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Chaudhary S, Kulkarni A. Metformin: Past, Present, and Future. Curr Diab Rep 2024; 24:119-130. [PMID: 38568468 DOI: 10.1007/s11892-024-01539-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2024] [Indexed: 05/12/2024]
Abstract
PURPOSE OF REVIEW This review provides the most recent update of metformin, a biguanide oral antihyperglycemic drug used as a first-line treatment in type 2 diabetes mellitus. RECENT FINDINGS Metformin continues to dominate in the world of antidiabetics, and its use will continue to rise because of its high efficiency and easy availability. Apart from type 2 diabetes, research is exploring its potential in other conditions such as cancer, memory loss, bone disorders, immunological diseases, and aging. Metformin is the most prescribed oral antidiabetic worldwide. It has been in practical use for the last six decades and continues to be the preferred drug for newly diagnosed type 2 diabetes mellitus. It reduces glucose levels by decreasing hepatic glucose production, reducing intestinal glucose absorption, and increasing insulin sensitivity. It can be used as monotherapy or combined with other antidiabetics like sulfonylureas, DPP-4 inhibitors, SGLT-2 inhibitors, or insulin, improving its efficacy. Metformin can be used once or twice daily, depending on requirements. Prolonged usage of metformin may lead to abdominal discomfort, deficiency of Vitamin B12, or lactic acidosis. It should be used carefully in patients with renal impairment. Recent studies have explored additional benefits of metformin in polycystic ovarian disease, gestational diabetes mellitus, cognitive disorders, and immunological diseases. However, more extensive studies are needed to confirm these additional benefits.
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Zhu Y, Engmann M, Medina D, Han X, Das P, Bartke A, Ellsworth BS, Yuan R. Metformin treatment of juvenile mice alters aging-related developmental and metabolic phenotypes in sex-dependent and sex-independent manners. GeroScience 2024; 46:3197-3218. [PMID: 38227136 PMCID: PMC11009201 DOI: 10.1007/s11357-024-01067-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 12/30/2023] [Indexed: 01/17/2024] Open
Abstract
Metformin has attracted increasing interest for its potential benefits in extending healthspan and longevity. This study examined the effects of early-life metformin treatment on the development and metabolism of C57BL/6 J (B6) mice, with metformin administered to juvenile mice from 15 to 56 days of age. Metformin treatment led to decreased body weight in both sexes (P < 0.05, t-test). At 9 weeks of age, mice were euthanized and organ weights were recorded. The relative weight of retroperitoneal fat was decreased in females, while relative weights of perigonadal and retroperitoneal fat were decreased, and relative liver weight was increased in males (P < 0.05, t-test). Glucose and insulin tolerance tests (GTT and ITT) were conducted at the age of 7 weeks. ANOVA revealed a significant impairment in insulin sensitivity by the treatment, and a significantly interactive effect on glucose tolerance between sex and treatment, underscoring a disparity in GTT between sexes in response to the treatment. Metformin treatment reduced circulating insulin levels in fasting and non-fasting conditions for male mice, with no significant alterations observed in female mice. qRT-PCR analysis of glucose metabolism-related genes (Akt2, Glut2, Glut4, Irs1, Nrip1, Pi3k, Pi3kca, Pkca) in the liver and skeletal muscle reveals metformin-induced sex- and organ-specific effects on gene expression. Comparison with previous studies in heterogeneous UM-HET3 mice receiving the same treatment suggests that genetic differences may contribute to variability in the effects of metformin treatment on development and metabolism. These findings indicate that early-life metformin treatment affects development and metabolism in both sex- and genetics-dependent manners.
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Affiliation(s)
- Yun Zhu
- Department of Internal Medicine, Southern Illinois University School of Medicine, 801 N. Rutledge, P.O. Box 19628, Springfield, IL, 62702, USA
| | - Morgan Engmann
- Department of Internal Medicine, Southern Illinois University School of Medicine, 801 N. Rutledge, P.O. Box 19628, Springfield, IL, 62702, USA
| | - David Medina
- Department of Internal Medicine, Southern Illinois University School of Medicine, 801 N. Rutledge, P.O. Box 19628, Springfield, IL, 62702, USA
| | - Xiuqi Han
- Department of Internal Medicine, Southern Illinois University School of Medicine, 801 N. Rutledge, P.O. Box 19628, Springfield, IL, 62702, USA
| | - Pratyusa Das
- Department of Physiology, Southern Illinois University SIU School of Medicine, 1135 Lincoln Drive, Life Science III, Room 2062, Carbondale, IL, 62901, USA
| | - Andrzej Bartke
- Department of Internal Medicine, Southern Illinois University School of Medicine, 801 N. Rutledge, P.O. Box 19628, Springfield, IL, 62702, USA
| | - Buffy S Ellsworth
- Department of Physiology, Southern Illinois University SIU School of Medicine, 1135 Lincoln Drive, Life Science III, Room 2062, Carbondale, IL, 62901, USA
| | - Rong Yuan
- Department of Internal Medicine, Southern Illinois University School of Medicine, 801 N. Rutledge, P.O. Box 19628, Springfield, IL, 62702, USA.
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Martine-Edith G, Johnson W, Petherick ES. Relationships Between Exposure to Gestational Diabetes Treatment and Neonatal Anthropometry: Evidence from the Born in Bradford (BiB) Cohort. Matern Child Health J 2024; 28:557-566. [PMID: 38019368 PMCID: PMC10914642 DOI: 10.1007/s10995-023-03851-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVES To examine the relationships between gestational diabetes mellitus (GDM) treatment and neonatal anthropometry. METHODS Covariate-adjusted multivariable linear regression analyses were used in 9907 offspring of the Born in Bradford cohort. GDM treatment type (lifestyle changes advice only, lifestyle changes and insulin or lifestyle changes and metformin) was the exposure, offspring born to mothers without GDM the control, and birth weight, head, mid-arm and abdominal circumference, and subscapular and triceps skinfold thickness the outcomes. RESULTS Lower birth weight in offspring exposed to insulin (- 117.2 g (95% CI - 173.8, - 60.7)) and metformin (- 200.3 g (- 328.5, - 72.1)) compared to offspring not exposed to GDM was partly attributed to lower gestational age at birth and greater proportion of Pakistani mothers in the treatment groups. Higher subscapular skinfolds in offspring exposed to treatment compared to those not exposed to GDM was partly attributed to higher maternal glucose concentrations at diagnosis. In fully adjusted analyses, offspring exposed to GDM treatment had lower weight, smaller abdominal circumference and skinfolds at birth than those not exposed to GDM. Metformin exposure was associated with smaller offspring mid-arm circumference (- 0.3 cm (- 0.6, - 0.07)) than insulin exposure in fully adjusted models with no other differences found. CONCLUSIONS FOR PRACTICE Offspring exposed to GDM treatment were lighter and smaller at birth than those not exposed to GDM. Metformin-exposed offspring had largely comparable birth anthropometric characteristics to those exposed to insulin.
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Affiliation(s)
- Gilberte Martine-Edith
- School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, LE11 3TU, UK
| | - William Johnson
- School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, LE11 3TU, UK
| | - Emily S Petherick
- School of Sport, Exercise and Health Sciences, Loughborough University, Epinal Way, Loughborough, LE11 3TU, UK.
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Semnani-Azad Z, Gaillard R, Hughes AE, Boyle KE, Tobias DK, Perng W. Precision stratification of prognostic risk factors associated with outcomes in gestational diabetes mellitus: a systematic review. COMMUNICATIONS MEDICINE 2024; 4:9. [PMID: 38216688 PMCID: PMC10786838 DOI: 10.1038/s43856-023-00427-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 12/12/2023] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND The objective of this systematic review is to identify prognostic factors among women and their offspring affected by gestational diabetes mellitus (GDM), focusing on endpoints of cardiovascular disease (CVD) and type 2 diabetes (T2D) for women, and cardiometabolic profile for offspring. METHODS This review included studies published in English language from January 1st, 1990, through September 30th, 2021, that focused on the above outcomes of interest with respect to sociodemographic factors, lifestyle and behavioral characteristics, traditional clinical traits, and 'omics biomarkers in the mothers and offspring during the perinatal/postpartum periods and across the lifecourse. Studies that did not report associations of prognostic factors with outcomes of interest among GDM-exposed women or children were excluded. RESULTS Here, we identified 109 publications comprising 98 observational studies and 11 randomized-controlled trials. Findings indicate that GDM severity, maternal obesity, race/ethnicity, and unhealthy diet and physical activity levels predict T2D and CVD in women, and greater cardiometabolic risk in offspring. However, using the Diabetes Canada 2018 Clinical Practice Guidelines for studies, the level of evidence was low due to potential for confounding, reverse causation, and selection biases. CONCLUSIONS GDM pregnancies with greater severity, as well as those accompanied by maternal obesity, unhealthy diet, and low physical activity, as well as cases that occur among women who identify as racial/ethnic minorities are associated with worse cardiometabolic prognosis in mothers and offspring. However, given the low quality of evidence, prospective studies with detailed covariate data collection and high fidelity of follow-up are warranted.
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Affiliation(s)
- Zhila Semnani-Azad
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Romy Gaillard
- Department of Pediatrics, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - Alice E Hughes
- Faculty of Health and Life Sciences, University of Exeter Medical School, Exeter, UK
| | - Kristen E Boyle
- Department of Pediatrics and the Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Deirdre K Tobias
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wei Perng
- Department of Epidemiology and the Lifecourse Epidemiology of Adiposity and Diabetes (LEAD) Center, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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Cantacorps L, Zhu J, Yagoub S, Coull BM, Falck J, Chesters RA, Ritter K, Serrano-Lope M, Tscherepentschuk K, Kasch LS, Paterson M, Täger P, Baidoe-Ansah D, Pandey S, Igual-Gil C, Braune A, Lippert RN. Developmental metformin exposure does not rescue physiological impairments derived from early exposure to altered maternal metabolic state in offspring mice. Mol Metab 2024; 79:101860. [PMID: 38142972 PMCID: PMC10792763 DOI: 10.1016/j.molmet.2023.101860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 12/26/2023] Open
Abstract
OBJECTIVE The incidence of gestational diabetes mellitus (GDM) and metabolic disorders during pregnancy are increasing globally. This has resulted in increased use of therapeutic interventions such as metformin to aid in glycemic control during pregnancy. Even though metformin can cross the placental barrier, its impact on offspring brain development remains poorly understood. As metformin promotes AMPK signaling, which plays a key role in axonal growth during development, we hypothesized that it may have an impact on hypothalamic signaling and the formation of neuronal projections in the hypothalamus, the key regulator of energy homeostasis. We further hypothesized that this is dependent on the metabolic and nutritional status of the mother at the time of metformin intervention. Using mouse models of maternal overnutrition, we aimed to assess the effects of metformin exposure on offspring physiology and hypothalamic neuronal circuits during key periods of development. METHODS Female C57BL/6N mice received either a control diet or a high-fat diet (HFD) during pregnancy and lactation periods. A subset of dams was fed a HFD exclusively during the lactation. Anti-diabetic treatments were given during the first postnatal weeks. Body weights of male and female offspring were monitored daily until weaning. Circulating metabolic factors and molecular changes in the hypothalamus were assessed at postnatal day 16 using ELISA and Western Blot, respectively. Hypothalamic innervation was assessed by immunostaining at postnatal days 16 and 21. RESULTS We identified alterations in weight gain and circulating hormones in male and female offspring induced by anti-diabetic treatment during the early postnatal period, which were critically dependent on the maternal metabolic state. Furthermore, hypothalamic agouti-related peptide (AgRP) and proopiomelanocortin (POMC) neuronal innervation outcomes in response to anti-diabetic treatment were also modulated by maternal metabolic state. We also identified sex-specific changes in hypothalamic AMPK signaling in response to metformin exposure. CONCLUSION We demonstrate a unique interaction between anti-diabetic treatment and maternal metabolic state, resulting in sex-specific effects on offspring brain development and physiological outcomes. Overall, based on our findings, no positive effect of metformin intervention was observed in the offspring, despite ameliorating effects on maternal metabolic outcomes. In fact, the metabolic state of the mother drives the most dramatic differences in offspring physiology and metformin had no rescuing effect. Our results therefore highlight the need for a deeper understanding of how maternal metabolic state (excessive weight gain versus stable weight during GDM treatment) affects the developing offspring. Further, these results emphasize that the interventions to treat alterations in maternal metabolism during pregnancy need to be reassessed from the perspective of the offspring physiology.
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Affiliation(s)
- Lídia Cantacorps
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany; German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Jiajie Zhu
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Selma Yagoub
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Bethany M Coull
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Joanne Falck
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Robert A Chesters
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Katrin Ritter
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Miguel Serrano-Lope
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Katharina Tscherepentschuk
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Lea-Sophie Kasch
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Maya Paterson
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Paula Täger
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - David Baidoe-Ansah
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Shuchita Pandey
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Carla Igual-Gil
- Department of Physiology of Energy Metabolism, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Nuthetal, Germany
| | - Annett Braune
- Research Group Intestinal Microbiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Rachel N Lippert
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany; German Center for Diabetes Research (DZD), München-Neuherberg, Germany; NeuroCure Cluster of Excellence, Charité-Universitätsmedizin, Berlin, Germany.
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Rowan JA, Rush EC, Plank LD. Metformin in Gestational Diabetes The Offspring Follow Up (MiGTOFU): Associations between maternal characteristics and size and adiposity of boys and girls at nine years. Aust N Z J Obstet Gynaecol 2023; 63:825-828. [PMID: 37469163 DOI: 10.1111/ajo.13739] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023]
Abstract
Data from 98 women recruited in the Metformin in Gestational Diabetes trial and dual-energy X-ray absorptiometry studies of their children at nine years were analysed to investigate associations between maternal measures during pregnancy and their children's size and adiposity. Mothers of boys (n = 56) and girls (n = 42) had been randomised to metformin or insulin treatment at 30.1 ± 2.8 and 29.3 ± 4.1 weeks gestation, respectively. In boys, fat-free mass indexed to height squared was associated with maternal weight, body mass index, maternal glycaemia and metformin treatment. In boys and girls, fat mass indexed to height squared was associated with maternal glycaemia measures before gestational diabetes treatment.
