID 2328844
Hayfaa A Wahabi, Rasmeia A Alzeidan, Ghada A Bawazeer, Lubna A Alansari, Samia A Esmaeil
Preconception care for diabetic women for improving maternal and fetal outcomes: a systematic review and meta-analysis.
BMC Pregnancy Childbirth. 2010 Oct 14;10:63. doi: 10.1186/1471-2393-10-63. Epub 2010 Oct 14.
Abstract/Text BACKGROUND: Preexisting diabetes mellitus is associated with increased risk for maternal and fetal adverse outcomes. Despite improvement in the access and quality of antenatal care recent population based studies demonstrating increased congenital abnormalities and perinatal mortality in diabetic mothers as compared to the background population. This systematic review was carried out to evaluate the effectiveness and safety of preconception care in improving maternal and fetal outcomes for women with preexisting diabetes mellitus.
METHODS: We searched the following databases, MEDLINE, EMBASE, WEB OF SCIENCE, Cochrane Library, including the CENTRAL register of controlled trials and CINHAL up to December 2009, without language restriction, for any preconception care aiming at health promotion, glycemic control and screening and treatment of diabetes complications in women of reproductive age group with type I or type II diabetes. Study design were trials (randomized and non-randomized), cohort and case-control studies. Of the 1612 title scanned 44 full papers were retrieved of those 24 were included in this review. Twelve cohort studies at low and medium risk of bias, with 2502 women, were included in the meta-analysis.
RESULTS: Meta-analysis suggested that preconception care is effective in reducing congenital malformation, RR 0.25 (95% CI 0.15-0.42), NNT17 (95% CI 14-24), preterm delivery, RR 0.70 (95% CI 0.55-0.90), NNT = 8 (95% CI 5-23) and perinatal mortality RR 0.35 (95% CI 0.15-0.82), NNT = 32 (95% CI 19-109). Preconception care lowers HbA1c in the first trimester of pregnancy by an average of 2.43% (95% CI 2.27-2.58). Women who received preconception care booked earlier for antenatal care by an average of 1.32 weeks (95% CI 1.23-1.40).
CONCLUSION: Preconception care is effective in reducing diabetes related congenital malformations, preterm delivery and maternal hyperglycemia in the first trimester of pregnancy.

PMID 20946676
Yuji Hiramatsu, Ikki Shimizu, Yasue Omori, Masao Nakabayashi, JGA (Japan Glycated Albumin) Study Group
Determination of reference intervals of glycated albumin and hemoglobin A1c in healthy pregnant Japanese women and analysis of their time courses and influencing factors during pregnancy.
Endocr J. 2012;59(2):145-51. doi: 10.1507/endocrj.k10e-410. Epub 2011 Dec 14.
Abstract/Text Glycemic control is an important issue in gestational diabetes mellitus (GDM) and in diabetic pregnant women. We determined the reference intervals of glycated albumin (GA) and hemoglobin A1c (HbA1c) as glycemic control markers in healthy Japanese pregnant women and analyzed their time courses and factors that influence these variables during pregnancy. 676 women were screened for the present study. After the exclusion of non-pregnant and puerperal women, 574 women were studied to determine the reference intervals. HbA1c, GA, casual plasma glucose, urinary glucose, urinary protein, and body mass index (BMI) (non-pregnancy) were measured. HbA1c levels significantly decreased in the second trimester of pregnancy and increased in the third trimester, while GA levels significantly decreased towards the third trimester. Casual plasma glucose levels decreased in the first trimester and subsequently remained constant. The reference intervals of GA and HbA1c in the healthy pregnant women were 11.5-15.7% and 4.5-5.7%, respectively. GA levels were lower (p<0.01) and HbA1c levels were higher (p<0.05) in pregnant women with proteinuria. In the obese group, GA levels were lower (p<0.01) than those of the control group (18.5≤ BMI <25kg/m²), and HbA1c levels were higher (p<0.01) than those of the control group. On the basis of the results of this multicenter study, the reference intervals of GA and HbA1c in healthy Japanese pregnant women were determined. Strict glycemic control is essential to reduce perinatal complications. GA appears to be a useful marker for pregnant women, since it can be measured easily and changes rapidly and markedly.

