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Zhang Y, Liu X, Yang L, Zou L. Current Researches, Rationale, Plausibility, and Evidence Gaps on Metformin for the Management of Hypertensive Disorders of Pregnancy. Front Pharmacol 2020; 11:596145. [PMID: 33381040 PMCID: PMC7768035 DOI: 10.3389/fphar.2020.596145] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/22/2020] [Indexed: 12/16/2022] Open
Abstract
Hypertensive disorders of pregnancy (HDP) are a group of morbid pregnancy complications, with preeclampsia (PE) being the most common subclassification among them. PE affects 2%–8% of pregnancies globally and threatens maternal and fetal health seriously. However, the only effective treatment of PE to date is the timely termination of pregnancy, albeit with increased perinatal risks. Hence, more emerging therapies for PE management are in urgent need. Originally introduced as the first-line therapy for type 2 diabetes mellitus, metformin (MET) has now been found in clinical trials to significantly reduce the incidence of gestational hypertension and PE in pregnant women with PE-related risks, including but not limited to pregestational diabetes mellitus, gestational diabetes mellitus, polycystic ovary syndrome, or obesity. Additionally, existing clinical data have preliminarily ensured the safety of taking MET during human pregnancies. Relevant lab studies have indicated that the underlying mechanism includes angiogenesis promotion, endothelial protection, anti-inflammatory effects, and particularly protective effects on trophoblast cells against the risk factors, which are beneficial to placental development. Together with its global availability, easy administration, and low cost, MET is expected to be a promising option for the prevention and treatment of PE. Nevertheless, there are still some limitations in current studies, and the design of the relevant research scheme is supposed to be further improved in the future. Herein, we summarize the relevant clinical and experimental researches to discuss the rationale, safety, and feasibility of MET for the management of HDP. At the end of the article, gaps in current researches are proposed. Concretely, experimental MET concentration and PE models should be chosen cautiously. Besides, the clinical trial protocol should be further optimized to evaluate the reduction in the prevalence of PE as a primary endpoint. All of those evidence gaps may be of guiding significance to improve the design of relevant experiments and clinical trials in the future.
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Affiliation(s)
- Yang Zhang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaoxia Liu
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liu Yang
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Zou
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Rudland VL, Price SAL, Hughes R, Barrett HL, Lagstrom J, Porter C, Britten FL, Glastras S, Fulcher I, Wein P, Simmons D, McIntyre HD, Callaway L. ADIPS 2020 guideline for pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol 2020; 60:E18-E52. [PMID: 33200400 DOI: 10.1111/ajo.13265] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
Abstract
This is the full version of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The guideline encompasses the management of women with pre-existing type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The management of women with monogenic diabetes or cystic fibrosis-related diabetes in relation to pregnancy is also discussed.
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Affiliation(s)
- Victoria L Rudland
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sarah A L Price
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Diabetes, Royal Women's Hospital, Melbourne, Victoria, Australia.,Mercy Hospital for Women, Melbourne, Victoria, Australia.,Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Ruth Hughes
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand
| | - Helen L Barrett
- Department of Endocrinology, Mater Health, Brisbane, Queensland, Australia.,Mater Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Janet Lagstrom
- Green St Specialists Wangaratta, Wangaratta, Victoria, Australia.,Denis Medical Yarrawonga, Yarrawonga, Victoria, Australia.,Corowa Medical Clinic, Corowa, New South Wales, Australia.,NCN Health, Numurkah, Victoria, Australia
| | - Cynthia Porter
- Geraldton Diabetes Clinic, Geraldton, Western Australia, Australia
| | - Fiona L Britten
- Department of Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Mater Private Hospital and Mater Mother's Private Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Sarah Glastras
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Ian Fulcher
- Liverpool Hospital, Sydney, New South Wales, Australia
| | - Peter Wein
- Mercy Hospital for Women, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - David Simmons
- Western Sydney University, Sydney, New South Wales, Australia.,Campbelltown Hospital, Sydney, New South Wales, Australia
| | - H David McIntyre
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Mater Health, Brisbane, Queensland, Australia
| | - Leonie Callaway
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Women's and Children's Services, Metro North Hospital and Health Service District, Brisbane, Queensland, Australia.,Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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53
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The Effects of Maternal Metformin Treatment on Late Prenatal and Early Postnatal Development of the Offspring Are Modulated by Sex. Pharmaceuticals (Basel) 2020; 13:ph13110363. [PMID: 33158193 PMCID: PMC7694275 DOI: 10.3390/ph13110363] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 10/31/2020] [Accepted: 11/03/2020] [Indexed: 11/17/2022] Open
Abstract
Metformin is currently used to improve pregnancy outcome in women affected by polycystic ovary syndrome (PCOS) or diabetes. However, metformin may also be useful in pregnancies at risk of intrauterine growth restriction (IUGR) since it improves placental efficiency and the fetuses' developmental competence. There is no data on the duration of the effect of this treatment from the prenatal up to the postnatal stages. Therefore, the present trial aimed at determining the impact of metformin treatment on the offspring neonatal traits and early postnatal development (i.e., during lactation) using an in vivo swine model. The results support that maternal metformin treatment during pregnancy induces protective changes in body shape and composition of the progeny (i.e., larger head size and body length at birth and higher total viscera weight at weaning). However, there were also major effects of the offspring sex (smaller corpulence in females and lower relative weight of main viscerae in males), which should be considered for further preclinical studies and when even the current clinical application in women affected by PCOS or diabetes is implemented.