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Affiliation(s)
- Janet Alison Rowan
- Department of Obstetrics, National Women's Health at Auckland City Hospital, Auckland, New Zealand
| | - Elaine Carolyn Rush
- Department of Nutrition, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand
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Frontino G, Succurro E, Corcoy R, Scialabba F, Poloniato A, Scavini M. Editorial: Current and future trends in gestational diabetes diagnosis, care and neonatal outcomes. Front Endocrinol (Lausanne) 2023; 14:1270472. [PMID: 38098867 PMCID: PMC10720917 DOI: 10.3389/fendo.2023.1270472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 08/11/2023] [Indexed: 12/17/2023] Open
Affiliation(s)
- Giulio Frontino
- Pediatric Diabetes Unit, Department of Pediatrics, IRCCS San Raffaele Hospital, Milano, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milano, Italy
| | - Elena Succurro
- Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
- Research Center for the Prevention and Treatment of Metabolic Diseases (CR METDIS), University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Rosa Corcoy
- Institut de Recerca de l’Hospital de la Santa Creu i Sant Pau, Translational Medicine, Barcelona, Spain
- Centro de Investigación Biomédica en Red -Bioingeniería, Biomateriales y Nanomedicina (CIBER -BBN), Madrid, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Francesco Scialabba
- Pediatric Diabetes Unit, Department of Pediatrics, IRCCS San Raffaele Hospital, Milano, Italy
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milano, Italy
| | - Antonella Poloniato
- Neonatology Unit, Department of Pediatrics, IRCCS San Raffaele Hospital, Milano, Italy
| | - Marina Scavini
- Diabetes Research Institute, IRCCS San Raffaele Hospital, Milano, Italy
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Titmuss A, Barzi F, Barr ELM, Webster V, Wood A, Kelaart J, Kirkwood M, Connors C, Boyle JA, Moore E, Oats J, McIntyre HD, Zimmet P, Brown ADH, Shaw JE, Craig ME, Maple-Brown LJ. Association between maternal hyperglycemia in pregnancy and offspring anthropometry in early childhood: the pandora wave 1 study. Int J Obes (Lond) 2023; 47:1120-1131. [PMID: 37608089 PMCID: PMC10599996 DOI: 10.1038/s41366-023-01366-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 07/30/2023] [Accepted: 08/10/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND In-utero hyperglycemia exposure influences later cardiometabolic risk, although few studies include women with pre-existing type 2 diabetes (T2D) or assess maternal body mass index (BMI) as a potential confounder. OBJECTIVE To explore the association of maternal T2D and gestational diabetes mellitus (GDM) with childhood anthropometry, and the influence of maternal BMI on these associations. METHODS The PANDORA cohort comprises women (n = 1138) and children (n = 1163). Women with GDM and T2D were recruited from a hyperglycemia in pregnancy register, and women with normoglycemia from the community. Wave 1 follow-up included 423 children, aged 1.5-5 years (median follow-up age 2.5 years). Multivariable linear regression assessed associations between maternal antenatal variables, including BMI and glycemic status, with offspring anthropometry (weight, height, BMI, skinfold thicknesses, waist, arm and head circumferences). RESULTS Greater maternal antenatal BMI was associated with increased anthropometric measures in offspring independent of maternal glycemic status. After adjustment, including for maternal BMI, children exposed to maternal GDM had lower mean weight (-0.54 kg, 95% CI: -0.99, -0.11), BMI (-0.55 kg/m2, 95% CI: -0.91, -0.20), head (-0.52 cm, 95% CI: -0.88, -0.16) and mid-upper arm (-0.32 cm, 95% CI: -0.63, -0.01) circumferences, and greater mean suprailiac skinfold (0.78 mm, 95% CI: 0.13, 1.43), compared to children exposed to normoglycemia. Adjustment for maternal BMI strengthened the negative association between GDM and child weight, BMI and circumferences. Children exposed to maternal T2D had smaller mean head circumference (-0.82 cm, 95% CI: -1.33, -0.31) than children exposed to normoglycemia. Maternal T2D was no longer associated with greater child mean skinfolds (p = 0.14) or waist circumference (p = 0.18) after adjustment for maternal BMI. CONCLUSIONS Children exposed to GDM had greater suprailiac skinfold thickness than unexposed children, despite having lower mean weight, BMI and mid-upper arm circumference, and both GDM and T2D were associated with smaller mean head circumference. Future research should assess whether childhood anthropometric differences influence lifetime cardiometabolic and neurodevelopmental risk.
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Affiliation(s)
- Angela Titmuss
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
- Paediatric Department, Division of Women, Child and Youth, Royal Darwin Hospital, Darwin, NT, Australia.
| | - Federica Barzi
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Poche Centre for Indigenous Health, University of Queensland, Brisbane, QLD, Australia
| | - Elizabeth L M Barr
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Clinical and Population Health, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Vanya Webster
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Anna Wood
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Endocrinology Department, Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
| | - Joanna Kelaart
- Aboriginal Health Domain, Baker Heart and Diabetes Institute, Alice Springs, NT, Australia
| | - Marie Kirkwood
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | | | - Jacqueline A Boyle
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Elizabeth Moore
- Public Health Unit, Aboriginal Medical Services Alliance of Northern Territory, Darwin, NT, Australia
| | - Jeremy Oats
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
| | - H David McIntyre
- Faculty of Medicine, Mater Medical Research Institute, University of Queensland, Brisbane, QLD, Australia
| | - Paul Zimmet
- Department of Diabetes, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Alex D H Brown
- University of South Australia, Adelaide, SA, Australia
- Wardliparingga Aboriginal Research Unit, South Australian Health and Medical Research Institute, Adelaide, SA, Australia
- Australian National University, Canberra, ACT, Australia
- Telethon Kids Institute, Perth, WA, Australia
| | - Jonathan E Shaw
- Clinical and Population Health, Baker Heart and Diabetes Institute, Melbourne, VIC, Australia
| | - Maria E Craig
- School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Louise J Maple-Brown
- Wellbeing and Preventable Chronic Diseases Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Endocrinology Department, Division of Medicine, Royal Darwin Hospital, Darwin, NT, Australia
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Sciacca L, Bianchi C, Burlina S, Formoso G, Manicardi E, Sculli MA, Resi V. Position paper of the Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), and the Italian Study Group of Diabetes in pregnancy: Metformin use in pregnancy. Acta Diabetol 2023; 60:1421-1437. [PMID: 37401946 PMCID: PMC10442287 DOI: 10.1007/s00592-023-02137-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/12/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE This document purpose is to create an evidence-based position statement on the role of metformin therapy in pregnancy complicated by obesity, gestational diabetes (GDM), type 2 diabetes mellitus (T2DM), polycystic ovary syndrome (PCOS) and in women undergoing assisted reproductive technology (ART). METHODS A comprehensive review of international diabetes guidelines and a search of medical literature was performed to identify studies presenting data on the use of metformin in pregnancy. The document was approved by the councils of the two scientific societies. RESULTS In condition affecting the fertility, as PCOS, metformin use in pre-conception or early in pregnancy may be beneficial for clinical pregnancy, even in ART treatment, and in obese-PCOS women may reduce preterm delivery. In obese women, even in the presence of GDM or T2DM, metformin use in pregnancy is associated with a lower gestational weight gain. In pregnancy complicated by diabetes (GDM or T2DM), metformin improves maternal glycemic control and may reduce insulin dose. Neonatal and infant outcomes related to metformin exposure in utero are lacking. Metformin use in women with GDM or T2DM is associated with lower birth weight. However, an increased tendency to overweight-obesity has been observed in children, later in life. CONCLUSIONS Metformin may represent a therapeutic option in selected women with obesity, PCOS, GDM, T2DM, and in women undergoing ART. However, more research is required specifically on the long-term effects of in utero exposition to metformin.
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Affiliation(s)
- Laura Sciacca
- Interassociative Diabetes and Pregnancy Study Group, Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Rome, Italy.
- Department of Clinical and Experimental Medicine, Endocrinology Section, University of Catania, Catania, Italy.
| | - Cristina Bianchi
- Interassociative Diabetes and Pregnancy Study Group, Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Rome, Italy
- Metabolic Diseases and Diabetes Unit, University Hospital of Pisa, Pisa, Italy
| | - Silvia Burlina
- Interassociative Diabetes and Pregnancy Study Group, Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Rome, Italy
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Gloria Formoso
- Interassociative Diabetes and Pregnancy Study Group, Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Rome, Italy
- Department of Medicine and Aging Sciences, Center for Advanced Studies and Technology (CAST, Ex CeSIMet) G. d'Annunzio University Chieti-Pescara, Chieti, Italy
| | - Elisa Manicardi
- Interassociative Diabetes and Pregnancy Study Group, Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Rome, Italy
- Diabetes Unit, Primary Health Care, Local Health Authority of Reggio Emilia-IRCCS, Reggio Emilia, Italy
| | - Maria Angela Sculli
- Interassociative Diabetes and Pregnancy Study Group, Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Rome, Italy
- Endocrinology and Diabetes, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | - Veronica Resi
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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Tocci V, Mirabelli M, Salatino A, Sicilia L, Giuliano S, Brunetti FS, Chiefari E, De Sarro G, Foti DP, Brunetti A. Metformin in Gestational Diabetes Mellitus: To Use or Not to Use, That Is the Question. Pharmaceuticals (Basel) 2023; 16:1318. [PMID: 37765126 PMCID: PMC10537239 DOI: 10.3390/ph16091318] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 09/12/2023] [Accepted: 09/15/2023] [Indexed: 09/29/2023] Open
Abstract
In recent years, there has been a dramatic increase in the number of pregnancies complicated by gestational diabetes mellitus (GDM). GDM occurs when maternal insulin resistance develops and/or progresses during gestation, and it is not compensated by a rise in maternal insulin secretion. If not properly managed, this condition can cause serious short-term and long-term problems for both mother and child. Lifestyle changes are the first line of treatment for GDM, but if ineffective, insulin injections are the recommended pharmacological treatment choice. Some guidance authorities and scientific societies have proposed the use of metformin as an alternative pharmacological option for treating GDM, but there is not yet a unanimous consensus on this. Although the use of metformin appears to be safe for the mother, concerns remain about its long-term metabolic effects on the child that is exposed in utero to the drug, given that metformin, contrary to insulin, crosses the placenta. This review article describes the existing lines of evidence about the use of metformin in pregnancies complicated by GDM, in order to clarify its potential benefits and limits, and to help clinicians make decisions about who could benefit most from this drug treatment.
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Affiliation(s)
- Vera Tocci
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Maria Mirabelli
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Alessandro Salatino
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Luciana Sicilia
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Stefania Giuliano
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
| | - Francesco S. Brunetti
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Eusebio Chiefari
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Giovambattista De Sarro
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
| | - Daniela P. Foti
- Department of Experimental and Clinical Medicine, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy;
| | - Antonio Brunetti
- Department of Health Sciences, University “Magna Græcia” of Catanzaro, 88100 Catanzaro, Italy; (V.T.); (M.M.)
- Operative Unit of Endocrinology, Diabetes in Pregnancy Ambulatory Care Center, Renato Dulbecco University Hospital, 88100 Catanzaro, Italy
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11
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Torunoglu ST, Zajda A, Tampio J, Markowicz-Piasecka M, Huttunen KM. Metformin derivatives - Researchers' friends or foes? Biochem Pharmacol 2023; 215:115743. [PMID: 37591450 DOI: 10.1016/j.bcp.2023.115743] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 08/09/2023] [Accepted: 08/09/2023] [Indexed: 08/19/2023]
Abstract
Metformin has been used for ages to treat diabetes mellitus due to its safety profile and low cost. However, metformin has variable pharmacokinetics in patients, and due to its poor oral absorption, the therapeutic doses are relatively high, causing unpleasant gastrointestinal adverse effects. Therefore, novel derivatives of metformin have been synthesized during the past decades. Particularly, after the mid-2000 s, when organic cation transporters were identified as the main metformin carriers, metformin derivatives have been under intensive investigation. Nevertheless, due to the biguanide structure, derivatives of metformin have been challenging to synthesize. Moreover, the mechanisms of metformin's action are not fully understood to date, and since it has multifunctional properties, the interests have switched to re-purposing for other diseases. Indeed, metformin derivatives have been demonstrated in many cases to be more effective than metformin itself and have the potential to be used in different diseases, including several types of cancers and neurodegenerative diseases. On the other hand, the pleiotropic nature of metformin and its derivatives can also create challenges. Not all properties are fit for all diseases. In this review, the history of the development of metformin-like compounds is summarized, and insights into their potential for future drug discovery are discussed.
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Affiliation(s)
- Sema Tuna Torunoglu
- School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland.
| | - Agnieszka Zajda
- Laboratory of Bioanalysis, Department of Pharmaceutical Chemistry, Drug Analysis and Radiopharmacy, Medical University of Lodz, ul. Muszyńskiego 1, 90-151 Lodz, Poland
| | - Janne Tampio
- School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland
| | | | - Kristiina M Huttunen
- School of Pharmacy, Faculty of Health Sciences, University of Eastern Finland, P.O. Box 1627, FI-70211 Kuopio, Finland.
