You will be presented with a collection of medical randomized controlled trial (RCT) reports addressing a shared clinical question -- for instance, the efficacy of a medical intervention on a disease or condition. Given the titles and abstracts of these reports, your task is to generate the conclusion of the systematic review article synthesizing the key findings. Your conclusion should be a few sentences long. In your response, include only the conclusion and no other text. The RCT reports are below.



Title 1:
Insulin and glyburide therapy: dosage, severity level of gestational diabetes, and pregnancy outcome.
Abstract 1:
OBJECTIVE We sought to investigate the association between glyburide dose , degree of severity in  gestational diabetes mellitus ( GDM ) ,  level of glycemic control , and  pregnancy outcome in insulin- and glyburide-treated patients . STUDY DESIGN In a secondary analysis of our previous r and omized study , 404 women were analyzed . The association among glyburide dose , severity of GDM , and selected maternal and neonatal factors was evaluated . Severity levels of GDM were stratified by fasting plasma glucose ( FPG ) from the oral glucose tolerance test ( OGTT ) . Infants with birth weight at or above the 90th percentile were considered large-for-gestational age ( LGA ) . Macrosomia was defined as birth weight > or = 4000 g. Well-controlled was defined as mean blood glucose < or = 95 mg/dL. The association between glyburide- and insulin-treated patients by severity of GDM and neonatal outcome was evaluated . RESULTS The dose received for the glyburide-treated patients was 2.5 mg-32 % ; 5 mg-23 % ; 10 mg-17 % ; 15 mg-8 % ; and 20 mg-20 % . Patients were grouped into low ( < or = 10 mg ) and high ( > 10 mg ) daily dose of glyburide . A comparison between severity of the disease ( fasting plasma glucose categories ) and highest dose of glyburide revealed a significant difference between the low-95 FPG and the other severity categories ( P = .02 ) . Of patients in the well-controlled glycemic group , only 6 % required the high dose of glyburide ( > 10 mg ) . In patients with poor glycemic control ( mean blood glucose > 95 mg/dL ) , 38 % received the high dose of glyburide ( P = .0001 ) . Comparison between the high glyburide ( > 10 mg ) and the low glyburide dosages ( < or = 10 mg ) revealed that the rate of macrosomia was 16 % vs 5 % and LGA 22 % vs 8 % , ( P = .01 ) , respectively . No significant difference was found in composite outcome , metabolic complications , and Ponderal Index between the 2 dose groups . Stratification by disease severity revealed a significantly lower rate of LGA for both the glyburide- and insulin-treated subjects . No significant difference was found between metabolic , respiratory , and neonatal intensive care unit ( NICU ) for patients within each fasting plasma glucose severity category . CONCLUSION Glyburide and insulin are equally efficient for treatment of GDM in all levels of disease severity . Achieving the established level of glycemic control , not the mode of pharmacologic therapy , is the key to improving the outcome in GDM


Title 2:
A comparison of glyburide and insulin in women with gestational diabetes mellitus.
Abstract 2:
Objective To compare the use of glyburide and insulin in the treatment of gestational diabetes . Design R and omized controlled trial . Setting Maternal health clinics in San Antonio , Texas . Patients Women with mild gestational diabetes ( n = 404 ) at 11 - 33 weeks gestation . Only women with a singleton pregnancy were eligible . Intervention Glyburide ( starting dose 2.5 mg , increased as necessary to achieve target glycaemic control to a maximum of 20 mg ) or insulin ( 0.7 U per kg body weight , three times daily , increased as necessary ) . If blood glucose goals were not met after 2 weeks of treatment with the maximal dose of glyburide , treatment was switched to insulin . Main outcome measures Primary outcome was achievement of a desirable level of glycaemic control ( strict target ranges were set for mean , fasting , prepr and ial and postpr and ial blood glucose , measured by frequent home monitoring ) . Neonatal outcomes were also assessed . Main results Eighty-two percent of women in the glyburide group and 88 % of women in the insulin group achieved the target blood glucose values ( difference = -6 % , 95 % confidence interval ( CI ) -13 % to + 1 % , P = 0.07 ) . Considerably less women in the glyburide group had blood glucose values below 40 mg ( 2.2 mmol/l ) per decilitre ( 2 % vs. 20 % , difference -18 % , 95 % CI -24 % to -13 % , P < 0.0001 ) . In the glyburide group , 4 % of women were switched to insulin as the maximal dose failed to produce target blood glucose values . There were no significant differences in neonatal outcomes , including cord serum insulin . Conclusion Treatment of women with gestational diabetes , after the first trimester of pregnancy , with glyburide rather than insulin can achieve similar glycaemic control , with less hypoglycaemia