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Paul P, Priyambada L, Abraham A, Manimegalai B, Paul TV, Princy S, Antonisamy B, Thomas N, Yenuberi H, Mathews JE. Follow‐up of offspring and mothers with gestational diabetes treated with metformin or glibenclamide: A randomized controlled trial. Int J Gynaecol Obstet 2020; 152:446-447. [DOI: 10.1002/ijgo.13380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 07/22/2020] [Accepted: 09/15/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Praveen Paul
- Department of Pediatrics Christian Medical College Vellore Tamil Nadu India
| | - Leena Priyambada
- Department of Pediatrics Christian Medical College Vellore Tamil Nadu India
| | - Anuja Abraham
- Department of Obstetrics and Gynecology Christian Medical College Vellore Tamil Nadu India
| | - Babuji Manimegalai
- Department of Dietetics Christian Medical College Vellore Tamil Nadu India
| | - Thomas V. Paul
- Department of Endocrinology Diabetes and Metabolism Christian Medical College Vellore Tamil Nadu India
| | - Sneha Princy
- Department of Bio‐Statistics Christian Medical College Vellore Tamil Nadu India
| | | | - Nihal Thomas
- Department of Endocrinology Diabetes and Metabolism Christian Medical College Vellore Tamil Nadu India
| | - Hilda Yenuberi
- Department of Obstetrics and Gynecology Christian Medical College Vellore Tamil Nadu India
| | - Jiji E. Mathews
- Department of Obstetrics and Gynecology Christian Medical College Vellore Tamil Nadu India
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Poprzeczny AJ, Louise J, Deussen AR, Dodd JM. Effect of metformin in addition to an antenatal diet and lifestyle intervention on fetal growth and adiposity: the GRoW randomised trial. BMC Endocr Disord 2020; 20:139. [PMID: 32928167 PMCID: PMC7488668 DOI: 10.1186/s12902-020-00618-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 08/31/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The infants born to women who are overweight or obese in pregnancy are at an increased risk of being born macrosomic or large for gestational age. Antenatal dietary and lifestyle interventions have been shown to be ineffective at reducing this risk. Our aim was to examine the effects of metformin in addition to a diet and lifestyle intervention on fetal growth and adiposity among women with a BMI above the healthy range. METHODS Women who had a body mass index ≥25 kg/m2 in early pregnancy, and a singleton gestation, were enrolled in the GRoW trial from three public maternity hospitals in metropolitan Adelaide. Women were invited to have a research ultrasounds at 28 and 36 weeks' gestation at which ultrasound measures of fetal biometry and adiposity were obtained. Fetal biometry z-scores and trajectories were calculated. Measurements and calculations were compared between treatment groups. This secondary analysis was pre-specified. RESULTS Ultrasound data from 511 women were included in this analysis. The difference in femur length at 36 weeks' gestation was (0.07 cm, 95% CI 0.01-0.14 cm, p = 0.019) and this was was statistically significant, however the magnitude of effect was small. Differences between treatment groups for all other fetal biometry measures, z-scores, estimated fetal weight, and adiposity measures at 28 and 36 weeks' gestation were similar. CONCLUSIONS The addition of metformin to dietary and lifestyle advice in pregnancy for overweight and obese women has no clinically relevant effect on ultrasound measures of fetal biometry or adiposity. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry ( ACTRN12612001277831 ).
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Affiliation(s)
- Amanda J Poprzeczny
- The University of Adelaide, The Robinson Research Institute, and Discipline of Obstetrics and Gynaecology, Adelaide, South Australia, Australia.
- Department of Perinatal Medicine, The Women's and Children's Hospital, Women's and Babies Division, Adelaide, South Australia, Australia.
- The University of Adelaide, Women's and Children's Hospital, 72 King William Road, North Adelaide, South Australia, 5006, Australia.
| | - Jennie Louise
- The University of Adelaide, The Robinson Research Institute, and Discipline of Obstetrics and Gynaecology, Adelaide, South Australia, Australia
- The University of Adelaide, School of Public Health, Adelaide, South Australia, Australia
| | - Andrea R Deussen
- The University of Adelaide, The Robinson Research Institute, and Discipline of Obstetrics and Gynaecology, Adelaide, South Australia, Australia
| | - Jodie M Dodd
- The University of Adelaide, The Robinson Research Institute, and Discipline of Obstetrics and Gynaecology, Adelaide, South Australia, Australia
- Department of Perinatal Medicine, The Women's and Children's Hospital, Women's and Babies Division, Adelaide, South Australia, Australia
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Panagiotopoulou O, Syngelaki A, Georgiopoulos G, Simpson J, Akolekar R, Shehata H, Nicolaides K, Charakida M. Metformin use in obese mothers is associated with improved cardiovascular profile in the offspring. Am J Obstet Gynecol 2020; 223:246.e1-246.e10. [PMID: 32017923 DOI: 10.1016/j.ajog.2020.01.054] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Revised: 01/26/2020] [Accepted: 01/27/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Maternal obesity increases the risk for pregnancy complications and adverse neonatal outcome and has been associated with long-lasting adverse effects in the offspring, including increased body fat mass, insulin resistance, and increased risk for premature cardiovascular disease. Lifestyle interventions in pregnancy have produced no or modest effects in the reduction of adverse pregnancy outcomes in obese mothers. The Metformin in Obese Pregnant Women trial was associated with reduced adverse pregnancy outcomes and had no effect on birthweight. However, the long-term implications of metformin on the health of offspring remain unknown. OBJECTIVE The purpose of this study was to assess whether prenatal exposure to metformin can improve the cardiovascular profile and body composition in the offspring of obese mothers. STUDY DESIGN In 151 children from the Metformin in Obese Pregnant Women trial, body composition, peripheral blood pressure, and arterial pulse wave velocity were measured. Central hemodynamics (central blood pressure and augmentation index) were estimated with the use of an oscillometric device. Left ventricular cardiac function and structure were assessed by echocardiography. RESULTS Children were 3.9±1.0 years old, and 77 of them had been exposed to metformin prenatally. There was no significant difference in peripheral blood pressure, arterial stiffness, and body composition apart from gluteal and tricep circumferences, which were lower in the metformin group (P<.05). The metformin group, compared with the placebo group, had lower central hemodynamics (mean adjusted decrease, -0.707 mm Hg for aortic systolic blood pressure, -1.65 mm Hg for aortic pulse pressure, and -2.68% for augmentation index; P<.05 for all) and lower left ventricular diastolic function (adjusted difference in left atrial area, -0.525 cm2, in isovolumic relaxation time, -0.324 msec, and in pulmonary venous systolic wave, 2.97 cm/s; P<.05 for all). There were no significant differences in metabolic profile between the groups. CONCLUSION Children of obese mothers who were exposed prenatally to metformin, compared with those who were exposed to placebo, had lower central hemodynamic and cardiac diastolic indices. These results suggest that the administration of metformin in obese pregnant women potentially may have a beneficial cardiovascular effect for their offspring.
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Affiliation(s)
- Olga Panagiotopoulou
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Argyro Syngelaki
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - Georgios Georgiopoulos
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - John Simpson
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Ranjit Akolekar
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK
| | - Hassan Shehata
- Department of Maternal Medicine, Epsom and St Helier University Hospitals NHS Trust, Surrey, UK
| | - Kypros Nicolaides
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - Marietta Charakida
- Harris Birthright Research Centre for Fetal Medicine, Fetal Medicine Research Institute, King's College Hospital, London, UK; School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK.
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Novi DRBS, Vidigal CB, Marques BVD, Forcato S, Raquel HA, Zaia DAM, Zaia CTBV, Martins-Pinge MC, Gerardin DCC, Ceravolo GS. Can maternal treatment with metformin during gestation and lactation cause metabolic and cardiovascular disorders in rat offspring? Arch Physiol Biochem 2020; 126:276-281. [PMID: 30270666 DOI: 10.1080/13813455.2018.1517804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective: The aim was to evaluate if maternal treatment with metformin (MET) during pregnancy and lactation could be safe for metabolic and cardiovascular parameters of adult male and female offspring.Materials and methods: Wistar female rats were treated with MET (293 mg/kg/d) or tap water, by gavage during gestation (METG or CTRG) or gestation and lactation (METGL or CTRGL).Results: At 75 days of life, male and female MET offspring presented similar blood pressure when compared with their CTR. The heart rate of female METGL was higher than in the CTRGL. The insulin sensitivity, basal glycaemia, body weight, Lee index of obesity, plasmatic concentration of triglycerides, total cholesterol and fat acid of male and female MET were similar to CTR groups. Lower fat pad deposition was observed in female METG and METGL.Conclusion: MET exposure during gestational and lactation does not program cardiovascular and metabolic alterations in adult offspring life.