PMID 22166921
Sumeet R Singh, Fida Ahmad, Avtar Lal, Changhua Yu, Zemin Bai, Heather Bennett
Efficacy and safety of insulin analogues for the management of diabetes mellitus: a meta-analysis.
CMAJ. 2009 Feb 17;180(4):385-97. doi: 10.1503/cmaj.081041.
Abstract/Text BACKGROUND: Although insulin analogues are commonly prescribed for the management of diabetes mellitus, there is uncertainty regarding their optimal use. We conducted meta-analyses to compare the outcomes of insulin analogues with conventional insulins in the treatment of type 1, type 2 and gestational diabetes.
METHODS: We updated 2 earlier systematic reviews of the efficacy and safety of rapid-and long-acting insulin analogues. We searched electronic databases, conference proceedings and "grey literature" up to April 2007 to identify randomized controlled trials that compared insulin analogues with conventional insulins. Study populations of interest were people with type 1 and type 2 diabetes (adult and pediatric) and women with gestational diabetes.
RESULTS: We included 68 randomized controlled trials in the analysis of rapid-acting insulin analogues and 49 in the analysis of long-acting insulin analogues. Most of the studies were of short to medium duration and of low quality. In terms of hemoglobin A1c, we found minimal differences between rapid-acting insulin analogues and regular human insulin in adults with type 1 diabetes (weighted mean difference for insulin lispro: -0.09%, 95% confidence interval [CI] -0.16% to -0.02%; for insulin aspart: -0.13%, 95% CI -0.20% to -0.07%). We observed similar outcomes among patients with type 2 diabetes (weighted mean difference for insulin lispro: -0.03%, 95% CI -0.12% to -0.06%; for insulin aspart: -0.09%, 95% CI -0.21% to 0.04%). Differences between long-acting insulin analogues and neutral protamine Hagedorn insulin in terms of hemoglobin A1c were marginal among adults with type 1 diabetes (weighted mean difference for insulin glargine: -0.11%, 95% CI -0.21% to -0.02%; for insulin detemir: -0.06%, 95% CI -0.13% to 0.02%) and among adults with type 2 diabetes (weighted mean difference for insulin glargine: -0.05%, 95% CI -0.13% to 0.04%; for insulin detemir: 0.13%, 95% CI 0.03% to 0.22%). Benefits in terms of reduced hypoglycemia were inconsistent. There were insufficient data to determine whether insulin analogues are better than conventional insulins in reducing long-term diabetes-related complications or death.
INTERPRETATION: Rapid-and long-acting insulin analogues offer little benefit relative to conventional insulins in terms of glycemic control or reduced hypoglycemia. Long-term, high-quality studies are needed to determine whether insulin analogues reduce the risk of long-term complications of diabetes.

PMID 19221352
Elisabeth R Mathiesen, Brendan Kinsley, Stephanie A Amiel, Simon Heller, David McCance, Santiago Duran, Shannon Bellaire, Anne Raben, Insulin Aspart Pregnancy Study Group
Maternal glycemic control and hypoglycemia in type 1 diabetic pregnancy: a randomized trial of insulin aspart versus human insulin in 322 pregnant women.
Diabetes Care. 2007 Apr;30(4):771-6. doi: 10.2337/dc06-1887.
Abstract/Text OBJECTIVE: To assess the safety and efficacy of insulin aspart (IAsp) versus regular human insulin (HI) in basal-bolus therapy with NPH insulin in pregnant women with type 1 diabetes.
RESEARCH DESIGN AND METHODS: Subjects (n = 322) who were pregnant or planning pregnancy were randomized to IAsp or HI as meal-time insulin in an open-label, parallel-group, multicenter study. Subjects had A1C < or =8% at confirmation of pregnancy. Insulin doses were titrated toward predefined glucose targets and A1C <6.5%. Outcomes assessed included risk of major maternal hypoglycemia, A1C, plasma glucose profiles, and maternal safety outcomes.
RESULTS: Major hypoglycemia occurred at a rate of 1.4 vs. 2.1 episodes/year exposure with IAsp and HI, respectively (relative risk 0.720 [95% CI 0.36-1.46]). Risk of major/major nocturnal hypoglycemia was 52% (RR 0.48 [0.20-1.143]; P = NS) lower with IAsp compared with HI. A1C was comparable with human insulin in second (IAsp-HI -0.04 [-0.18 to 0.11]) and third (-0.08 [-0.23 to 0.06]) trimesters. A total of 80% of subjects achieved an A1C < or =6.5%. At the end of first and third trimesters, average postprandial plasma glucose increments were significantly lower with IAsp than HI (P = 0.003 and P = 0.044, respectively), as were mean plasma glucose levels 90 min after breakfast (P = 0.044 and P = 0.001, respectively). Maternal safety profiles and pregnancy outcomes were similar between treatments.
CONCLUSIONS: IAsp is at least as safe and effective as HI when used in basal-bolus therapy with NPH insulin in pregnant women with type 1 diabetes and may potentially offer some benefits in terms of postprandial glucose control and preventing severe hypoglycemia.