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12
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Nikparast A, Rahmani J, Bagheri R, Mohammadpour S, Shadnoosh M, Wong A, Ghanavati M. Maternal uric acid levels and risk of gestational diabetes mellitus: A systematic review and dose-response meta-analysis of cohort studies including 105,380 participants. J Diabetes Investig 2023; 14:973-984. [PMID: 37132415 PMCID: PMC10360376 DOI: 10.1111/jdi.14022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 04/04/2023] [Accepted: 04/07/2023] [Indexed: 05/04/2023] Open
Abstract
AIMS/INTRODUCTION Although the association between uric acid levels and adverse pregnancy outcomes has been investigated, the effects of higher uric acid levels on the risk of gestational diabetes mellitus (GDM) have yet to be established. Therefore, this systematic review and meta-analysis aimed to investigate the relationship between uric acid levels during pregnancy and the risk of GDM. MATERIALS AND METHODS PubMed/Medline, Scopus and Web of Science databases were searched up to April 2022 for relevant observational studies. A random effects model was used to estimate pooled odds ratios (OR) and 95% confidence intervals (95% CI). To assess the heterogeneity of included studies, the I2 index was used. RESULTS Among the initial 262 studies that were recognized from the databases search, 23 studies including 105,380 participants were eligible. Pooled analysis showed that higher uric acid levels significantly affected the risk of GDM (OR 2.58, 95% CI 1.89-3.52, I2 = 90.8%, P < 0.001). Subgroup analyses based on the gestational week showed that higher uric acid levels before the 20th week of gestation were significantly associated with the risk of GDM (OR 3.26, 95% CI 2.26-4.71, I2 = 89.3%, P < 0.001). Based on the meta-regression analysis, uric acid levels and odds of GDM were significantly correlated with the participants' age, and it was more significant in younger pregnant women. CONCLUSIONS This study showed a positive association between uric acid levels and the risk of GDM. Also, our results indicate that measuring uric acid levels before 20 weeks of gestation can potentially predict GDM, especially in younger women.
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Affiliation(s)
- Ali Nikparast
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition Science and Food TechnologyShahid Beheshti University of Medical SciencesTehranIran
| | - Jamal Rahmani
- Cancer Research CenterShahid Beheshti University of Medical SciencesTehranIran
| | - Reza Bagheri
- Department of Exercise PhysiologyUniversity of IsfahanIsfahanIran
| | - Saba Mohammadpour
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition Science and Food TechnologyShahid Beheshti University of Medical SciencesTehranIran
| | - Mehdi Shadnoosh
- Department of Clinical Nutrition and Dietetics, Faculty of Nutrition Science and Food TechnologyShahid Beheshti University of Medical SciencesTehranIran
| | - Alexei Wong
- Department of Health and Human PerformanceMarymount UniversityArlingtonVirginiaUSA
| | - Matin Ghanavati
- National Nutrition and Food Technology Research InstituteShahid Beheshti University of Medical SciencesTeheranIran
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13
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Newman C, Rabbitt L, Ero A, Dunne FP. Focus on Metformin: Its Role and Safety in Pregnancy and Beyond. Drugs 2023:10.1007/s40265-023-01899-0. [PMID: 37354354 PMCID: PMC10322786 DOI: 10.1007/s40265-023-01899-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/26/2023]
Abstract
Metformin is used worldwide in the treatment of type 2 diabetes and has been used in the treatment of diabetes in pregnancy since the 1970s. It is highly acceptable to patients due to its ease of administration, cost and adverse effect profile. It is effective in reducing macrosomia, large-for-gestational-age infants and reduces maternal weight gain. Despite its many advantages, metformin has been associated with reductions in foetal size and has been associated with an increase in infants born small-for-gestational-age in certain cohorts. In this article, we review its efficacy, adverse effects and long-term follow-up before, during and after pregnancy for both mother and infant. We also evaluate the other forms of treatment for gestational diabetes, including oral therapies, insulin therapy and emerging treatments.
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Affiliation(s)
- Christine Newman
- Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospital, Galway, Ireland.
- Diabetes Collaborative Clinical Trial Network, Clinical Research Facility, University of Galway, Galway, Ireland.
| | - Louise Rabbitt
- Department of Clinical Pharmacology and Therapeutics, Galway University Hospital, Galway, Ireland
- Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway, Ireland
| | - Adesuwa Ero
- Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospital, Galway, Ireland
| | - Fidelma P Dunne
- Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospital, Galway, Ireland
- Diabetes Collaborative Clinical Trial Network, Clinical Research Facility, University of Galway, Galway, Ireland
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14
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Tosti G, Barberio A, Tartaglione L, Rizzi A, Di Leo M, Viti L, Sirico A, De Carolis S, Pontecorvi A, Lanzone A, Pitocco D. Lights and shadows on the use of metformin in pregnancy: from the preconception phase to breastfeeding and beyond. Front Endocrinol (Lausanne) 2023; 14:1176623. [PMID: 37409227 PMCID: PMC10319127 DOI: 10.3389/fendo.2023.1176623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/17/2023] [Indexed: 07/07/2023] Open
Abstract
During pregnancy, the complex hormonal changes lead to a progressive decrease of insulin sensitivity that can drive the onset of gestational diabetes (GDM) or worsen an already-known condition of insulin resistance like type 2 diabetes, polycystic ovarian syndrome (PCOS), and obesity, with complications for the mother and the fetus. Metformin during pregnancy is proving to be safe in a growing number of studies, although it freely crosses the placenta, leading to a fetal level similar to maternal concentration. The aim of this literature review is to analyze the main available evidence on the use of metformin during, throughout, and beyond pregnancy, including fertilization, lactation, and medium-term effects on offspring. Analyzed studies support the safety and efficacy of metformin during pregnancy. In pregnant women with GDM and type 2 diabetes, metformin improves obstetric and perinatal outcomes. There is no evidence that it prevents GDM in women with pregestational insulin resistance or improves lipid profile and risk of GDM in pregnant women with PCOS or obesity. Metformin could have a role in reducing the risk of preeclampsia in pregnant women with severe obesity, the risk of late miscarriages and preterm delivery in women with PCOS, and the risk of ovarian hyperstimulation syndrome, increasing the clinical pregnancy rate in women with PCOS undergoing in vitro fertilization (IVF/FIVET). Offspring of mothers with GDM exposed to metformin have no significant differences in body composition compared with insulin treatment, while it appears to be protective for metabolic and cardiovascular risk.
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Affiliation(s)
- Giulia Tosti
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Annarita Barberio
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Linda Tartaglione
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Alessandro Rizzi
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Mauro Di Leo
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Luca Viti
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Angelo Sirico
- Catholic University School of Medicine, Rome, Italy
- Department of Woman and Child Health, Woman Health Area Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Sara De Carolis
- Catholic University School of Medicine, Rome, Italy
- Department of Woman and Child Health, Woman Health Area Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Alfredo Pontecorvi
- Catholic University School of Medicine, Rome, Italy
- Department of Endocrinology, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Antonio Lanzone
- Catholic University School of Medicine, Rome, Italy
- Department of Woman and Child Health, Woman Health Area Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Dario Pitocco
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
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15
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Wang X, Wang H, Yi P, Baker C, Casey G, Xie X, Luo H, Cai J, Fan X, Soong L, Hu H, Shi PY, Liang Y, Sun J. Metformin restrains ZIKV replication and alleviates virus-induced inflammatory responses in microglia. Int Immunopharmacol 2023; 121:110512. [PMID: 37343373 DOI: 10.1016/j.intimp.2023.110512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 06/05/2023] [Accepted: 06/12/2023] [Indexed: 06/23/2023]
Abstract
The re-emergence of Zika virus (ZIKV) remains a major public health threat that has raised worldwide attention. Accumulating evidence suggests that ZIKV can cause serious pathological changes to the human nervous system, including microcephaly in newborns. Recent studies suggest that metformin, an established treatment for diabetes may play a role in viral infection; however, little is known about the interactions between ZIKV infection and metformin administration. Using fluorescent ZIKV by flow cytometry and immunofluorescence imaging, we found that ZIKV can infect microglia in a dose-dependent manner. Metformin diminished ZIKV replication without the alteration of viral entry and phagocytosis. Our study demonstrated that metformin downregulated ZIKV-induced inflammatory response in microglia in a time- and dose-dependent manner. Our RNA-Seq and qRT-PCR analysis found that type I and III interferons (IFN), such as IFNα2, IFNβ1 and IFNλ3 were upregulated in ZIKV-infected cells by metformin treatment, accompanied with the downregulation of GBP4, OAS1, MX1 and ISG15. Together, our results suggest that metformin-mediated modulation in multiple pathways may attribute to restraining ZIKV infection in microglia, which may provide a potential tool to consider for use in unique clinical circumstances.
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Affiliation(s)
- Xiaofang Wang
- Department of Infectious Disease, Hunan Provincial People's Hospital (The First Affiliated Hospital of Hunan Normal University), Changsha, Hunan 410005, China; Department of Infectious Diseases, Key Laboratory of Viral Hepatitis of Hunan, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China; Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Hui Wang
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Panpan Yi
- Department of Infectious Diseases, Key Laboratory of Viral Hepatitis of Hunan, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Coleman Baker
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Gonzales Casey
- Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Xuping Xie
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Huanle Luo
- School of Public Health (Shenzhen), Sun Yat-sen University, Guangzhou 510275, China
| | - Jiyang Cai
- Department of Ophthalmology, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Xuegong Fan
- Department of Infectious Diseases, Key Laboratory of Viral Hepatitis of Hunan, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
| | - Lynn Soong
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX 77555, USA; Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA; Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Haitao Hu
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX 77555, USA; Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Pei-Yong Shi
- Department of Biochemistry and Molecular Biology, University of Texas Medical Branch, Galveston, TX 77555, USA; Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, TX 77555, USA; Sealy Center for Structural Biology and Molecular Biophysics, University of Texas Medical Branch, Galveston, TX 77555, USA; Sealy Institute for Vaccine Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA; Center for Biodefense and Emerging Infectious Diseases, University of Texas Medical Branch, Galveston, TX 77555, USA; Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX 77555, USA
| | - Yuejin Liang
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX 77555, USA; Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, TX 77555, USA.
| | - Jiaren Sun
- Department of Microbiology and Immunology, University of Texas Medical Branch, Galveston, TX 77555, USA; Department of Pathology, University of Texas Medical Branch, Galveston, TX 77555, USA; Institute for Human Infections and Immunity, University of Texas Medical Branch, Galveston, TX 77555, USA.
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16
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Paavilainen E, Niinikoski H, Parkkola R, Koskensalo K, Nikkinen H, Veijola R, Vääräsmäki M, Loo BM, Tossavainen P, Rönnemaa T, Tertti K. Metformin versus insulin for gestational diabetes: Adiposity variables and adipocytokines in offspring at age of 9 years. Diabetes Res Clin Pract 2023:110780. [PMID: 37331522 DOI: 10.1016/j.diabres.2023.110780] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/30/2023] [Accepted: 06/13/2023] [Indexed: 06/20/2023]
Abstract
AIMS To compare body composition, visceral adiposity, adipocytokines, and low-grade inflammation markers in prepubertal offspring of mothers who were treated with metformin or insulin for gestational diabetes mellitus (GDM). METHODS 172 offspring of 311 mothers randomized to receive metformin (n=82) or insulin (n=90) for GDMwere studied at 9 years of age (follow-up rate 55%). Measurements included anthropometrics, adipocytokines, markers of the low-grade inflammation, abdominal magnetic resonance imaging (MRI), magnetic liver spectrometry (MRS), and whole body dual-energy X-ray absorptiometry (DXA). RESULTS Serum markers of low-grade inflammation, visceral adipose tissue volume, total fat percentage, and liver fat percentage were similar between the study groups. Serum adiponectin concentration was higher in children in the metformin group compared to insulin group (median 10.37 vs 9.50 µg/ml, p = 0.016). This difference between groups was observed in boys only (median 12.13 vs 7.50 µg/ml, p<0.001). Leptin/adiponectin-ratio was lower in boys in the metformin group than in the insulin group (median 0.30 vs 0.75; p = 0.016). CONCLUSIONS Maternal metformin treatment for GDM had no effects on adiposity, body composition, liver fat, or inflammation markers in prepubertal offspring compared to maternal insulin treatment but was associated with higher adiponectin concentration and lower leptin/adiponectin-ratio in boys.
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Affiliation(s)
- Elisa Paavilainen
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland.
| | - Harri Niinikoski
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Riitta Parkkola
- Department of Radiology, University of Turku and Turku University Hospital, Turku, Finland
| | - Kalle Koskensalo
- Department of Medical Physics, Turku University Hospital, Turku, Finland
| | - Hilkka Nikkinen
- Department of Obstetrics and Gynecology, Research Unit of Clinical Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Riitta Veijola
- Department of Pediatrics, Research Unit of Clinical Medicine, Medical Research Center, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Marja Vääräsmäki
- Department of Obstetrics and Gynecology, Research Unit of Clinical Medicine, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Britt-Marie Loo
- Joint Clinical Biochemistry Laboratory of University of Turku and Turku University Hospital, Turku, Finland
| | - Päivi Tossavainen
- Department of Pediatrics, Research Unit of Clinical Medicine, Medical Research Center, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tapani Rönnemaa
- Department of Medicine, University of Turku and Division of Medicine, Turku University Hospital, Turku, Finland
| | - Kristiina Tertti
- Department of Obstetrics and Gynecology, University of Turku and Turku University Hospital, Turku, Finland
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17
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Sheng B, Ni J, Lv B, Jiang G, Lin X, Li H. Short-term neonatal outcomes in women with gestational diabetes treated using metformin versus insulin: a systematic review and meta-analysis of randomized controlled trials. Acta Diabetol 2023; 60:595-608. [PMID: 36593391 PMCID: PMC10063481 DOI: 10.1007/s00592-022-02016-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/08/2022] [Indexed: 01/04/2023]
Abstract
AIMS To expand the evidence base for the clinical use of metformin, we conducted a meta-analysis of randomized controlled trials (RCTs) comparing the efficacy and safety of metformin versus insulin with respect to short-term neonatal outcomes. METHODS A comprehensive search of electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) was performed. Two reviewers extracted the data and calculated pooled estimates by use of a random-effects model. In total, 24 studies involving 4355 participants met the eligibility criteria and were included in the quantitative analyses. RESULTS Unlike insulin, metformin lowered neonatal birth weights (mean difference - 122.76 g; 95% confidence interval [CI] - 178.31, - 67.21; p < 0.0001), the risk of macrosomia (risk ratio [RR] 0.68; 95% CI 0.54, 0.86; p = 0.001), the incidence of neonatal intensive care unit admission (RR 0.73; 95% CI 0.61, 0.88; p = 0.0009), and the incidence of neonatal hypoglycemia (RR 0.65; 95% CI 0.52, 0.81; p = 0.0001). Subgroup analysis based on the maximum daily oral dose of metformin indicated that metformin-induced neonatal birth weight loss was independent of the oral dose. CONCLUSIONS Our meta-analysis provides further evidence that metformin is a safe oral antihyperglycemic drug and has some benefits over insulin when used for the treatment of gestational diabetes, without an increased risk of short-term neonatal adverse outcomes. Metformin may be particularly useful in women with gestational diabetes at high risk for neonatal hypoglycemia, women who want to limit maternal and fetal weight gain, and women with an inability to afford or use insulin safely.
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Affiliation(s)
- Bo Sheng
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
| | - Juan Ni
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
| | - Bin Lv
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
| | - Guoguo Jiang
- Department of Hospital Infection Management, The Second Hospital of Chengdu City, Chengdu, 610041 Sichuan China
| | - Xuemei Lin
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
| | - Hao Li
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
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18
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Semnani-Azad Z, Gaillard R, Hughes AE, Boyle KE, Tobias DK, Perng W. Predictors and risk factors of short-term and long-term outcomes among women with gestational diabetes mellitus (GDM) and their offspring: Moving toward precision prognosis? MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.14.23288199. [PMID: 37131686 PMCID: PMC10153333 DOI: 10.1101/2023.04.14.23288199] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
As part of the American Diabetes Association Precision Medicine in Diabetes Initiative (PMDI) - a partnership with the European Association for the Study of Diabetes (EASD) - this systematic review is part of a comprehensive evidence evaluation in support of the 2 nd International Consensus Report on Precision Diabetes Medicine. Here, we sought to synthesize evidence from empirical research papers published through September 1 st , 2021 to evaluate and identify prognostic conditions, risk factors, and biomarkers among women and children affected by gestational diabetes mellitus (GDM), focusing on clinical endpoints of cardiovascular disease (CVD) and type 2 diabetes (T2D) among women with a history of GDM; and adiposity and cardiometabolic profile among offspring exposed to GDM in utero. We identified a total of 107 observational studies and 12 randomized controlled trials testing the effect of pharmaceutical and/or lifestyle interventions. Broadly, current literature indicates that greater GDM severity, higher maternal body mass index, belonging to racial/ethnic minority group; and unhealthy lifestyle behaviors would predict a woman's risk of incident T2D and CVD, and an unfavorable cardiometabolic profile among offspring. However, the level of evidence is low (Level 4 according to the Diabetes Canada 2018 Clinical Practice Guidelines for diabetes prognosis) largely because most studies leveraged retrospective data from large registries that are vulnerable to residual confounding and reverse causation bias; and prospective cohort studies that may suffer selection and attrition bias. Moreover, for the offspring outcomes, we identified a relatively small body of literature on prognostic factors indicative of future adiposity and cardiometabolic risk. Future high-quality prospective cohort studies in diverse populations with granular data collection on prognostic factors, clinical and subclinical outcomes, high fidelity of follow-up, and appropriate analytical approaches to deal with structural biases are warranted.
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Hummel M, Füchtenbusch M, Battefeld W, Bührer C, Groten T, Haak T, Kainer F, Kautzky-Willer A, Lechner A, Meissner T, Nagel-Reuper C, Schäfer-Graf U, Siegmund T. Diabetes and Pregnancy. Exp Clin Endocrinol Diabetes 2023; 131:4-12. [PMID: 36626920 DOI: 10.1055/a-1946-3648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Affiliation(s)
- Michael Hummel
- Internal Medicine Group Practice and Diabetological Practice, Rosenheim, Germany.,Research Group Diabetes e.V. at Helmholtz Center Munich, Munich, Germany
| | - Martin Füchtenbusch
- Research Group Diabetes e.V. at Helmholtz Center Munich, Munich, Germany.,Diabetes Center am Marienplatz Munich, Munich, Germany
| | - Wilgard Battefeld
- Diabetology and Endocrinology, Medical Care Center Kempten-Allgäu, Kempten, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité - Medical University of Berlin, Berlin, Germany
| | - Tanja Groten
- Department of Obstetrics and Maternal Health, University Hospital Jena, Jena, Germany
| | - Thomas Haak
- Diabetes Center Mergentheim, Bad Mergentheim, Germany
| | - Franz Kainer
- Department of Obstetrics and Prenatal Medicine, Hallerwiese Hospital, Nuremberg, Germany
| | | | - Andreas Lechner
- Department of Internal Medicine IV, Diabetes Center, Ludwigs-Maximilians-University Munich, Munich, Germany
| | - Thomas Meissner
- Department of General Pediatrics, Neonatology and Pediatric Cardiology, University Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Ute Schäfer-Graf
- Berlin Diabetes Center for Pregnant Women, St. Joseph Hospital Berlin Tempelhof, Berlin, Germany
| | - Thorsten Siegmund
- Diabetes, Hormone, and Metabolism Center, Private Practice at Isar Clinic, Munich, Germany
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20
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Kautzky-Willer A, Winhofer Y, Kiss H, Falcone V, Berger A, Lechleitner M, Weitgasser R, Harreiter J. [Gestational diabetes mellitus (Update 2023)]. Wien Klin Wochenschr 2023; 135:115-128. [PMID: 37101032 PMCID: PMC10132924 DOI: 10.1007/s00508-023-02181-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 04/28/2023]
Abstract
Gestational diabetes (GDM) is defined as any degree of glucose intolerance with onset during pregnancy and is associated with increased feto-maternal morbidity as well as long-term complications in mothers and the offspring. Women detected to have diabetes early in pregnancy receive the diagnosis of overt, non-gestational, diabetes (glucose: fasting ≥ 126 mg/dl, spontaneous ≥ 200 mg/dl or HbA1c ≥ 6.5% before 20 weeks of gestation). GDM is diagnosed by an oral glucose tolerance test (oGTT) or increased fasting glucose (≥ 92 mg/dl). Screening for undiagnosed type 2 diabetes at the first prenatal visit is recommended in women at increased risk (history of GDM/pre-diabetes; malformation, stillbirth, successive abortions or birth weight > 4500 g previously; obesity, metabolic syndrome, age > 35 years, vascular disease; clinical symptoms of diabetes (e.g. glucosuria) or ethnic origin with increased risk for GDM/T2DM (Arab, South- and Southeast Asian, Latin American)) using standard diagnostic criteria. Performance of the oGTT (120 min; 75 g glucose) may already be indicated in the first trimester in high-risk women but is mandatory between gestational week 24-28 in all pregnant women with previous non-pathological glucose metabolism. Following WHO recommendations, which are based on the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study, GDM is defined, if fasting venous plasma glucose is ≥ 92 mg/dl or 1 h ≥ 180 mg/dl or 2 h ≥ 153 mg/dl after glucose loading (international consensus criteria). In case of one pathological value a strict metabolic control is mandatory. After bariatric surgery we do not recommend to perform an oGTT due to risk of postprandial hypoglycemia. All women with GDM should receive nutritional counseling, be instructed in blood glucose self-monitoring and motivated to increase physical activity to moderate intensity levels-if not contraindicated (Evidence level A). If blood glucose levels cannot be maintained in the therapeutic range (fasting < 95 mg/dl and 1 h after meals < 140 mg/dl, Evidence level B) insulin therapy should be initiated as first choice (Evidence level A). Maternal and fetal monitoring is required in order to minimize maternal and fetal/neonatal morbidity and perinatal mortality. Regular obstetric examinations including ultrasound examinations are recommended (Evidence level A). Neonatal care of GDM offspring at high risk for hypoglycaemia includes blood glucose measurements after birth and if necessary appropriate intervention. Monitoring the development of the children and recommendation of healthy lifestyle are important issues to be tackled for the whole family. After delivery all women with GDM have to be reevaluated as to their glucose tolerance by a 75 g oGTT (WHO criteria) 4-12 weeks postpartum. Assessment of glucose parameters (fasting glucose, random glucose, HbA1c or optimally oGTT) are recommended every 2-3 years in case of normal glucose tolerance. All women have to be instructed about their increased risk of type 2 diabetes and cardiovascular disease at follow-up. Possible preventive meassures, in particular lifestyle changes as weight management and maintenance/increase of physical activity should be discussed (evidence level A).
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Affiliation(s)
- Alexandra Kautzky-Willer
- Gender Medicine Unit, Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich.
| | - Yvonne Winhofer
- Gender Medicine Unit, Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
| | - Herbert Kiss
- Abteilung für Geburtshilfe und feto-maternale Medizin, Universitätsklinik für Frauenheilkunde, Medizinische Universität Wien, Wien, Österreich
| | - Veronica Falcone
- Abteilung für Geburtshilfe und feto-maternale Medizin, Universitätsklinik für Frauenheilkunde, Medizinische Universität Wien, Wien, Österreich
| | - Angelika Berger
- Abteilung für Neonatologie, Pädiatrische Intensivmedizin und Neuropädiatrie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Wien, Wien, Österreich
| | - Monika Lechleitner
- Interne Abteilung, Landeskrankenhaus Hochzirl - Natters, Hochzirl, Österreich
| | - Raimund Weitgasser
- Abteilung für Innere Medizin/Diabetologie, Privatklinik Wehrle-Diakonissen, Salzburg, Österreich
| | - Jürgen Harreiter
- Gender Medicine Unit, Abteilung für Endokrinologie und Stoffwechsel, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich
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Verma V, Mehendale AM. A Review on the Use of Metformin in Pregnancy and Its Associated Fetal Outcomes. Cureus 2022; 14:e30039. [PMID: 36381747 PMCID: PMC9637404 DOI: 10.7759/cureus.30039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 10/07/2022] [Indexed: 11/05/2022] Open
Abstract
A commonly used first-line anti-diabetic medication, metformin, has been used in pregnancy. The drug is known to have specific effects on different organs around the body. One of these organs includes the ovaries. Therefore, for more than 40 years, it has often been prescribed for maternal obesity along with gestational diabetes mellitus. Untreated pregnancies like these frequently result in complications for both the mother and the fetus, like macrosomia, pregnancy-induced hypertension, obstructed labor, stillbirths, and perinatal deaths. In addition, there is also evidence that these mothers tend to develop type II diabetes mellitus during their pregnancy and even a few years post-delivery. These complications can be controlled or even reduced with the help of metformin, sometimes combining it with insulin or clomiphene citrate if required. There is still a need to cautiously prescribe the drug by outweighing its benefits against the risk associated with it. The current research on the subject leans more towards the benefits offered to the mother during pregnancy. Only a few randomized, controlled trials have been conducted on the fetal condition after the mother has been administered metformin. Furthermore, these studies lack the appropriate sample size and long-term follow-up on these metformin-exposed offspring. As a result, there are no reliable data available to clinicians and physicians about the drug. Owing to its benefits in certain pregnancies, it is less likely that the drug will cease to be prescribed. Therefore, it becomes increasingly imperative to conduct more research on this topic to ensure the drug is safe for the mother and the offspring.
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22
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Hummel M, Füchtenbusch M, Battefeld W, Bührer C, Groten T, Haak T, Kainer F, Kautzky-Willer A, Lechner A, Meissner T, Nagel-Reuper C, Schäfer-Graf U, Siegmund T. Diabetes und Schwangerschaft. DIABETOL STOFFWECHS 2022. [DOI: 10.1055/a-1901-0499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Michael Hummel
- Internistische Gemeinschaftspraxis und Diabetologische Schwerpunktpraxis, Rosenheim, Deutschland
- Forschergruppe Diabetes e.V. am Helmholtz-Zentrum München, München, Deutschland
| | - Martin Füchtenbusch
- Forschergruppe Diabetes e.V. am Helmholtz-Zentrum München, München, Deutschland
- Diabeteszentrum am Marienplatz München, München, Deutschland
| | - Wilgard Battefeld
- Diabetologie und Endokrinologie, Medizinisches Versorgungszentrum Kempten-Allgäu, Kempten, Deutschland
| | - Christoph Bührer
- Klinik für Neonatologie, Charité -Universitätsmedizin Berlin, Berlin, Deutschland
| | - Tanja Groten
- Geburtsmedizin und maternale Gesundheit, Universitätsklinikum Jena, Jena, Deutschland
| | - Thomas Haak
- Diabetes Zentrum Mergentheim, Bad Mergentheim, Deutschland
| | - Franz Kainer
- Abteilung für Geburtshilfe und Pränatalmedizin, Klinik Hallerwiese, Nürnberg, Deutschland
| | | | - Andreas Lechner
- Forschergruppe Diabetes e.V. am Helmholtz-Zentrum München, München, Deutschland
- Medizinische Klinik und Poliklinik IV, Diabeteszentrum, Ludwigs-Maximilians-Universität München, München, Deutschland
| | - Thomas Meissner
- Klinik für Allgemeine Pädiatrie, Neonatologie und Kinderkardiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | | | - Ute Schäfer-Graf
- Berliner Diabetes Zentrum für Schwangere, St. Joseph Krankenhaus Berlin Tempelhof, Berlin, Deutschland
| | - Thorsten Siegmund
- Diabetes-, Hormon-, und Stoffwechselzentrum, Privatpraxis am Isar Klinikum, München, Deutschland
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23
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Ramalho D, Correia S, Realista R, Rocha G, Alves H, Almeida L, Ferreira E, Monteiro S, Oliveira MJ, Almeida MC. Impact of pharmacological treatment of gestational diabetes on the mode of delivery and birth weight: a nationwide population-based study on a subset of singleton pregnant Portuguese women. Acta Diabetol 2022; 59:1361-1368. [PMID: 35879479 DOI: 10.1007/s00592-022-01931-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 06/29/2022] [Indexed: 11/01/2022]
Abstract
AIMS To access the impact of increasing use of metformin on cesarean section and large for gestational age rates, when compared to insulin. METHODS A retrospective observational study was developed using data from the Portuguese National Registry, between 2011 and 2019, of 5038 Portuguese women with single pregnancies and gestational diabetes treated with metformin and/or insulin. Three groups were defined according to the therapeutic regimen adopted: g1-insulin in monotherapy (n = 3027[60.1%]); g2-metformin in monotherapy (n = 1366[27.1%]); g3-metformin and insulin (n = 645[12.8%]). Multivariate analysis was adjusted for statistically significant covariates. RESULTS The cesarean section rate in g1 was similar to g2 (g1:36.9% vs. g2:37%, p = 0.982), although g3 was associated with cesarean delivery (g3:43.6% vs. g1:36.9%, p = 0.005; g3:43.6% vs. g1:37.0%, p = 0.002), with no differences reported in the multivariate analysis adjusted for year of delivery and pregestational body mass index. A delivery of a large for gestational age newborn was less frequently observed in g2 than in g1 (g2:4.1% vs. g1:5.4%, p = 0.044) and in g3 (g2:4.1% vs. g3:9.1%, p < 0.001), and in g1, when compared to g3 (g1:5.4% vs. g3:9.1%, p < 0.001). In the multivariate analysis, g2 showed lower odds of delivering a large for gestational age newborn, compared to g1 (β = -0.511, OR = 0.596, CI95% = 0.428-0.832, p < 0.001). CONCLUSIONS The use of metformin was not associated with higher cesarean section rates, compared to insulin. Instead, it was suggested a protective role of metformin on large gestational age rates. The concomitant use of dual therapy suggests more complex pregnancies, requiring closer surveillance that mitigate serious perinatal and obstetrical outcomes.
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Affiliation(s)
- Diogo Ramalho
- Endocrinology Department, Centro Hospitalar de Vila Nova de Gaia / Espinho, Rua Conceição Fernandes S/N, 4434-502, Vila Nova de Gaia, Portugal.
| | - Sara Correia
- Endocrinology Department, Centro Hospitalar de Vila Nova de Gaia / Espinho, Rua Conceição Fernandes S/N, 4434-502, Vila Nova de Gaia, Portugal
| | - Rodrigo Realista
- Obstetrics Department, Centro Hospitalar e Universitário de São João. Alameda Professor Hernâni Monteiro, 4200-319, Porto, Portugal
| | - Gustavo Rocha
- Endocrinology Department, Centro Hospitalar de Vila Nova de Gaia / Espinho, Rua Conceição Fernandes S/N, 4434-502, Vila Nova de Gaia, Portugal
| | - Helena Alves
- Endocrinology Department, Centro Hospitalar de Vila Nova de Gaia / Espinho, Rua Conceição Fernandes S/N, 4434-502, Vila Nova de Gaia, Portugal
| | - Lúcia Almeida
- Endocrinology Department, Centro Hospitalar de Vila Nova de Gaia / Espinho, Rua Conceição Fernandes S/N, 4434-502, Vila Nova de Gaia, Portugal
| | - Eva Ferreira
- Nutrition Department, Centro Hospitalar de Vila Nova de Gaia / Espinho, Rua Conceição Fernandes S/N, 4434-502, Vila Nova de Gaia, Portugal
| | - Sara Monteiro
- Endocrinology Department, Centro Hospitalar de Vila Nova de Gaia / Espinho, Rua Conceição Fernandes S/N, 4434-502, Vila Nova de Gaia, Portugal
| | - Maria João Oliveira
- Endocrinology Department, Centro Hospitalar de Vila Nova de Gaia / Espinho, Rua Conceição Fernandes S/N, 4434-502, Vila Nova de Gaia, Portugal
| | - Maria Céu Almeida
- Obstetrics Department, Maternidade Bissaya Barreto. Rua Augusta 36, 3000-045, Coimbra, Portugal
- Diabetes and Pregnancy Study Group of the Portuguese Society of Diabetology, Rua do Salitre 149, 1250-198, Lisbon, Portugal
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24
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Abstract
Gestational diabetes mellitus (GDM) traditionally refers to abnormal glucose tolerance with onset or first recognition during pregnancy. GDM has long been associated with obstetric and neonatal complications primarily relating to higher infant birthweight and is increasingly recognized as a risk factor for future maternal and offspring cardiometabolic disease. The prevalence of GDM continues to rise internationally due to epidemiological factors including the increase in background rates of obesity in women of reproductive age and rising maternal age and the implementation of the revised International Association of the Diabetes and Pregnancy Study Groups' criteria and diagnostic procedures for GDM. The current lack of international consensus for the diagnosis of GDM reflects its complex historical evolution and pragmatic antenatal resource considerations given GDM is now 1 of the most common complications of pregnancy. Regardless, the contemporary clinical approach to GDM should be informed not only by its short-term complications but also by its longer term prognosis. Recent data demonstrate the effect of early in utero exposure to maternal hyperglycemia, with evidence for fetal overgrowth present prior to the traditional diagnosis of GDM from 24 weeks' gestation, as well as the durable adverse impact of maternal hyperglycemia on child and adolescent metabolism. The major contribution of GDM to the global epidemic of intergenerational cardiometabolic disease highlights the importance of identifying GDM as an early risk factor for type 2 diabetes and cardiovascular disease, broadening the prevailing clinical approach to address longer term maternal and offspring complications following a diagnosis of GDM.
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Affiliation(s)
- Arianne Sweeting
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jencia Wong
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Helen R Murphy
- Diabetes in Pregnancy Team, Cambridge University Hospitals, Cambridge, UK.,Norwich Medical School, Bob Champion Research and Education Building, University of East Anglia, Norwich, UK.,Division of Women's Health, Kings College London, London, UK
| | - Glynis P Ross
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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Dunne F, Newman C, Devane D, Smyth A, Alvarez-Iglesias A, Gillespie P, Browne M, O'Donnell M. A randomised placebo-controlled trial of the effectiveness of early metformin in addition to usual care in the reduction of gestational diabetes mellitus effects (EMERGE): study protocol. Trials 2022; 23:795. [PMID: 36131291 PMCID: PMC9494837 DOI: 10.1186/s13063-022-06694-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/26/2022] [Indexed: 11/12/2022] Open
Abstract
Background Pregnancies affected by gestational diabetes mellitus (GDM) are associated with an increased risk of adverse maternal and foetal outcomes. Current treatments for GDM involve initial medical nutritional therapy (MNT) and exercise and pharmacotherapy in those with persistent hyperglycaemia. Insulin is considered first-line pharmacotherapy but is associated with hypoglycaemia, excessive gestational weight gain (GWG) and an increased caesarean delivery rate. Metformin is safe in selected groups of women with GDM but is not first-line therapy in many guidelines due to a lack of long-term data on efficacy. The EMERGE trial will evaluate the effectiveness of early initiation of metformin in GDM. Methods EMERGE is a phase III, superiority, parallel, 1:1 randomised, double-blind, placebo-controlled trial comparing the effectiveness of metformin versus placebo initiated by 28 weeks (+6 days) plus usual care. Women aged 18–50 years will be recruited. Women with established diabetes, multiple pregnancies, known major congenital malformation or small for gestational age (<10th centile), intolerance or contraindication to the use of metformin, shock or sepsis, current gestational hypertension or pre-eclampsia, significant gastrointestinal problems, congestive heart failure, severe mental illness or galactose intolerance are excluded. Intervention Immediate introduction of metformin or placebo in addition to MNT and usual care. Metformin is initiated at 500mg/day and titrated to a maximum dose of 2500mg over 10 days. Women are followed up at 4 and 12 weeks post-partum to assess maternal and neonatal outcomes. The composite primary outcome measure is initiation of insulin or fasting blood glucose ≥ 5.1 mmol/L at gestational weeks 32 or 38. The secondary outcomes are the time to insulin initiation and insulin dose required; maternal morbidity at delivery; mode and time of delivery; postpartum glucose status; insulin resistance; postpartum body mass index (BMI); gestational weight gain; infant birth weight; neonatal height and head circumference at delivery; neonatal morbidities (neonatal care unit admission, respiratory distress, jaundice, congenital anomalies, Apgar score); neonatal hypoglycaemia; cost-effectiveness; treatment acceptability and quality of life determined by the EQ5D-5L scale. Discussion The EMERGE trial will determine the effectiveness and safety of early and routine use of metformin in GDM. Trial registration EudraCT Number 2016-001644-19l; NCT NCT02980276. Registered on 6 June 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06694-y.
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Affiliation(s)
- F Dunne
- Department of Medicine, HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland.
| | - C Newman
- Department of Medicine, HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
| | - D Devane
- HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland.,School of Nursing and Midwifery, National University of Ireland, Galway, Ireland.,Evidence Synthesis Ireland, National University of Ireland Galway, Galway, Ireland.,Cochrane Ireland, National University of Ireland Galway, Galway, Ireland
| | - A Smyth
- Department of Medicine, HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
| | - A Alvarez-Iglesias
- Department of Medicine, HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
| | - P Gillespie
- Health Economics & Policy Analysis Centre (HEPAC), Institute for Lifecourse and Society (ILAS), National University of Ireland Galway, Galway, Ireland.,CÚRAM, the SFI Research Centre for Medical Devices (12/RC/2073_2), National University of Ireland Galway, Galway, Ireland
| | - M Browne
- Department of Medicine, HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
| | - M O'Donnell
- Department of Medicine, HRB Clinical Research Facility, National University of Ireland Galway, Galway, Ireland
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Qi J, Wu B, Chen X, Wei W, Yao X. Diagnostic biomolecules and combination therapy for pre-eclampsia. Reprod Biol Endocrinol 2022; 20:136. [PMID: 36068569 PMCID: PMC9446775 DOI: 10.1186/s12958-022-01003-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 08/24/2022] [Indexed: 11/10/2022] Open
Abstract
Pre-eclampsia (PE), associated with placental malperfusion, is the primary reason for maternal and perinatal mortality and morbidity that can cause vascular endothelial injury and multi-organ injury. Despite considerable research efforts, no pharmaceutical has been shown to stop disease progression. If women precisely diagnosed with PE can achieve treatment at early gestation, the maternal and fetal outcomes can be maximally optimized by expectant management. Current diagnostic approaches applying maternal characteristics or biophysical markers, including blood test, urine analysis and biophysical profile, possess limitations in the precise diagnosis of PE. Biochemical factor research associated with PE development has generated ambitious diagnostic targets based on PE pathogenesis and dissecting molecular phenotypes. This review focuses on current developments in biochemical prediction of PE and the corresponding interventions to ameliorate disease progression, aiming to provide references for clinical diagnoses and treatments.
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Affiliation(s)
- Jingqi Qi
- International Institutes of Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, No. N1, Shangcheng Avenue, Yiwu, 322000, China
- Zhejiang University-University of Edinburgh Institute (ZJU-UoE Institute), Zhejiang University School of Medicine, International Campus, Zhejiang University, 718 East Haizhou Road, Haining, 314400, China
| | - Bingbing Wu
- International Institutes of Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, No. N1, Shangcheng Avenue, Yiwu, 322000, China
| | - Xiuying Chen
- International Institutes of Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, No. N1, Shangcheng Avenue, Yiwu, 322000, China
| | - Wei Wei
- International Institutes of Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, No. N1, Shangcheng Avenue, Yiwu, 322000, China.
| | - Xudong Yao
- International Institutes of Medicine, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, No. N1, Shangcheng Avenue, Yiwu, 322000, China.
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27
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Maternal Treatment with Metformin Persistently Ameliorates High-Fat Diet-Induced Metabolic Symptoms and Modulates Gut Microbiota in Rat Offspring. Nutrients 2022; 14:nu14173612. [PMID: 36079869 PMCID: PMC9460832 DOI: 10.3390/nu14173612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/26/2022] [Accepted: 08/29/2022] [Indexed: 11/17/2022] Open
Abstract
A maternal high-fat (HF) diet has long-term deleterious effect on offspring. This study aims to evaluate whether maternal metformin (MT) treatment ameliorates the adverse effects of maternal HF diet on offspring and the role of gut microbiota in it. Pregnant Sprague-Dawley rats were randomly assigned to a HF diet (60% fat) or a standard chow diet (11.8% fat) group, and part of the HF diet group rats were co-treated with MT via drinking water (300 mg/kg/day), resulting in three groups according to maternal diet and MT treatment during gestation and lactation. All offspring were weaned on a chow diet. A maternal HF diet showed a significant deleterious effect on offspring’s metabolic phenotype and induced colonic inflammation and gut-barrier disruption through the reshaped gut microbiota. The daily oral administration of MT to HF-fed dams during gestation and lactation reversed the dysbiosis of gut microbiota in both dams and adult offspring. The hypothalamic TGR5 expression and plasma bile acids composition in adult male offspring was restored by maternal MT treatment, which could regulate hypothalamic appetite-related peptides expression and alleviate inflammation, thereby improving male offspring’s metabolic phenotype. The present study indicates that targeting the gut–brain axis through the mother may be an effective strategy to control the metabolic phenotype of offspring.
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28
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Lovell H, Mitchell A, Ovadia C, Pitrelli N, Briley A, Singh C, Marschall HU, Cruickshank K, Murphy H, Seed P, Williamson C. A multi-centered trial investigating gestational treatment with ursodeoxycholic acid compared to metformin to reduce effects of diabetes mellitus (GUARD): a randomized controlled trial protocol. Trials 2022; 23:571. [PMID: 35854327 PMCID: PMC9295112 DOI: 10.1186/s13063-022-06462-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Each year in the UK, approximately 35,000 women develop gestational diabetes mellitus (GDM). The condition increases the risk of obstetric and neonatal complications for mother and child, including preeclampsia, preterm birth, and large for gestational age babies. Biochemical consequences include maternal hyperglycemia, neonatal hypoglycemia, and dyslipidemia. Metformin is the most commonly used firstline pharmacological treatment. However, there are concerns about its widespread use during pregnancy, due to its limited efficacy and potential safety concerns. Therefore, there is a need for additional therapies that improve both maternal-fetal glucose and lipid metabolism. Ursodeoxycholic acid (UDCA) is not currently used for treatment for GDM. However, it can improve glucose control in type 2 diabetes, and it improves fetal lipid profiles in gestational cholestasis. Consequentially, it is hypothesized that treatment with UDCA for women with GDM may improve both maternal metabolism and neonatal outcomes. The primary outcome of this trial is to assess the efficacy of UDCA compared with metformin to improve glucose levels in women with GDM. METHODS The trial is a two-armed, open-label, multi-center, randomized controlled trial. Women are eligible if they have been diagnosed with GDM by an oral glucose tolerance test between 24 + 0 and 30 + 6 weeks' gestation, and if they require pharmacological intervention. In total, 158 pregnant women will be recruited across seven NHS Trusts in England and Wales. Women who consent will be recruited and randomized to either metformin or UDCA, which will be taken daily until the birth of their baby. Maternal and neonatal blood samples will be taken to evaluate the impact of the treatments on maternal glucose control, and maternal and neonatal lipid metabolism. Maternal and fetal outcomes will be evaluated, and acceptability of UDCA compared with metformin will be assessed. DISCUSSION This trial has the potential to identify a potential new treatment for women with GDM. If successful, a future large multi-center trial will be designed to investigate where decisions can be personalized to identify which women will respond more effectively to UDCA than alternatives to improve maternal and baby outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT04407650.
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Affiliation(s)
- Holly Lovell
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | | | | - Annette Briley
- Caring Futures Institute, Flinders University South Australia, Adelaide, Australia
| | | | | | | | - Helen Murphy
- University of East Angela/ Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Healy AM. Diabetes in Pregnancy: Preconception to Postpartum. Prim Care 2022; 49:287-300. [DOI: 10.1016/j.pop.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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30
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Vilalta A, Gutiérrez JA, Chaves S, Hernández M, Urbina S, Hompesch M. Adipose tissue measurement in clinical research for obesity, type 2 diabetes and NAFLD/NASH. Endocrinol Diabetes Metab 2022; 5:e00335. [PMID: 35388643 PMCID: PMC9094496 DOI: 10.1002/edm2.335] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 03/04/2022] [Accepted: 03/09/2022] [Indexed: 01/25/2023] Open
Affiliation(s)
| | - Julio A. Gutiérrez
- ProSciento San Diego California USA
- Scripps Center for Organ Transplantation La Jolla California USA
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31
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Bastian B, Smithers LG, Davis W, Pape A, Francois ME. Metformin: A promising option for the management of gestational diabetes mellitus - Exploring the benefits, challenges and clinical needs in the current management of gestational diabetes mellitus. Aust N Z J Obstet Gynaecol 2022; 62:453-456. [PMID: 35362563 PMCID: PMC9542201 DOI: 10.1111/ajo.13513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The incidence of gestational diabetes mellitus (GDM) is increasing. One in three women require insulin to achieve glycaemic targets in GDM. However, it is unclear whether insulin therapy alone is the most effective treatment for all women in achieving glycaemic control and preventing adverse pregnancy outcomes. Although no oral hypoglycaemic agents are approved for pregnancy in Australia, recent research indicates that metformin is effective in preventing adverse perinatal outcomes and may even have possible benefits in the long term. Furthermore, there appears to be a specific role for both metformin and insulin among the GDM population. Metformin provides an option to offer an individualised approach to treat GDM.
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Affiliation(s)
- Beenu Bastian
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia.,Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia.,Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Lisa Gaye Smithers
- Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia.,School of Health and Society, University of Wollongong, Wollongong, New South Wales, Australia
| | - Warren Davis
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia.,Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Alexia Pape
- Wollongong Hospital, Illawarra Shoalhaven Local Health District, Wollongong, New South Wales, Australia
| | - Monique E Francois
- School of Medicine, University of Wollongong, Wollongong, New South Wales, Australia.,Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia
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32
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Paavilainen E, Tertti K, Nikkinen H, Veijola R, Vääräsmäki M, Loo B, Tossavainen P, Rönnemaa T, Niinikoski H. Metformin versus insulin therapy for gestational diabetes: Effects on offspring anthropometrics and metabolism at the age of 9 years: A follow-up study of two open-label, randomized controlled trials. Diabetes Obes Metab 2022; 24:402-410. [PMID: 34738701 PMCID: PMC9299154 DOI: 10.1111/dom.14589] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 10/22/2021] [Accepted: 10/31/2021] [Indexed: 12/12/2022]
Abstract
AIMS To compare anthropometrics, and lipid and glucose metabolism in the 9-year-old offspring of mothers treated with metformin or insulin for gestational diabetes mellitus (GDM). MATERIALS AND METHODS This was a Finnish two-centre, 9-year follow-up study of two open-label, randomized controlled trials comparing the effects observed in the offspring of mothers who received metformin and insulin treatment for GDM. Measurements included anthropometrics, blood pressure, lipoproteins, and oral glucose tolerance tests. This study was registered with ClinicalTrials.gov, number NCT02417090. RESULTS At the age of 9 years 172 children (55% of the original study cohort, 82 from the metformin and 90 from the insulin group) participated in the study. No differences were found between the 9-year-old offspring groups in anthropometric variables, including body mass index and waist-to-height ratio. The offspring in the metformin group had higher high-density lipoprotein (HDL) cholesterol concentrations (1.72 vs. 1.54 mmol/L; P = 0.039) but lower low-density lipoprotein cholesterol (2.39 vs. 2.58 mmol/L; P = 0.046) and apolipoprotein B concentrations (0.63 vs. 0.67 g/L; P = 0.043) than the offspring in the insulin group. The difference in HDL cholesterol concentration was found to be significant only in boys (P = 0.003). The 2-hour glucose value in the oral glucose tolerance test was 0.6-mmol/L lower in boys from the metformin group than in those from the insulin group (P = 0.015). CONCLUSIONS Metformin treatment for GDM is associated with similar offspring growth and glucose metabolism but a more favourable lipid profile at the age of 9 years as compared to insulin treatment.
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Affiliation(s)
- Elisa Paavilainen
- Department of Paediatrics and Adolescent MedicineUniversity of Turku and Turku University HospitalTurkuFinland
| | - Kristiina Tertti
- Department of Obstetrics and GynaecologyUniversity of Turku and Turku University HospitalTurkuFinland
| | - Hilkka Nikkinen
- Department of Obstetrics and Gynaecology, PEDEGO Research Unit, Medical Research CenterUniversity of Oulu and Oulu University HospitalOuluFinland
| | - Riitta Veijola
- Department of Paediatrics, PEDEGO Research Unit, Medical Research CentreUniversity of Oulu and Oulu University HospitalOuluFinland
| | - Marja Vääräsmäki
- Department of Obstetrics and Gynaecology, PEDEGO Research Unit, Medical Research CenterUniversity of Oulu and Oulu University HospitalOuluFinland
| | - Britt‐Marie Loo
- Joint Clinical Biochemistry Laboratory of University of Turku and Turku University HospitalTurkuFinland
| | - Päivi Tossavainen
- Department of Paediatrics, PEDEGO Research Unit, Medical Research CentreUniversity of Oulu and Oulu University HospitalOuluFinland
| | - Tapani Rönnemaa
- Department of MedicineUniversity of Turku and Division of Medicine, Turku University HospitalTurkuFinland
| | - Harri Niinikoski
- Department of Paediatrics and Adolescent MedicineUniversity of Turku and Turku University HospitalTurkuFinland
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33
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Newman C, Dunne FP. Metformin for pregnancy and beyond: the pros and cons. Diabet Med 2022; 39:e14700. [PMID: 34569082 DOI: 10.1111/dme.14700] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 08/26/2021] [Accepted: 09/21/2021] [Indexed: 12/16/2022]
Abstract
CONTEXT AND AIM Metformin has been used in pregnancy since the 1970s. It is cheap, widely available and is acceptable to women. Despite its increasing use, controversy remains surrounding its benefits and risks. Metformin effectively reduces hyperglycaemia for the mother during pregnancy and it reduces rates of macrosomia and neonatal hypoglycaemia. However, concern exists surrounding an increase in the rate of SGA births and obesity in childhood. We aim to review the evidence and expert opinion behind metformin in pregnancy through to the post-partum period. METHODS We performed a literature review of relevant studies from online databases using a combination of keywords. We also searched the references of retrieved articles for pertinent studies. RESULTS There is strong evidence that metformin is safe in early pregnancy with no risk of congenital malformations. If used throughout pregnancy, it is likely to lead to reduced maternal weight gain and reduced insulin dose in women with type 2 diabetes. In infants, metformin reduces hypoglycaemia and macrosomia but may increase the rate of infants born SGA. There is some evidence of an increased risk of obesity and altered fat distribution in offspring. Metformin appears well tolerated in pregnancy and is more acceptable to women than insulin therapy. CONCLUSION Due to increasing rates of maternal obesity, GDM and type 2 diabetes, metformin use in pregnancy is increasing. Overall, it appears safe and effective but further research is needed to examine mechanisms linking metformin to obesity reported during childhood in some follow-up studies.
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Affiliation(s)
- Christine Newman
- College of Medicine, Nursing and Health Science, National University of Ireland, Galway, Republic of Ireland
| | - Fidelma P Dunne
- College of Medicine, Nursing and Health Science, National University of Ireland, Galway, Republic of Ireland
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34
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Zera CA, Seely EW. Controversies in Gestational Diabetes. TOUCHREVIEWS IN ENDOCRINOLOGY 2022; 17:102-107. [PMID: 35118455 DOI: 10.17925/ee.2021.17.2.102] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 02/23/2021] [Indexed: 11/24/2022]
Abstract
Gestational diabetes mellitus (GDM) complicates approximately 7% of pregnancies in the USA. Despite recognition of the benefits of diagnosing and treating GDM, there are several areas of controversy that remain unresolved. There is debate as to whether to screen for GDM with the one-step versus the two-step approach. While the former identifies more pregnancies with potential adverse outcomes, data are lacking as to whether treatment of these pregnancies will improve outcomes, while increasing costs by diagnosing more women. Though it is well established that the diagnosis of even mild GDM, and treatment with lifestyle recommendations and insulin, improves pregnancy outcomes, it is controversial as to which type and regimen of insulin is optimal, and whether oral agents can be used safely and effectively to control glucose levels. Finally, it is recommended that women with GDM get tested for type 2 diabetes within several months of delivery; however, many women do not undergo this testing and alternative approaches are needed. These controversies are discussed with data from both sides of the debate to enable clinicians to make patient-centered decisions until more definitive data are available.
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Affiliation(s)
- Chloe A Zera
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Ellen W Seely
- Harvard Medical School, Boston, MA, USA.,Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
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35
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Hufnagel A, Fernandez-Twinn DS, Blackmore HL, Ashmore TJ, Heaton RA, Jenkins B, Koulman A, Hargreaves IP, Aiken CE, Ozanne SE. Maternal but not fetoplacental health can be improved by metformin in a murine diet-induced model of maternal obesity and glucose intolerance. J Physiol 2022; 600:903-919. [PMID: 34505282 PMCID: PMC7612651 DOI: 10.1113/jp281902] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/26/2021] [Indexed: 12/19/2022] Open
Abstract
Maternal obesity is a global problem that increases the risk of short- and long-term adverse outcomes for mother and child, many of which are linked to gestational diabetes mellitus. Effective treatments are essential to prevent the transmission of poor metabolic health from mother to child. Metformin is an effective glucose lowering drug commonly used to treat gestational diabetes mellitus; however, its wider effects on maternal and fetal health are poorly explored. In this study we used a mouse (C57Bl6/J) model of diet-induced (high sugar/high fat) maternal obesity to explore the impact of metformin on maternal and feto-placental health. Metformin (300 mg kg-1 day-1 ) was given to obese females via the diet and was shown to achieve clinically relevant concentrations in maternal serum (1669 ± 568 nM in late pregnancy). Obese dams developed glucose intolerance during pregnancy and had reduced uterine artery compliance. Metformin treatment of obese dams improved maternal glucose tolerance, reduced maternal fat mass and restored uterine artery function. Placental efficiency was reduced in obese dams, with increased calcification and reduced labyrinthine area. Consequently, fetuses from obese dams weighed less (P < 0.001) at the end of gestation. Despite normalisation of maternal parameters, metformin did not correct placental structure or fetal growth restriction. Metformin levels were substantial in the placenta and fetal circulation (109.7 ± 125.4 nmol g-1 in the placenta and 2063 ± 2327 nM in fetal plasma). These findings reveal the distinct effects of metformin administration during pregnancy on mother and fetus and highlight the complex balance of risk vs. benefits that are weighed in obstetric medical treatments. KEY POINTS: Maternal obesity and gestational diabetes mellitus have detrimental short- and long-term effects for mother and child. Metformin is commonly used to treat gestational diabetes mellitus in many populations worldwide but the effects on fetus and placenta are unknown. In a mouse model of diet-induced obesity and glucose intolerance in pregnancy we show reduced uterine artery compliance, placental structural changes and reduced fetal growth. Metformin treatment improved maternal metabolic health and uterine artery compliance but did not rescue obesity-induced changes in the fetus or placenta. Metformin crossed the placenta into the fetal circulation and entered fetal tissue. Metformin has beneficial effects on maternal health beyond glycaemic control. However, despite improvements in maternal physiology, metformin did not prevent fetal growth restriction or placental ageing. The high uptake of metformin into the placental and fetal circulation highlights the potential for direct immediate effects of metformin on the fetus with possible long-term consequences postnatally.