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Affiliation(s)
- Daniella R B S Novi
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Camila B Vidigal
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Bruno V D Marques
- Department of Pharmacology, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Simone Forcato
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Hiviny A Raquel
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Dimas A M Zaia
- Department of Chemistry, State University of Londrina, Londrina, Brazil
| | - Cássia T B V Zaia
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Marli C Martins-Pinge
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Daniela C C Gerardin
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
| | - Graziela S Ceravolo
- Department of Physiological Sciences, Biological Sciences Center, State University of Londrina, Londrina, Brazil
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Murray SR, Reynolds RM. Short- and long-term outcomes of gestational diabetes and its treatment on fetal development. Prenat Diagn 2020; 40:1085-1091. [PMID: 32946125 DOI: 10.1002/pd.5768] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 06/08/2020] [Accepted: 06/15/2020] [Indexed: 12/26/2022]
Abstract
Globally the prevalence of gestational diabetes mellitus (GDM) is rising mainly due to the increase in maternal obesity. A number of different methods to screen for and diagnose GDM have been described although consensus on the preferred methods does not yet exist. GDM has significant short- and long-term health risks for the mother, developing fetus and the children born to mothers with GDM. Short-term risks for the fetus include macrosomia (excessive birthweight), shoulder dystocia, birth trauma, and hypoglycaemia in the immediate postpartum period. Long-term risks for offspring born to mothers with GDM include increased rates of childhood and adulthood obesity and an increased cardiometabolic risk. A number of pharmacological treatments for GDM have been identified, these include insulin and oral glucose-lowering drugs metformin and glibenclamide. Whilst these oral glucose-lowering drugs show similar short-term childhood outcomes to insulin there is increasing evidence that these drugs may have adverse long-term outcomes on children and adults exposed to the drugs in utero. Future research on treatments for GDM should include long-term follow- up of children exposed to glucose lowering medication in utero to determine the long-term cardiometabolic risk in the offspring born to mothers with GDM.
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Affiliation(s)
- Sarah R Murray
- MRC Centre for Reproductive Health, University of Edinburgh Queen's Medical Research Institute, Edinburgh, Scotland
| | - Rebecca M Reynolds
- BHF/University Centre for Cardiovascular Science, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, Scotland
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Jorquera G, Echiburú B, Crisosto N, Sotomayor-Zárate R, Maliqueo M, Cruz G. Metformin during Pregnancy: Effects on Offspring Development and Metabolic Function. Front Pharmacol 2020; 11:653. [PMID: 32625081 PMCID: PMC7311748 DOI: 10.3389/fphar.2020.00653] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Accepted: 04/22/2020] [Indexed: 12/14/2022] Open
Abstract
Maternal obesity during pregnancy and gestational diabetes mellitus (GDM) are both associated with of several postnatal diseases in the offspring, including obesity, early onset hypertension, diabetes mellitus, and reproductive alterations. Metformin is an oral drug that is being evaluated to treat GDM, obesity-associated insulin resistance, and polycystic ovary syndrome (PCOS) during pregnancy. The beneficial effects of metformin on glycemia and pregnancy outcomes place it as a good alternative for its use during pregnancy. In this line of thought, improving the metabolic status of the pregnant mother by using metformin should avoid the consequences of insulin resistance on the offspring's fetal and postnatal development. However, some human and animal studies have shown that metformin during pregnancy could amplify these alterations and be associated with excessive postnatal weight gain and obesity. In this minireview, we discuss not only the clinical and experimental evidence that supports the benefits of using metformin during pregnancy but also the evidence showing a possible negative impact of this drug on the offspring's development.
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Affiliation(s)
- Gonzalo Jorquera
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valpararaíso, Chile
| | - Bárbara Echiburú
- Laboratory of Endocrinology and Metabolism, West Division, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Nicolás Crisosto
- Laboratory of Endocrinology and Metabolism, West Division, Faculty of Medicine, University of Chile, Santiago, Chile.,Unit of Endocrinology, Clínica Las Condes, Santiago, Chile
| | - Ramón Sotomayor-Zárate
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valpararaíso, Chile
| | - Manuel Maliqueo
- Laboratory of Endocrinology and Metabolism, West Division, Faculty of Medicine, University of Chile, Santiago, Chile
| | - Gonzalo Cruz
- Centro de Neurobiología y Fisiopatología Integrativa (CENFI), Instituto de Fisiología, Facultad de Ciencias, Universidad de Valparaíso, Valpararaíso, Chile
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do Nascimento IB, Sales WB, Dienstmann G, de Souza MLR, Fleig R, Silva JC. Metformin for prevention of cesarean delivery and large-for-gestational-age newborns in non-diabetic obese pregnant women: a randomized clinical trial. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2020; 64:290-297. [PMID: 32555996 PMCID: PMC10522222 DOI: 10.20945/2359-3997000000251] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 02/17/2020] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the use of metformin for preventing cesarean deliveries and large-for-gestational-age (LGA) newborn (NB) outcomes in non-diabetic obese pregnant women. SUBJECTS AND METHODS This is a randomized clinical trial with obese pregnant women, divided into 2 groups: metformin group and control group, with followed-up prenatal routine. The gestational age of participants was less than or equal to 20 weeks and were monitored throughout entire prenatal period. For outcomes of delivery and LGA newborns, absolute risk reduction (ARR) and the number needed to treat (NNT) were calculated with a 95% confidence interval (CI). RESULTS 357 pregnant women were evaluated. From the metformin group (n = 171), 68 (39.8%) subjects underwent cesarean delivery, and 117 (62.9%) subjects from the control group (n = 186) had intercurrence (p < 0.01). As for the mothers' general characteristics, there was significance for marital status (p < 0.01). Maternal-fetal results presented reduced preeclampsia (p < 0,01). Primary prophylactic results presented an ARR of 23.1 times (95% CI: 13.0-33.4) with NNT of 4 (95% CI: 3.0-7.7) and no significant values for LGA NB (p > 0.01). Secondary prophylactic outcomes presented decreased odds ratio for preeclampsia (OR = 0.17, 95% CI: 0.10-0.41). CONCLUSION The use of metformin reduced cesarean section rates, resulted in a small number of patients to be treated, but it did not reduce LGA NB. Administering a lower dosage of metformin from the early stages to the end of treatment may yield significant results with fewer side effects. Arch Endocrinol Metab. 2020;64(3):290-7.