Title 3:
Pregnancy outcome in obese and morbidly obese gestational diabetic women.
Abstract 3:
OBJECTIVE We sought to determine whether pregnancy outcome differs between obese and morbidly obese GDM patients and to assess pregnancy outcome in association with mode of treatment and level of glycemic control . METHODS A cohort study of 4,830 patients with gestational diabetes ( GDM ) , treated in the same center using the same diabetic protocol , was performed . Obesity was defined as prepregnancy BMI > 30 and < 35 kg/m(2 ) ; morbid obesity was defined as prepregnancy BMI > or=35 kg/m(2 ) . Well-controlled GDM was defined as mean blood glucose < 105 mg/dl . Pregnancy outcome measures included the rates of large for gestational age ( LGA ) and macrosomic babies , metabolic complications , the need for NICU admission and /or respiratory support , rate of shoulder dystocia , and the rate of cesarean section . RESULTS Among the GDM patients , the rates of obesity and morbid obesity were 15.7 % ( 760 out of 4830 , BMI : 32.4+/-1.6 kg/m(2 ) ) and 11.6 % ( 559 out of 4830 , BMI : 42.6+/-2.2 kg/m(2 ) ) , respectively . No differences were found with regard to maternal age , ethnicity , gestational age at delivery or oral glucose tolerance test ( OGTT ) results . Moreover , similar rates of cesarean section , fetal macrosomia , shoulder dystocia , composite outcome , and metabolic complications were noted . Insulin treatment was initiated for 62 % of the obese and 73 % of the morbidly obese GDM patients ( P<0.002 ) . Similar rates of obese and morbidly obese patients achieved desired levels of glycemic control ( 63 % versus 61 % , respectively ) . In both obese and morbidly obese patients who achieved a desired level of glycemic control ( < 105 mg/dl ) , no difference was found in pregnancy outcome except that both neonatal metabolic complications and composite outcomes were more prevalent in diet-treated subjects in comparison to insulin-treated GDM patients . CONCLUSION In obese women with GDM , pregnancy outcome is compromised regardless of the level of obesity or treatment modality


Title 4:
Use of glyburide for the treatment of gestational diabetes: the San Antonio experience.
Abstract 4:
OBJECTIVES Equivalent efficacy of glyburide and insulin for treatment of gestational diabetes ( GDM ) was demonstrated in a recent r and omized trial . We describe our experience with glyburide in practice , and suggest factors that predict failure of glyburide treatment . METHODS Women with GDM treated with glyburide were studied . They were divided into two groups : those who achieved adequate glycemic control with glyburide , and those who did not . The groups were compared in terms of baseline characteristics , including diabetes risk factors and glucose testing values . Receiver operating characteristics ( ROC ) curves were generated to identify thresholds for fasting plasma glucose and body mass index ( BMI ) that would predict glyburide failure . RESULTS Seventy-five women were analyzed : 63 ( 84 % ) were successfully treated with glyburide , and 12 ( 16 % ) were not . Baseline characteristics were similar between the groups , except that failures had higher 3-h glucose tolerance test ( GTT ) values at all time points . ROC curves for fasting plasma glucose , pre-pregnancy BMI and BMI at diagnosis revealed no cut-off points for predicting failure of glyburide therapy . However , when fasting plasma glucose value on the GTT was > or = 110 mg/dl , 24 % of women failed to respond to glyburide , compared to 12 % at < 110 mg/dl ( p = 0.15 ) . CONCLUSIONS In treatment of GDM , glyburide is successful in achieving good glycemic control in most women . Women with high fasting plasma glucose levels , however , may not respond adequately to glyburide therapy
The rate of congenital malformations did not differ between pregnancies treated with insulin and those treated with oral agents .
: No substantial maternal or neonatal outcome differences were found with the use of glyburide or metformin compared with use of insulin in women with GDM