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Affiliation(s)
- Antonia Hufnagel
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
| | - Denise S Fernandez-Twinn
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
| | - Heather L Blackmore
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
| | - Thomas J Ashmore
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
| | - Robert A Heaton
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK
| | - Benjamin Jenkins
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
| | - Albert Koulman
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
| | - Iain P Hargreaves
- School of Pharmacy and Biomolecular Sciences, Liverpool John Moores University, Liverpool L3 3AF, UK
| | - Catherine E Aiken
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, United Kingdom; National Institute for Health Research Cambridge Biomedical Research Centre, Cambridge, University of Cambridge, United Kingdom
| | - Susan E Ozanne
- University of Cambridge Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, Level 4, Addenbrooke’s Hospital, Cambridge, Cambridgeshire, United Kingdom, CB22 0QQ
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36
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Quadir H. Current Therapeutic Use of Metformin During Pregnancy: Maternal Changes, Postnatal Effects and Safety. Cureus 2021; 13:e18818. [PMID: 34804675 PMCID: PMC8592788 DOI: 10.7759/cureus.18818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 10/16/2021] [Indexed: 11/28/2022] Open
Abstract
Metformin is one of the most easily available medications for diabetes and has a relatively low cost. It is not only used in diabetes but is also effective in polycystic ovarian syndrome (PCOS) and obesity. Although insulin is the first choice when it comes to treating pregnant women with gestational diabetes mellitus (GDM), metformin has also been debated as a good choice after modification of diet. As metformin passes through the placenta, it is essential to know its consequence of leading to insulin resistance in the fetus as well as the impact on postnatal development. The use of metformin during GDM has raised many trials demonstrating that outcomes from the use of metformin are similar to those achieved with insulin. Follow-up studies were also conducted that assessed the impact on children exposed to metformin in utero. This review highlights the experimental evidence relating to the use of metformin during pregnancy for different conditions, and its impact on the growth and development of offspring.
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Affiliation(s)
- Huma Quadir
- Internal Medicine/Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA.,Neurology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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37
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Roy A, Sahoo J. Long-term effects of metformin use in gestational diabetes mellitus on offspring health. World J Diabetes 2021; 12:1812-1817. [PMID: 34888009 PMCID: PMC8613655 DOI: 10.4239/wjd.v12.i11.1812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/15/2021] [Accepted: 10/14/2021] [Indexed: 02/06/2023] Open
Abstract
Metformin is the first-line drug for the treatment of type 2 diabetes mellitus, but its role in gestational diabetes mellitus (GDM) management is not clear. Recent evidence suggests a certain beneficial effect of metformin in the treatment of GDM, but a high treatment failure rate leads to the initiation of additional medications, such as insulin. Moreover, since metformin crosses the placental barrier and reaches a significant level in the fetus, it is likely to influence the fetal metabolic milieu. The evidence indicates the long-term safety in children exposed to metformin in utero except for mild adverse anthropometric profiles. Diligent follow-up of metformin-exposed offspring is warranted from the clinician’s point of view.
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Affiliation(s)
- Ayan Roy
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, Jodhpur 342005, Rajasthan, India
| | - Jayaprakash Sahoo
- Department of Endocrinology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry 605006, India
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38
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Yu DQ, Xu GX, Teng XY, Xu JW, Tang LF, Feng C, Rao JP, Jin M, Wang LQ. Glycemic control and neonatal outcomes in women with gestational diabetes mellitus treated using glyburide, metformin, or insulin: a pairwise and network meta-analysis. BMC Endocr Disord 2021; 21:199. [PMID: 34641848 PMCID: PMC8513183 DOI: 10.1186/s12902-021-00865-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 09/24/2021] [Indexed: 02/06/2023] Open
Abstract
AIMS We aimed to assess the comparative efficiency and safety of the use of glyburide, metformin, and insulin in gestational diabetes mellitus (GDM). METHODS We searched for randomized controlled trials that compared glyburide, metformin, and insulin in GDM. Data regarding glycemic control and neonatal safety were collected and analyzed in pairwise and network meta-analyses. RESULTS A total of 4533 individuals from 23 trials were included. Compared with glyburide, metformin reduced 2-h postprandial blood glucose (2HPG) to a greater extent (standard mean difference (SMD) 0.18; 95% credible interval (CI) 0.01, 0.34). There were significantly lower prevalence of neonatal hypoglycemia (risk difference (RD) - 0.07; 95%CI - 0.11, - 0.02) and preeclampsia (RD - 0.03; 95%CI - 0.06, 0) in the metformin group than in the insulin group. The metformin group had significantly lower birth weight (SMD - 0.17; 95%CI - 0.25, - 0.08) and maternal weight gain (SMD - 0.61; 95%CI - 0.86,- 0.35) compared with the insulin group. Network meta-analysis suggested that metformin had the highest probability of successfully controlling glycemia and preventing neonatal complications. CONCLUSIONS The present meta-analysis suggests that metformin may be as effective as insulin for glycemic control and is the most promising drug for the prevention of neonatal and maternal complications.
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Affiliation(s)
- Dan-Qing Yu
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Guan-Xin Xu
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Xin-Yuan Teng
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Jing-Wei Xu
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Liang-Fang Tang
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Chun Feng
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Jin-Peng Rao
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Min Jin
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Li-Quan Wang
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China.
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39
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Nguyen L, Lim LY, Ding SSL, Amirruddin NS, Hoon S, Chan SY, Teo AKK. Metformin Perturbs Pancreatic Differentiation From Human Embryonic Stem Cells. Diabetes 2021; 70:1689-1702. [PMID: 33958328 DOI: 10.2337/db20-0722] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 05/04/2021] [Indexed: 11/13/2022]
Abstract
Metformin is becoming a popular treatment before and during pregnancy, but current literature on in utero exposure to metformin lacks long-term clinical trials and mechanistic studies. Current literature on the effects of metformin on mature pancreatic β-cells highlights its dual, opposing, protective, or inhibitory effects, depending on metabolic environment. However, the impact of metformin on developing human pancreatic β-cells remains unknown. In this study, we investigated the potential effects of metformin exposure on human pancreatic β-cell development and function in vitro. In the absence of metabolic challenges such as high levels of glucose and fatty acids, metformin exposure impaired the development and function of pancreatic β-cells, with downregulation of pancreatic genes and dysfunctional mitochondrial respiration. It also affected the insulin secretion function of pancreatic β-cells. These findings call for further in-depth evaluation of the exposure of human embryonic and fetal tissue during pregnancy to metformin and its implications for long-term offspring health.
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Affiliation(s)
- Linh Nguyen
- Stem Cells and Diabetes Laboratory, Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Lillian Yuxian Lim
- Stem Cells and Diabetes Laboratory, Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore
| | - Shirley Suet Lee Ding
- Stem Cells and Diabetes Laboratory, Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore
| | - Nur Shabrina Amirruddin
- Stem Cells and Diabetes Laboratory, Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Shawn Hoon
- Molecular Engineering Laboratory, Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore
| | - Shiao-Yng Chan
- Singapore Institute for Clinical Sciences, Agency for Science, Technology and Research, Singapore
- Department of Obstetrics and Gynaecology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Adrian Kee Keong Teo
- Stem Cells and Diabetes Laboratory, Institute of Molecular and Cell Biology, Agency for Science, Technology and Research, Singapore
- Department of Biochemistry, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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40
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Maternal Metformin Intervention during Obese Glucose-Intolerant Pregnancy Affects Adiposity in Young Adult Mouse Offspring in a Sex-Specific Manner. Int J Mol Sci 2021; 22:ijms22158104. [PMID: 34360870 PMCID: PMC8347264 DOI: 10.3390/ijms22158104] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/18/2021] [Accepted: 07/26/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Metformin is commonly used to treat gestational diabetes mellitus. This study investigated the effect of maternal metformin intervention during obese glucose-intolerant pregnancy on the gonadal white adipose tissue (WAT) of 8-week-old male and female mouse offspring. Methods: C57BL/6J female mice were provided with a control (Con) or obesogenic diet (Ob) to induce pre-conception obesity. Half the obese dams were treated orally with 300 mg/kg/d of metformin (Ob-Met) during pregnancy. Gonadal WAT depots from 8-week-old offspring were investigated for adipocyte size, macrophage infiltration and mRNA expression of pro-inflammatory genes using RT-PCR. Results: Gestational metformin attenuated the adiposity in obese dams and increased the gestation length without correcting the offspring in utero growth restriction and catch-up growth caused by maternal obesity. Despite similar body weight, the Ob and Ob-Met offspring of both sexes showed adipocyte hypertrophy in young adulthood. Male Ob-Met offspring had increased WAT depot weight (p < 0.05), exaggerated adipocyte hyperplasia (p < 0.05 vs. Con and Ob offspring), increased macrophage infiltration measured via histology (p < 0.05) and the mRNA expression of F4/80 (p < 0.05). These changes were not observed in female Ob-Met offspring. Conclusions: Maternal metformin intervention during obese pregnancy causes excessive adiposity, adipocyte hyperplasia and WAT inflammation in male offspring, highlighting sex-specific effects of prenatal metformin exposure on offspring WAT.
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The Role of Metformin in Treating Preeclampsia. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Bedell S, Hutson J, de Vrijer B, Eastabrook G. Effects of Maternal Obesity and Gestational Diabetes Mellitus on the Placenta: Current Knowledge and Targets for Therapeutic Interventions. Curr Vasc Pharmacol 2021; 19:176-192. [PMID: 32543363 DOI: 10.2174/1570161118666200616144512] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/16/2020] [Accepted: 05/17/2020] [Indexed: 02/08/2023]
Abstract
Obesity and gestational diabetes mellitus (GDM) are becoming more common among pregnant women worldwide and are individually associated with a number of placenta-mediated obstetric complications, including preeclampsia, macrosomia, intrauterine growth restriction and stillbirth. The placenta serves several functions throughout pregnancy and is the main exchange site for the transfer of nutrients and gas from mother to fetus. In pregnancies complicated by maternal obesity or GDM, the placenta is exposed to environmental changes, such as increased inflammation and oxidative stress, dyslipidemia, and altered hormone levels. These changes can affect placental development and function and lead to abnormal fetal growth and development as well as metabolic and cardiovascular abnormalities in the offspring. This review aims to summarize current knowledge on the effects of obesity and GDM on placental development and function. Understanding these processes is key in developing therapeutic interventions with the goal of mitigating these effects and preventing future cardiovascular and metabolic pathology in subsequent generations.
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Affiliation(s)
- Samantha Bedell
- Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, ON N6A 3B4, Canada
| | - Janine Hutson
- Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, ON N6A 3B4, Canada
| | - Barbra de Vrijer
- Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, ON N6A 3B4, Canada
| | - Genevieve Eastabrook
- Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, The University of Western Ontario, London, Ontario, ON N6A 3B4, Canada
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Interaction between Metformin, Folate and Vitamin B 12 and the Potential Impact on Fetal Growth and Long-Term Metabolic Health in Diabetic Pregnancies. Int J Mol Sci 2021; 22:ijms22115759. [PMID: 34071182 PMCID: PMC8198407 DOI: 10.3390/ijms22115759] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 05/24/2021] [Accepted: 05/25/2021] [Indexed: 12/15/2022] Open
Abstract
Metformin is the first-line treatment for many people with type 2 diabetes mellitus (T2DM) and gestational diabetes mellitus (GDM) to maintain glycaemic control. Recent evidence suggests metformin can cross the placenta during pregnancy, thereby exposing the fetus to high concentrations of metformin and potentially restricting placental and fetal growth. Offspring exposed to metformin during gestation are at increased risk of being born small for gestational age (SGA) and show signs of ‘catch up’ growth and obesity during childhood which increases their risk of future cardiometabolic diseases. The mechanisms by which metformin impacts on the fetal growth and long-term health of the offspring remain to be established. Metformin is associated with maternal vitamin B12 deficiency and antifolate like activity. Vitamin B12 and folate balance is vital for one carbon metabolism, which is essential for DNA methylation and purine/pyrimidine synthesis of nucleic acids. Folate:vitamin B12 imbalance induced by metformin may lead to genomic instability and aberrant gene expression, thus promoting fetal programming. Mitochondrial aerobic respiration may also be affected, thereby inhibiting placental and fetal growth, and suppressing mammalian target of rapamycin (mTOR) activity for cellular nutrient transport. Vitamin supplementation, before or during metformin treatment in pregnancy, could be a promising strategy to improve maternal vitamin B12 and folate levels and reduce the incidence of SGA births and childhood obesity. Heterogeneous diagnostic and screening criteria for GDM and the transient nature of nutrient biomarkers have led to inconsistencies in clinical study designs to investigate the effects of metformin on folate:vitamin B12 balance and child development. As rates of diabetes in pregnancy continue to escalate, more women are likely to be prescribed metformin; thus, it is of paramount importance to improve our understanding of metformin’s transgenerational effects to develop prophylactic strategies for the prevention of adverse fetal outcomes.
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Versace VL, Beks H, Wesley H, McNamara K, Hague W, Anjana RM, Mohan V, Khunti K, Dunbar JA. Metformin for Preventing Type 2 Diabetes Mellitus in Women with a Previous Diagnosis of Gestational Diabetes: A Narrative Review. Semin Reprod Med 2021; 38:366-376. [PMID: 33860488 DOI: 10.1055/s-0041-1727203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Women with a history of gestational diabetes mellitus (GDM) are at greater risk of developing type 2 diabetes mellitus (T2DM) when compared with women who have not had GDM. To delay or prevent T2DM, guidelines recommend regular screening in the primary care setting and lifestyle interventions that are largely focused on dietary and physical activity modifications. As the postpartum period can be challenging for women, uptake and engagement in screening and lifestyle interventions have been poor. Poor uptake and engagement places women with a history of GDM at heightened risk for future morbidity and development of T2DM. Metformin has been a longstanding and safe treatment for the control of blood glucose in people with T2DM. Research has supported the efficacy of metformin, used as an adjunct to a lifestyle intervention or as a stand-alone treatment, in preventing T2DM in people at high risk of T2DM. Findings from longitudinal studies have demonstrated the potential for metformin to reduce conversion to T2DM when used by women with a previous diagnosis of GDM. This review examines the potential effectiveness of metformin to reduce the incidence of T2DM among women with a previous diagnosis of GDM in the "real-world" setting.
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Affiliation(s)
| | - Hannah Beks
- School of Medicine, Deakin University, Geelong, Australia
| | - Hannah Wesley
- School of Medicine, Deakin University, Geelong, Australia.,Madras Diabetes Research Foundation, Chennai, India
| | - Kevin McNamara
- School of Medicine, Deakin University, Geelong, Australia
| | - William Hague
- Robinson Research Institute, The University of Adelaide, Adelaide, Australia
| | | | | | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - James A Dunbar
- School of Medicine, Deakin University, Geelong, Australia
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Rossiter C, Cheng H, Appleton J, Campbell KJ, Denney-Wilson E. Addressing obesity in the first 1000 days in high risk infants: Systematic review. MATERNAL AND CHILD NUTRITION 2021; 17:e13178. [PMID: 33780128 PMCID: PMC8189222 DOI: 10.1111/mcn.13178] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 02/14/2021] [Accepted: 02/16/2021] [Indexed: 12/11/2022]
Abstract
Early intervention is critical for addressing the challenge of childhood obesity. Yet many preventive interventions do not target infants most at risk of future overweight or obesity. This systematic review examines interventions delivered before 2 years that aim to ameliorate excess weight gain among infants at high risk of overweight or obesity, due to sociodemographic characteristics, parental weight or health status, infant feeding or health behaviours. We searched six databases for interventions: (a) delivered before age two, (b) specifically aimed at infants at high risk of childhood obesity and (c) that reported outcomes by weight status beyond 28 days. The search identified over 27,000 titles, and 49 papers from 38 studies met inclusion criteria: 10 antenatal interventions, 16 postnatal and 12 conducted both before and after birth. Nearly all targeted infant and/or maternal nutrition. Studies varied widely in design, obesity risk factors, outcomes and quality. Overall, nine interventions of varying quality reported some evidence of significantly improved child weight trajectory, although effects tended to diminish over time. Interventions that improved weight outcomes tended to engage parents for a longer period, and most offered health professional input and support. Two studies of limited quality reported significantly worse weight outcomes in the intervention group.
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Affiliation(s)
- Chris Rossiter
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Heilok Cheng
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Jessica Appleton
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Sydney Institute for Women, Children and their Families, Sydney, New South Wales, Australia.,Tresillian Family Care Centres, Belmore, New South Wales, Australia
| | - Karen J Campbell
- Institute for Physical Activity and Nutrition (IPAN), Deakin University, Burwood, Victoria, Australia
| | - Elizabeth Denney-Wilson
- Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Sydney Institute for Women, Children and their Families, Sydney, New South Wales, Australia
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Feghali M, Atlass J, Abebe KZ, Comer D, Catov J, Caritis S, Arslanian S, Scifres C. Treatment of Gestational Diabetes Mellitus and Offspring Early Childhood Growth. J Clin Endocrinol Metab 2021; 106:e1849-e1858. [PMID: 33057663 PMCID: PMC7993564 DOI: 10.1210/clinem/dgaa742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 10/09/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is associated with fetal overgrowth, and certain treatments are associated with an increased risk of macrosomia. However, there are limited data about the long-term effect of GDM treatment on childhood growth. METHODS Cohort study of 816 women with GDM and their offspring delivered between 2009 and 2012. Childhood height and weight through age 3 were collected from the medical record and z-scores and body mass index (BMI) were calculated. We assessed the association between GDM treatment and childhood growth using linear mixed modeling. RESULTS Treatment was divided into medical nutritional therapy (MNT) (n = 293), glyburide (n = 421), and insulin (n = 102). At delivery, birthweight, z-score, and BMI were higher in the offspring of women treated with either glyburide or insulin compared to MNT. However, weight, z-score, and BMI were similar among all offspring at 6 months and 1, 2, and 3 years of age. After controlling for covariates, there were differences in the weight z-score (P = 0.01) over the 3-year period by treatment group, but no differences in weight (P = 0.06) or change in BMI (P = 0.28). Pairwise comparisons indicated that insulin was associated with more weight gain compared with MNT (0.69 kg; 95% CI, 0.10-1.28; P = 0.02) and glyburide was associated with a trend toward lower weight z-score compared with MNT (-0.24; 95% CI, -0.47 to 0.003; P = 0.05). CONCLUSION Despite growth differences detected at birth, we observed no meaningful differences in childhood growth from 6 months to 3 years among treatment groups, including in the offspring of women with GDM treated with glyburide.
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Affiliation(s)
- Maisa Feghali
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Correspondence: Maisa Feghali, MD, 300 Halket St, Pittsburgh, PA 15213.
| | - Jacqueline Atlass
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kaleab Z Abebe
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Diane Comer
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Janet Catov
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Steve Caritis
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Silva Arslanian
- Department of Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Christina Scifres
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana
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Van Dam JM, Goldsworthy MR, Hague WM, Coat S, Pitcher JB. Cortical Plasticity and Interneuron Recruitment in Adolescents Born to Women with Gestational Diabetes Mellitus. Brain Sci 2021; 11:brainsci11030388. [PMID: 33808544 PMCID: PMC8003113 DOI: 10.3390/brainsci11030388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/12/2021] [Accepted: 03/15/2021] [Indexed: 11/16/2022] Open
Abstract
Exposure to gestational diabetes mellitus (GDM) in utero is associated with a range of adverse cognitive and neurological outcomes. Previously, we reported altered neuroplastic responses to continuous theta burst stimulation (cTBS) in GDM-exposed adolescents. Recent research suggests that the relative excitability of complex oligosynaptic circuits (late I-wave circuits) can predict these responses. We aimed to determine if altered I-wave recruitment was associated with neuroplastic responses in adolescents born to women with GDM. A total of 20 GDM-exposed adolescents and 10 controls (aged 13.1 ± 1.0 years) participated. cTBS was used to induce neuroplasticity. I-wave recruitment was assessed by comparing motor-evoked potential latencies using different TMS coil directions. Recruitment of late I-waves was associated with stronger LTD-like neuroplastic responses to cTBS (p = < 0.001, R2 = 0.36). There were no differences between groups in mean neuroplasticity (p = 0.37), I-wave recruitment (p = 0.87), or the association between these variables (p = 0.41). The relationship between I-wave recruitment and the response to cTBS previously observed in adults is also present in adolescents and does not appear to be altered significantly by in utero GDM exposure. Exposure to GDM does not appear to significantly impair LTD-like synaptic plasticity or interneuron recruitment.
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Affiliation(s)
- Jago M. Van Dam
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia 5005, Australia; (J.M.V.D.); (W.M.H.); (S.C.)
| | - Mitchell R. Goldsworthy
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia 5005, Australia; (J.M.V.D.); (W.M.H.); (S.C.)
- Hopwood Centre for Neurobiology, Lifelong Health Theme, South Australian Health and Medical Research Institute (SAHMRI), Adelaide, South Australia 5000, Australia
- Correspondence: (M.R.G.); (J.B.P.)
| | - William M. Hague
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia 5005, Australia; (J.M.V.D.); (W.M.H.); (S.C.)
- Obstetric Medicine, Women’s and Children’s Hospital Network, North Adelaide, South Australia 5006, Australia
| | - Suzette Coat
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia 5005, Australia; (J.M.V.D.); (W.M.H.); (S.C.)
| | - Julia B. Pitcher
- Robinson Research Institute, Adelaide Medical School, University of Adelaide, Adelaide, South Australia 5005, Australia; (J.M.V.D.); (W.M.H.); (S.C.)
- Institute for Mental and Physical Health and Clinical Translation, School of Medicine, Deakin University, Geelong, Victoria 3220, Australia
- Correspondence: (M.R.G.); (J.B.P.)
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Raperport C, Chronopoulou E, Homburg R. Effects of metformin treatment on pregnancy outcomes in patients with polycystic ovary syndrome. Expert Rev Endocrinol Metab 2021; 16:37-47. [PMID: 33634727 DOI: 10.1080/17446651.2021.1889366] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/09/2021] [Indexed: 01/28/2023]
Abstract
INTRODUCTION This review covers the current evidence regarding the use of metformin as a therapeutic intervention for optimizing pregnancy outcomes in women with polycystic ovary syndrome (PCOS). AREAS COVERED After searching Medline, Embase and CINAHL, all important large clinical trials and observational studies plus systematic reviews, meta-analyses and Cochrane reviews have been summarized here. The results have been compared to culminate in a thorough review and discussion on the use of metformin in relation to reproductive outcomes for women with PCOS. The role of metformin in PCOS is explored both in terms of achieving conception and during pregnancy. The existing evidence around metformin use is summarized both during the preconceptual period and during pregnancy, in relation to reproductive outcomes. EXPERT OPINION Metformin is a widely used medication, often prescribed to improve reproductive outcomes for women with PCOS. However, the evidence remains equivocal regarding its efficacy both in optimizing fertility and pregnancy outcomes. More research is required with special emphasis on metformin use within different populations, including ethnic groups and women with varying BMI ranges.
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Affiliation(s)
- Claudia Raperport
- Fertility Unit, Homerton University Hospital, London, UK
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Roy Homburg
- Fertility Unit, Homerton University Hospital, London, UK
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Villota SD, Toledo-Rodriguez M, Leach L. Compromised barrier integrity of human feto-placental vessels from gestational diabetic pregnancies is related to downregulation of occludin expression. Diabetologia 2021; 64:195-210. [PMID: 33001231 PMCID: PMC7716932 DOI: 10.1007/s00125-020-05290-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 08/18/2020] [Indexed: 12/16/2022]
Abstract
AIMS/HYPOTHESIS Reduced occupancy of junctional occludin is a feature of human placental vessels in the diabetic milieu. However, the functional consequence of this and whether this loss is due to differential expression of occludin splice variants is not known. Our study aimed to investigate the effects of gestational diabetes mellitus (GDM), and its treatment, on endothelial junctional integrity, gene and protein expression of occludin splice variants, and potential regulation of expression by microRNAs (miRNAs). METHODS Term placentas were obtained from normal pregnancies (n = 21), and pregnancies complicated by GDM where glucose levels were controlled by diet (n = 11) or metformin (n = 6). Gene and microRNA (miRNA) expression were determined by quantitative real-time PCR; protein expression by immunoblotting; endothelial junctional occupancy by fluorescence microscopy and systematic sampling; and paracellular leakage by perfusion of placental microvascular beds with 76 Mr dextran. Transfection studies of miRNAs that target OCLN were performed in HUVECs, and the trans-endothelial electrical resistance and tracer permeability of the HUVECs were measured. RESULTS All three predicted OCLN gene splice variants and two occludin protein isoforms were found in human placental samples. In placental samples from diet-controlled GDM (d-GDM) pregnancies we found a lower percentage of conduit vessels showing occludin immunoreactivity (12%, p < 0.01), decreased levels of the fully functional occludin isoform-A protein (29%), and differential gene expression of OCLN variant 2 (33% decrease), variant 3 (3.3-fold increase). These changes were not seen in samples from the group with metformin-controlled GDM. In d-GDM placentas, increased numbers of conduit microvessels demonstrated extravasation of 76 Mr dextran (2.0-fold). In d-GDM expression of one of the five potential miRNAs targeting OCLN, miR-181a-5p, expression was 2.1-fold that in normal pregnancies. Experimental overexpression of miR-181a-5p in HUVECs from normal pregnancies resulted in a highly significant downregulation of OCLN variant 1 (69%) and variant 2 (46%) gene expression, with decreased trans-endothelial resistance (78%) and increase in tracer permeability (1.3-fold). CONCLUSIONS/INTERPRETATION Downregulation of expression of OCLN variant 2 and the fully functional occludin isoform-A protein are a feature of placentas in d-GDM pregnancies. These may be behind the loss of junctional occludin and the increased extravasation of exogenous dextran observed. miR-181a-5p was in part responsible for the downregulation of occludin in placentas from d-GDM pregnancies. Induced overexpression of miR-181a-5p compromised the integrity of the endothelial barrier. Our data suggest that, despite good glucose control, the adoption of lifestyle changes alone during a GDM pregnancy may not be enough to prevent an alteration in the expression of occludin and the subsequent functional consequences in placentas and impaired vascular barrier function in offspring. Graphical abstract.
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Affiliation(s)
| | | | - Lopa Leach
- School of Life Sciences, University of Nottingham, Nottingham, UK.
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Carroll DT, Sassin AM, Aagaard KM, Gannon M. Developmental effects of in utero metformin exposure. TRENDS IN DEVELOPMENTAL BIOLOGY 2021; 14:1-17. [PMID: 36589485 PMCID: PMC9802655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
According to the Developmental Origins of Health and Disease (DOHaD) hypothesis, the intrauterine environment influences fetal programming and development, affecting offspring disease susceptibility in adulthood. In recent years, therapeutic use of the Type 2 diabetes drug metformin has expanded to the treatment of pre-diabetes, polycystic ovarian syndrome, and gestational diabetes. Because metformin both undergoes renal excretion and binds to receptors on the placenta, the fetus receives equivalent maternal dosing. Although no teratogenic nor short-term harmful fetal impact of metformin is known to occur, the effects of metformin exposure on longer-range offspring development have not yet been fully elucidated. This review encapsulates the (albeit limited) existing knowledge regarding the potential longer-term impact of intrauterine metformin exposure on the development of key organs including the liver, central nervous system, heart, gut, and endocrine pancreas in animal models and humans. We discuss molecular and cellular mechanisms that would be altered in response to treatment and describe the potential consequences of these developmental changes on postnatal health. Further studies regarding the influence of metformin exposure on fetal programming and adult metabolic health will provide necessary insight to its long-term risks, benefits, and limitations in order to guide decisions for use of metformin during pregnancy.
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Affiliation(s)
- Darian T. Carroll
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN
| | - Alexa M. Sassin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, and Departments of Molecular and Human Genetics, and Molecular and Cell Biology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX
| | - Kjersti M. Aagaard
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, and Departments of Molecular and Human Genetics, and Molecular and Cell Biology, Baylor College of Medicine and Texas Children’s Hospital, Houston, TX
| | - Maureen Gannon
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, TN
- Department of Veterans Affairs Tennessee Valley, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN, USA
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