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Affiliation(s)
- Iramar Baptistella do Nascimento
- Centro de Ciências da Saúde e do EsporteUniversidade do Estado de Santa CatarinaFlorianópolisSCBrasilCentro de Ciências da Saúde e do Esporte (Cefid), Universidade do Estado de Santa Catarina (Udesc), Florianópolis, SC, Brasil
| | - Willian Barbosa Sales
- Universidade da Região de JoinvilleJoinvilleSCBrasilUniversidade da Região de Joinville (Univille), Joinville, SC, Brasil
| | - Guilherme Dienstmann
- Universidade da Região de JoinvilleJoinvilleSCBrasilUniversidade da Região de Joinville (Univille), Joinville, SC, Brasil
| | - Matheus Leite Ramos de Souza
- Universidade da Região de JoinvilleJoinvilleSCBrasilUniversidade da Região de Joinville (Univille), Joinville, SC, Brasil
| | - Raquel Fleig
- Centro de Educação do Planalto NorteUniversidade do Estado de Santa CatarinaFlorianópolisSCBrasilCentro de Educação do Planalto Norte (Ceplan), Universidade do Estado de Santa Catarina (Udesc), Florianópolis, SC, Brasil
| | - Jean Carl Silva
- Maternidade Darcy VargasUniversidade da Região de JoinvilleJoinvilleSCBrasilMaternidade Darcy Vargas; Universidade da Região de Joinville (Univille), Joinville, SC, Brasil
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61
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Tarry-Adkins JL, Aiken CE, Ozanne SE. Comparative impact of pharmacological treatments for gestational diabetes on neonatal anthropometry independent of maternal glycaemic control: A systematic review and meta-analysis. PLoS Med 2020; 17:e1003126. [PMID: 32442232 PMCID: PMC7244100 DOI: 10.1371/journal.pmed.1003126] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 04/23/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Fetal growth in gestational diabetes mellitus (GDM) is directly linked to maternal glycaemic control; however, this relationship may be altered by oral anti-hyperglycaemic agents. Unlike insulin, such drugs cross the placenta and may thus have independent effects on fetal or placental tissues. We investigated the association between GDM treatment and fetal, neonatal, and childhood growth. METHODS AND FINDINGS PubMed, Ovid Embase, Medline, Web of Science, ClinicalTrials.gov, and Cochrane databases were systematically searched (inception to 12 February 2020). Outcomes of GDM-affected pregnancies randomised to treatment with metformin, glyburide, or insulin were included. Studies including preexisting diabetes or nondiabetic women were excluded. Two reviewers independently assessed eligibility and risk of bias, with conflicts resolved by a third reviewer. Maternal outcome measures were glycaemic control, weight gain, and treatment failure. Offspring anthropometric parameters included fetal, neonatal, and childhood weight and body composition data. Thirty-three studies (n = 4,944), from geographical locations including Europe, North Africa, the Middle East, Asia, Australia/New Zealand, and the United States/Latin America, met eligibility criteria. Twenty-two studies (n = 2,801) randomised women to metformin versus insulin, 8 studies (n = 1,722) to glyburide versus insulin, and 3 studies (n = 421) to metformin versus glyburide. Eleven studies (n = 2,204) reported maternal outcomes. No differences in fasting blood glucose (FBS), random blood glucose (RBS), or glycated haemoglobin (HbA1c) were reported. No studies reported fetal growth parameters. Thirty-three studies (n = 4,733) reported birth weight. Glyburide-exposed neonates were heavier at birth (58.20 g, 95% confidence interval [CI] 10.10-106.31, p = 0.02) with increased risk of macrosomia (odds ratio [OR] 1.38, 95% CI 1.01-1.89, p = 0.04) versus neonates of insulin-treated mothers. Metformin-exposed neonates were born lighter (-73.92 g, 95% CI -114.79 to -33.06 g, p < 0.001) with reduced risk of macrosomia (OR 0.60, 95% CI 0.45-0.79, p < 0.001) than insulin-exposed neonates. Metformin-exposed neonates were born lighter (-191.73 g, 95% CI -288.01 to -94.74, p < 0.001) with a nonsignificant reduction in macrosomia risk (OR 0.32, 95% CI 0.08-1.19, I2 = 0%, p = 0.09) versus glyburide-exposed neonates. Glyburide-exposed neonates had a nonsignificant increase in total fat mass (103.2 g, 95% CI -3.91 to 210.31, p = 0.06) and increased abdominal (0.90 cm, 95% CI 0.03-1.77, p = 0.04) and chest circumferences (0.80 cm, 95% CI 0.07-1.53, p = 0.03) versus insulin-exposed neonates. Metformin-exposed neonates had decreased ponderal index (-0.13 kg/m3, 95% CI -0.26 to -0.00, p = 0.04) and reduced head (-0.21, 95% CI -0.39 to -0.03, p = 0.03) and chest circumferences (-0.34 cm, 95% CI -0.62 to -0.05, p = 0.02) versus the insulin-treated group. Metformin-exposed neonates had decreased ponderal index (-0.09 kg/m3, 95% CI -0.17 to -0.01, p = 0.03) versus glyburide-exposed neonates. Study limitations include heterogeneity in dosing, heterogeneity in GDM diagnostic criteria, and few studies reporting longitudinal growth outcomes. CONCLUSIONS Maternal randomisation to glyburide resulted in heavier neonates with a propensity to increased adiposity versus insulin- or metformin-exposed groups. Metformin-exposed neonates were lighter with reduced lean mass versus insulin- or glyburide-exposed groups, independent of maternal glycaemic control. Oral anti-hyperglycaemics cross the placenta, so effects on fetal anthropometry could result from direct actions on the fetus and/or placenta. We highlight a need for further studies examining the effects of intrauterine exposure to antidiabetic agents on longitudinal growth, and the importance of monitoring fetal growth and maternal glycaemic control when treating GDM. This review protocol was registered with PROSPERO (CRD42019134664/CRD42018117503).
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Affiliation(s)
- Jane L. Tarry-Adkins
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Obstetrics and Gynaecology, the Rosie Hospital and NIHR Cambridge Comprehensive Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Catherine E. Aiken
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Obstetrics and Gynaecology, the Rosie Hospital and NIHR Cambridge Comprehensive Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Susan E. Ozanne
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
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Relationship between BMI and adiposity among different ethnic groups in 2-year-old New Zealand children. Br J Nutr 2020; 121:670-677. [PMID: 30912736 DOI: 10.1017/s000711451800380x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Age- and sex-based BMI cut-offs are used to define overweight and obesity, but the relationship between BMI and body composition has not been very well studied in children or compared between children of different ethnic groups. Body size and composition in childhood are also influenced by size at birth. Our aim was to compare body size and composition at 2 years in children with different ethnicity and size at birth. We prospectively followed a multi-ethnic cohort of 300 children born with risk factors for neonatal hypoglycaemia (infants of diabetics, large or small at birth or late preterm) to 2 years corrected age. Complete data on weight, height and head circumference and body composition using bioelectrical impedance 24±1 months corrected age were available in 209 children. At birth, compared with European children, Chinese, Indian and other ethnicity children were lighter, and Indian children had smaller head circumferences, but birth lengths were similar in all ethnic groups. At 2 years, Pacific children were heavier and had higher BMI z scores, and Indian children had smaller head circumferences and lower BMI z scores than those from other ethnic groups. However, fat mass and fat-free mass indices were similar in all groups. At median BMI, fat mass:fat-free mass ratio was 23 % lower in Pacific than in Indian children (0·22 v. 0·27, P=0·03). BMI is not a good indicator of adiposity in this multi-ethnic cohort of 2-year-old New Zealand children.
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Abstract
PURPOSE OF REVIEW To review the rationale and biological plausibility and discuss the current research on novel interventions for the prevention of preeclampsia. RECENT FINDINGS Preeclampsia affects up to 8% of pregnancies worldwide and remains a major cause of maternal and neonatal morbidity and mortality. Multiple medications have been investigated or repurposed as potential effective interventions for preeclampsia prevention. Aspirin is currently the only drug for which there is some evidence of benefit for preeclampsia prevention, and its use is recommended by professional societies for pregnancies at risk. Statins have shown promise for prevention of preeclampsia in animal models and human pilot studies, without any trend or concerns for safety signals or teratogenicity. The use of metformin has also gained popularity in experimental studies, but observations from randomized clinical trials were not consistent on its utility as a possible intervention for preeclampsia prevention. While initial studies evaluating esomeprazole were promising, randomized trials failed to show benefit. Contemporary research shows exciting new opportunities for prophylactic treatment for preeclampsia, to prevent this debilitating and life-threatening disease.
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Affiliation(s)
- Marwan Ma'ayeh
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, 395 W 12th Avenue, Columbus, OH, 43210, USA. Marwan.Ma'
| | - Kara M Rood
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, 395 W 12th Avenue, Columbus, OH, 43210, USA
| | - Douglas Kniss
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, 395 W 12th Avenue, Columbus, OH, 43210, USA
| | - Maged M Costantine
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, The Ohio State University College of Medicine, 395 W 12th Avenue, Columbus, OH, 43210, USA
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Pancer J, Wu N, Mahmoud I, Dasgupta K. Pharmacological intervention for diabetes after pregnancy prevention in women with prior gestational diabetes: A scoping review. Diabetes Res Clin Pract 2020; 160:107998. [PMID: 31911249 DOI: 10.1016/j.diabres.2020.107998] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 12/31/2019] [Indexed: 11/18/2022]
Abstract
Women with previous gestational diabetes mellitus (GDM) are at increased risk of developing diabetes after pregnancy (DAP), especially 5-10 years postpartum. Two well-known diabetes prevention trials demonstrated a significant reduction in DAP incidence using metformin and troglitazone; however, since their publication, several novel classes of anti-hyperglycemic agents have emerged. This review aimed to conduct a systematic literature search for new evidence in support of pharmacotherapy in DAP prevention and to analyze the results based on special considerations for women of reproductive potential. The only studies whose primary outcome was DAP incidence were those examining metformin, the thiazolidinediones troglitazone and pioglitazone, and the dipeptidyl peptidase-4 inhibitor vildagliptin. Metformin was effective in DAP reduction and was well tolerated, but participants were on average 12 years beyond their GDM pregnancy. Troglitazone was also shown to prevent DAP, but was withdrawn from the market due to hepatotoxicity. There was no comparator arm in the pioglitazone study, which limits its interpretability. The vildagliptin study was underpowered. There are ongoing trials with glucagon-like peptide 1 receptor agonists and sodium-glucose cotransporter 2 inhibitors, but none with diabetes incidence as a primary outcome. This review highlights the limited evidence base for pharmacological prevention of DAP.
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Affiliation(s)
- Jill Pancer
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montréal, Québec, Canada; Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Nancy Wu
- Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montréal, Québec, Canada; Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada
| | - Ibtisam Mahmoud
- Medical Library, McGill University Health Centre, Montréal, Québec, Canada
| | - Kaberi Dasgupta
- Divisions of Internal Medicine, Endocrinology & Metabolism, and Epidemiology, Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada; Centre for Outcomes Research and Evaluation (CORE), Research Institute of the McGill University Health Centre, Montréal, Québec, Canada; Department of Medicine, McGill University Health Centre, Montréal, Québec, Canada.
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Helal KF, Badr MS, Rafeek MES, Elnagar WM, Lashin MEB. Can glyburide be advocated over subcutaneous insulin for perinatal outcomes of women with gestational diabetes? A systematic review and meta-analysis. Arch Gynecol Obstet 2020; 301:19-32. [DOI: 10.1007/s00404-019-05430-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 08/08/2019] [Indexed: 02/08/2023]
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Maternal gestational diabetes and infant feeding, nutrition and growth: a systematic review and meta-analysis. Br J Nutr 2020; 123:1201-1215. [PMID: 31964432 DOI: 10.1017/s0007114520000264] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Gestational diabetes mellitus (GDM) is a major health problem, with increased risks of obesity and diabetes in offspring. However, little is known about the effect of GDM on infant feeding, nutrition and growth, and whether these factors play a role in mediating these risks. We systematically reviewed evidence for the effect of GDM on infant feeding, nutrition and growth. We searched MEDLINE, Web-of-Science, Embase, CINAHL and CENTRAL for studies that reported outcomes in infants <2 years who were and were not exposed to GDM. Studies of pre-gestational diabetes were excluded. Meta-analysis was performed for three epochs (1–6, 7–12, 13–24 months), using inverse-variance, fixed-effects methods. Primary outcomes were energy intake (kJ) and BMI (kg/m2). Twenty-five studies and 308 455 infants were included. Infants exposed to GDM, compared with those not exposed, had similar BMI at age 1–6 months (standardised mean difference (SMD) = 0·01, 95 % CI −0·04, 0·06; P = 0·69) and 7–12 months (SMD = 0·04, 95 % CI −0·01, 0·10; P = 0·09), reduced length at 1–6 and 7–12 months, increased whole-body fat at 1–6 months, higher rates of formula supplementation in hospital, shorter duration of breast-feeding and decreased rates of continued breast-feeding at 12 months. Breast milk of women with GDM had lower protein content. There was no association between GDM and infant weight and skinfold thickness. No data were available for nutritional intake and outcomes at 13–24 months. Low- or very low-quality evidence suggests GDM is not associated with altered BMI in infancy, but is associated with increased fat mass, high rates of formula use and decreased duration of breast-feeding.
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Gökçay Canpolat A, Şahin M. Glucose Lowering Treatment Modalities of Type 2 Diabetes Mellitus. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1307:7-27. [PMID: 32200500 DOI: 10.1007/5584_2020_516] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
This chapter gives an overview of present knowledge and clinical aspects of antidiabetic drugs according to the recently available research evidence and clinical expertise.Many agents are acting on eight groups of pathophysiological mechanisms, which is commonly called as "Ominous Octet" by DeFronzo. The muscle, liver and β-cell, the fat cell, gastrointestinal tract, α-cell, kidney, and brain play essential roles in the development of glucose intolerance in type 2 diabetic individuals (Defronzo, Diabetes 58:773-795, 2009).A treatment paradigm shift is seen in the initiation of anti-hyperglycemic agents from old friends (meglitinides or sulphonylürea) to newer agents effecting on GLP-1 RA or SGLT-2 inhibitors. It is mostly about the other protective positive effects of these agents for kidney, heart, etc. Although there are concerns for the long term safety profiles; they are used widely around the World. The delivery of patient-centered care, facilitating medication adherence, the importance of weight loss in obese patients, the importance of co-morbid conditions are the mainstays of selecting the optimal agent.
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Affiliation(s)
- Asena Gökçay Canpolat
- Department of Endocrinology and Metabolism, Ankara University School of Medicine, Ankara, Turkey
| | - Mustafa Şahin
- Department of Endocrinology and Metabolism, Ankara University School of Medicine, Ankara, Turkey.
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68
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Insulin Resistance in Pregnancy: Implications for Mother and Offspring. CONTEMPORARY ENDOCRINOLOGY 2020. [DOI: 10.1007/978-3-030-25057-7_5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Abstract
Importance Diabetes affects 6% to 9% of pregnancies, with gestational diabetes mellitus accounting for more than 90% of cases. Pregestational and gestational diabetes are associated with significant maternal and fetal risks; therefore, screening and treatment during pregnancy are recommended. Recommendations regarding the preferred treatment of diabetes in pregnancy have recently changed, with slight differences between American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) recommendations. Objective Our review discusses the diagnosis, management, and treatment of pregestational and gestational diabetes with the oral hypoglycemic agents metformin and glyburide as well as insulin. We also review the evidence for the safety and efficacy of these medications in pregnancy. Evidence Acquisition Articles were obtained from PubMed, the ACOG Practice Bulletin on Gestational Diabetes Mellitus, and the SMFM statement on the pharmacological treatment of gestational diabetes. Results Insulin does not cross the placenta and has an established safety profile in pregnancy and is therefore considered a first-line treatment for gestational diabetes. Metformin and glyburide have also been shown to be relatively safe in pregnancy but with more limited long-term data. Regarding maternal and fetal outcomes, metformin is superior to glyburide and similar to insulin. Conclusions and Relevance Insulin is the preferred pharmacologic treatment according to ACOG. However, SMFM has stated that outcomes with metformin are similar, and it may also be considered as first-line therapy. Both agree that the available data show that metformin is safer and superior to glyburide, and glyburide is no longer recommended as a first-line therapy for the treatment of gestational diabetes.
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Kumar R, Lowe J, Thompson-Hutchison F, Steinberg D, Shah B, Lipscombe L, Halperin I. Implementation and Evaluation of the “Metformin First” Protocol for Management of Gestational Diabetes. Can J Diabetes 2019; 43:554-559. [DOI: 10.1016/j.jcjd.2019.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/21/2019] [Accepted: 06/20/2019] [Indexed: 11/25/2022]
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Banaszewska B, Pawelczyk L, Spaczynski R. Current and future aspects of several adjunctive treatment strategies in polycystic ovary syndrome. Reprod Biol 2019; 19:309-315. [DOI: 10.1016/j.repbio.2019.09.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 09/20/2019] [Accepted: 09/21/2019] [Indexed: 12/12/2022]
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Prentice PM, Olga L, Petry CJ, Simmons D, Murphy HR, Hughes IA, Acerini CL, Ong KK, Dunger DB. Reduced size at birth and persisting reductions in adiposity in recent, compared with earlier, cohorts of infants born to mothers with gestational diabetes mellitus. Diabetologia 2019; 62:1977-1987. [PMID: 31396660 PMCID: PMC6805804 DOI: 10.1007/s00125-019-4970-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 06/27/2019] [Indexed: 02/06/2023]
Abstract
AIMS/HYPOTHESIS This study aimed to explore the infancy growth trajectories of 'recent' and 'earlier' offspring of mothers with gestational diabetes mellitus (OGDM), each compared with the same control infants, and investigate whether 'recent' OGDM still exhibit a classical phenotype, with macrosomia and increased adiposity. METHODS Within a prospective observational birth cohort, 98 'earlier' OGDM born between 2001 and 2009 were identified using 75 g oral glucose tolerance testing at 28 weeks gestation, 122 recent OGDM born between 2011 and 2013 were recruited postnatally through antenatal diabetes clinics, and 876 normal birthweight infants of mothers with no history of diabetes were recruited across the full study period as the control group. All infants followed the same study protocol (measurements at birth, 3, 12 and 24 months, including weight, length and skinfold thickness indicating adiposity, and detailed demographic data). In all cases, GDM was defined using the International Association of Diabetes and Pregnancy Study Group criteria. RESULTS Earlier OGDM had higher birthweight SD scores (SDS) than control infants. Conversely, recent OGDM had similar birthweight- and length SDS to control infants (mean ± SD, 0.1 ± 1.0 and- 0.1 ± 0.9, respectively), but lower mean skinfold thickness SDS (-0.4 ± 0.6 vs 0.0 ± 0.9; p < 0.001). After birth, earlier OGDM showed reduced gains in weight and length between 3 and 12 months. In contrast, recent OGDM had increased weight and skinfold thickness gains until 3 months, followed by reduced gains in those variables from 3 to 12 months, compared with control infants. At 24 months, recent OGDM had lower adiposity than control infants (mean skinfold thickness SDS -0.3 ± 0.7 vs 0.0 ± 0.8; p < 0.001). At all time points recent OGDM had lower growth measurements than earlier OGDM. CONCLUSIONS/INTERPRETATION Recent OGDM showed different growth trajectories to the earlier group, namely normalisation of birthweight and reduced adiposity at birth, followed by initial rapid weight gain but subsequent reduced adiposity postnatally. While avoidance of macrosomia at birth may be advantageous, the longer-term health implications of these changing growth trajectories are uncertain.
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Affiliation(s)
- Philippa M Prentice
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- Department of Paediatrics, North Middlesex University Hospital NHS Trust, London, UK
| | - Laurentya Olga
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Clive J Petry
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - David Simmons
- Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Macarthur Clinical School, Western Sydney University, Sydney, NSW, Australia
| | - Helen R Murphy
- Wolfson Diabetes and Endocrine Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Diabetes and Endocrinology, Norfolk and Norwich University Hospital, Norwich, UK
- Women's Health Academic Centre, Division of Women's and Children's Health, King's College London, London, UK
| | - Ieuan A Hughes
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Carlo L Acerini
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
| | - Ken K Ong
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK
- MRC Epidemiology Unit, Institute of Metabolic Science, Cambridge, UK
- Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - David B Dunger
- Department of Paediatrics, University of Cambridge, Box 116, Level 8, Cambridge Biomedical Campus, Cambridge, CB2 0QQ, UK.
- Institute of Metabolic Science, University of Cambridge, Cambridge, UK.
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Bao LX, Shi WT, Han YX. Metformin versus insulin for gestational diabetes: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2019; 34:2741-2753. [PMID: 31558075 DOI: 10.1080/14767058.2019.1670804] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Metformin is increasingly used in clinical practice for the treatment of gestational diabetes mellitus. However, its safety and long-term effects on fetuses exposed to metformin in uterus remain controversial. METHODS We systematically searched PubMed, Embase, and the Cochrane database (last search was updated on 1 May 2019) for randomized controlled trials comparing metformin with insulin. Two reviewers extracted the data and calculated pooled estimates by use of a random-effects model. RESULTS Twenty-four studies were included. Among these, seventeen RCTs (N = 2828 participants) were included for quantitative analyses and seven studies were included only for qualitative synthesis. Metformin lowered the risk of pregnancy-induced hypertension (p = .03; risk ratio (RR) = 0.64; confidence interval (95%CI) [0.44, 0.95]), large for gestational age babies (p = .04; RR = 0.82; 95% CI [0.68, 0.99]), macrosomia (p = .01; RR = 0.63; 95%CI [0.45, 0.90]), neonatal hypoglycemia (p = .001; RR = 0.72; 95%CI [0.59, 0.88]), and neonatal intensive care unit admission (p = .01; RR = 0.74; 95%CI [0.58, 0.94]). Metformin did not increase premature delivery (p = .11; RR = 1.28; 95%CI [0.95, 1.73]), preeclampsia (p = .45; RR = 0.89; 95%CI [0.65, 1.21]), caesarean delivery (p = .20; RR = 0.94; 95%CI [0.85, 1.04]), small for gestational age babies (p = .95; RR = 0.99; 95%CI [0.69, 1.42]). The long-term results seemed to have no adverse effect, but the information was still limited. CONCLUSIONS According to our review, metformin may have potential benefits for pregnant women and newborns with no obvious adverse effects. However, even more studies are needed to provide evidence for the future use of metformin.
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Affiliation(s)
- Le-Xin Bao
- Affiliated Hospital of Qingdao, University, Qingdao University, Qingdao, People's Republic of China
| | - Wan-Ting Shi
- Affiliated Hospital of Qingdao, University, Qingdao University, Qingdao, People's Republic of China
| | - Yu-Xin Han
- Affiliated Hospital of Qingdao, University, Qingdao University, Qingdao, People's Republic of China
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Wexler DJ, Powe CE, Barbour LA, Buchanan T, Coustan DR, Corcoy R, Damm P, Dunne F, Feig DS, Ferrara A, Harper LM, Landon MB, Meltzer SJ, Metzger BE, Roeder H, Rowan JA, Sacks DA, Simmons D, Umans JG, Catalano PM. Research Gaps in Gestational Diabetes Mellitus: Executive Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop. Obstet Gynecol 2019; 132:496-505. [PMID: 29995731 DOI: 10.1097/aog.0000000000002726] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The National Institute of Diabetes and Digestive and Kidney Diseases convened a workshop on research gaps in gestational diabetes mellitus (GDM) with a focus on 1) early pregnancy diagnosis and treatment and 2) pharmacologic treatment strategies. This article summarizes the proceedings of the workshop. In early pregnancy, the appropriate diagnostic criteria for the diagnosis of GDM remain poorly defined, and an effect of early diagnosis and treatment on the risk of adverse outcomes has not been demonstrated. Despite many small randomized controlled trials of glucose-lowering medication treatment in GDM, our understanding of medication management of GDM is incomplete as evidenced by discrepancies among professional society treatment guidelines. The comparative effectiveness of insulin, metformin, and glyburide remains uncertain, particularly with respect to long-term outcomes. Additional topics in need of further research identified by workshop participants included phenotypic heterogeneity in GDM and novel and individualized treatment approaches. Further research on these topics is likely to improve our understanding of the pathophysiology and treatment of GDM to improve both short- and long-term outcomes for mothers and their children.