PMID 17392539
Erika Pollex, Myla E Moretti, Gideon Koren, Denice S Feig
Safety of insulin glargine use in pregnancy: a systematic review and meta-analysis.
Ann Pharmacother. 2011 Jan;45(1):9-16. doi: 10.1345/aph.1P327. Epub 2011 Jan 4.
Abstract/Text BACKGROUND: The prevalence of diabetes in women of childbearing age is increasing. As such, the number of pregnancies complicated by diabetes will inevitably increase. New insulin analogues such as the long-acting analogue insulin glargine may represent beneficial treatment options in pregnancy by ensuring that patients achieve excellent glycemic control without risk of maternal hypoglycemia.
OBJECTIVE: To determine the fetal safety of insulin glargine use in the treatment of diabetes in pregnancy compared with NPH insulin therapy.
METHODS: A systematic review and meta-analysis was performed of all original human studies that reported neonatal outcomes among women with pregestational or gestational diabetes who were managed with either insulin glargine or NPH insulin during pregnancy. A systematic literature search was conducted using MEDLINE, EMBASE, CINAHL, the Cochrane Central Register for Controlled Trials database, and Web of Science from 1980 to June 1, 2010. Outcomes included large size for gestational age, macrosomia, neonatal hypoglycemia, neonatal intensive care unit admissions, birth trauma, congenital anomalies, preterm delivery, perinatal mortality, respiratory distress, and hyperbilirubinemia. Relative risk ratios and weighted mean differences were computed with 95% confidence intervals.
RESULTS: Eight studies reporting on a total of 702 women with pregestational or gestational diabetes in pregnancy treated with either insulin glargine (n = 331) or NPH insulin (n = 371) met the inclusion criteria. There were no statistically significant differences in the occurrence of fetal outcomes studied with the use of insulin glargine compared to NPH insulin.
CONCLUSIONS: No evidence has been documented for increased adverse fetal outcomes with the use of insulin glargine in pregnancy compared to the use of NPH insulin. These results increase the choices for women requiring basal insulin therapy in pregnancy.

PMID 21205954
Elisabeth R Mathiesen, Moshe Hod, Marina Ivanisevic, Santiago Duran Garcia, Lise Brøndsted, Lois Jovanovic, Peter Damm, David R McCance, Detemir in Pregnancy Study Group
Maternal efficacy and safety outcomes in a randomized, controlled trial comparing insulin detemir with NPH insulin in 310 pregnant women with type 1 diabetes.
Diabetes Care. 2012 Oct;35(10):2012-7. doi: 10.2337/dc11-2264. Epub 2012 Jul 30.
Abstract/Text OBJECTIVE: This randomized, controlled noninferiority trial aimed to compare the efficacy and safety of insulin detemir (IDet) versus neutral protamine Hagedorn (NPH) (both with prandial insulin aspart) in pregnant women with type 1 diabetes.
RESEARCH DESIGN AND METHODS: Patients were randomized and exposed to IDet or NPH up to 12 months before pregnancy or at 8-12 weeks gestation. The primary analysis aimed to demonstrate noninferiority of IDet to NPH with respect to A1C at 36 gestational weeks (GWs) (margin of 0.4%). The data were analyzed using linear regression, taking several baseline factors and covariates into account.
RESULTS: A total of 310 type 1 diabetic women were randomized and exposed to IDet (n = 152) or NPH (n = 158) up to 12 months before pregnancy (48%) or during pregnancy at 8-12 weeks (52%). The estimated A1C at 36 GWs was 6.27% for IDet and 6.33% for NPH in the full analysis set (FAS). IDet was declared noninferior to NPH (FAS, -0.06% [95% CI -0.21 to 0.08]; per protocol, -0.15% [-0.34 to 0.04]). Fasting plasma glucose (FPG) was significantly lower with IDet versus NPH at both 24 GWs (96.8 vs. 113.8 mg/dL, P = 0.012) and 36 GWs (85.7 vs. 97.4 mg/dL, P = 0.017). Major and minor hypoglycemia rates during pregnancy were similar between groups.
CONCLUSIONS: Treatment with IDet resulted in lower FPG and noninferior A1C in late pregnancy compared with NPH insulin. Rates of hypoglycemia were comparable.

PMID 22851598

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから