What is the recommended next step in managing a patient with diagnosed gestational diabetes whose glucose levels remain elevated?

In the management of gestational diabetes, when a patient's glucose levels remain elevated despite adherence to dietary modifications and exercise, the recommended next step is typically the initiation of insulin therapy. Insulin is considered the first-line pharmacological treatment for gestational diabetes because it effectively lowers blood glucose levels without crossing the placenta, thus providing safety for the developing fetus.

Insulin therapy can help achieve tighter glycemic control, reducing the risk of complications associated with uncontrolled gestational diabetes, such as fetal macrosomia, preterm birth, and increased risk of cesarean delivery.

While glyburide and metformin have been used in some cases, they are generally prescribed when lifestyle modifications alone do not suffice, and they are typically not the first choice due to varying efficacy and potential side effects. Continuing with diet and exercise alone is insufficient if glucose levels are still elevated, as these methods have already proven ineffective in managing the patient's condition. Therefore, starting insulin is the most appropriate next step for effective management in this scenario.