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Affiliation(s)
- Deborah J Wexler
- Diabetes Unit, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; the Divisions of Endocrinology, Metabolism, and Diabetes and Maternal-Fetal Medicine, University of Colorado School of Medicine and Anschutz Medical Campus, Aurora, Colorado; the Division of Endocrinology and Diabetes, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California; Women & Infants Hospital of Rhode Island and Warren Alpert Medical School of Brown University, Providence, Rhode Island; the Diabetes Unit, Hospital de la Santa Creu I Sant Pau, Universitat Autonoma de Barcelona, Bellaterra, Barcelona, CIBER-BBN, Spain; the Center for Pregnant Women with Diabetes, Department of Obstetrics, Rigshospitalet, Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark; College Medicine Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland; the Diabetes & Endocrine in Pregnancy Program, Mount Sinai Hospital and University of Toronto, Toronto, Canada; the Division of Research, Kaiser Permanente Northern California, Oakland, California; the Department of Maternal-Fetal Medicine, Center for Women's Reproductive Health, University of Alabama at Birmingham, Birmingham, Alabama; the Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio; the Departments of Medicine and Obstetrics and Gynecology, McGill University Health Centre, Montreal, Quebec, Canada; Northwestern University Feinberg School of Medicine, Chicago, Illinois; Kaiser Permanente Southern California, San Diego, California; National Women's Health, Auckland, New Zealand; the Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California; Campbelltown Hospital and Western Sydney University, Sydney, Australia; MedStar Health Research Institute, Hyattsville, Maryland; Georgetown-Howard Universities Center for Clinical and Translational Science, Washington, DC; and the Center for Reproductive Health, Case Western Reserve University at MetroHealth Medical Center, Cleveland, Ohio
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Abstract
Gestational diabetes mellitus (GDM) is defined as a glucose tolerance disorder with onset during pregnancy and is associated with increased feto-maternal morbidity as well as long-term complications in mother and child. Women who fulfil the criteria of a manifest diabetes in early pregnancy (fasting plasma glucose >126 mg/dl, spontaneous glucose level >200 mg/dl or HbA1c > 6.5% before 20 weeks of gestation) should be classified as having manifest diabetes in pregnancy and treated as such. Screening for undiagnosed type 2 diabetes at the first prenatal visit (evidence level B) is particularly recommended in women at increased risk (history of GDM or prediabetes, malformation, stillbirth, successive abortions or birth weight >4500 g in previous pregnancies, obesity, metabolic syndrome, age >35 years, vascular disease, clinical symptoms of diabetes, e. g. glucosuria, or ethnic groups with increased risk for GDM/T2DM, e.g. Arabian countries, south and southeast Asia and Latin America). A GDM is diagnosed by an oral glucose tolerance test (OGTT) or a fasting glucose concentration ≥92 mg/dl. 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 24-28 gestational weeks in all pregnant women with previous non-pathological glucose metabolism (evidence level B). Based on the results of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study and following the recent WHO recommendations, GDM is present if the fasting plasma glucose level exceeds 92 mg/dl, the 1 h level exceeds 180 mg/dl or the 2 h level exceeds 153 mg/dl after glucose loading (OGTT international consensus criteria). A single increased value is sufficient for the diagnosis and a strict metabolic control is mandatory. After bariatric surgery an OGTT is not recommended due to the risk of postprandial hypoglycemia. All women with GDM should receive nutritional counselling, be instructed in self-monitoring of blood glucose and to increase physical activity to moderate intensity levels, if not contraindicated. If blood glucose levels cannot be maintained in the therapeutic range (fasting <95 mg/dl and 1 h postprandial <140 mg/dl) insulin therapy should be initiated as first choice. Maternal and fetal monitoring is required in order to minimize maternal and fetal/neonatal morbidity and perinatal mortality. After delivery all women with GDM have to be re-evaluated by a 75 g OGTT (WHO criteria) 4-12 weeks postpartum to reclassify the glucose tolerance and every 2 years in cases of normal glucose tolerance (evidence level B). All women have to be informed about their (sevenfold increased relative) risk of developing type 2 diabetes (T2DM) at follow-up and possible preventive measures, in particular weight management, healthy diet and maintenance/increase of physical activity. Monitoring of the development of children and recommendations for a healthy lifestyle are necessary for the whole family. Regular obstetric examinations including ultrasound examinations are recommended. Within the framework of neonatal care, neonates of GDM mothers should undergo blood glucose measurements and if necessary appropriate measures should be initiated.
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76
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Hu J, Zhang J, Zhu B. Protective effect of metformin on a rat model of lipopolysaccharide-induced preeclampsia. Fundam Clin Pharmacol 2019; 33:649-658. [PMID: 31334867 DOI: 10.1111/fcp.12501] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 07/05/2019] [Accepted: 07/18/2019] [Indexed: 12/23/2022]
Abstract
Recent in vitro and clinical studies have found that metformin (MET) may play a preventive or therapeutic role in preeclampsia (PE) and may be a candidate drug for the prevention and/or treatment of PE. In this study, we used lipopolysaccharide (LPS) to induce a PE-like rat model and investigated the intervention effect of MET from the perspectives of clinical manifestations, placental morphology, serum marker for placental injury, systemic inflammatory response and oxidative/nitrative stress, and placental nuclear factor-κB (NF-κB) signaling. The results showed that MET improved LPS-induced hypertension, proteinuria, fetal growth restriction (FGR) and stillbirth, alleviated placental injury and decreased maternal serum marker alpha-fetoprotein (MS-AFP) level; MET suppressed LPS-induced TNF-α and IL-6 productions, reduced oxidative/nitrative stress as evidenced by increased superoxide dismutase (SOD) activity, decreased inducible nitric oxide synthase (iNOS) activity, and decreased levels of malondialdehyde (MDA) and nitric oxide (NO); MET inhibited LPS-induced NF-κB activation in placentas. Based on these findings, it can be concluded that MET is beneficial to the PE-like rat model by protecting placentas from injury, suppressing systemic inflammatory response and oxidative/nitrative stress, and inhibiting placental NF-κB signaling pathway. MET is a promising drug for prevention and/or treatment of PE.
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Affiliation(s)
- Jilin Hu
- Faculty of Environmental Science and Engineering, Kunming University of Science and Technology, Kunming, 650500, China.,Medical School, Kunming University of Science and Technology, Kunming, 650500, China
| | - Jinman Zhang
- Medical School, Kunming University of Science and Technology, Kunming, 650500, China.,National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming, 650032, China
| | - Baosheng Zhu
- Medical School, Kunming University of Science and Technology, Kunming, 650500, China.,National Health Commission's Key Laboratory for Healthy Births in Western China, Department of Obstetrics and Gynecology, First People's Hospital of Yunnan Province, Kunming, 650032, China
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77
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Tarry-Adkins JL, Aiken CE, Ozanne SE. Neonatal, infant, and childhood growth following metformin versus insulin treatment for gestational diabetes: A systematic review and meta-analysis. PLoS Med 2019; 16:e1002848. [PMID: 31386659 PMCID: PMC6684046 DOI: 10.1371/journal.pmed.1002848] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 06/04/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Metformin is increasingly offered as an acceptable and economic alternative to insulin for treatment of gestational diabetes mellitus (GDM) in many countries. However, the impact of maternal metformin treatment on the trajectory of fetal, infant, and childhood growth is unknown. METHODS AND FINDINGS PubMed, Ovid Embase, Medline, Web of Science, ClinicalTrials.gov, and the Cochrane database were systematically searched (from database inception to 26 February 2019). Outcomes of GDM-affected pregnancies randomised to treatment with metformin versus insulin were included (randomised controlled trials and prospective randomised controlled studies) from cohorts including European, American, Asian, Australian, and African women. Studies including pregnant women with pre-existing diabetes or non-diabetic women were excluded, as were trials comparing metformin treatment with oral glucose-lowering agents other than insulin. Two reviewers independently assessed articles for eligibility and risk of bias, and conflicts were resolved by a third reviewer. Outcome measures were parameters of fetal, infant, and childhood growth, including weight, height, BMI, and body composition. In total, 28 studies (n = 3,976 participants) met eligibility criteria and were included in the meta-analysis. No studies reported fetal growth parameters; 19 studies (n = 3,723 neonates) reported measures of neonatal growth. Neonates born to metformin-treated mothers had lower birth weights (mean difference -107.7 g, 95% CI -182.3 to -32.7, I2 = 83%, p = 0.005) and lower ponderal indices (mean difference -0.13 kg/m3, 95% CI -0.26 to 0.00, I2 = 0%, p = 0.04) than neonates of insulin-treated mothers. The odds of macrosomia (odds ratio [OR] 0.59, 95% CI 0.46 to 0.77, p < 0.001) and large for gestational age (OR 0.78, 95% CI 0.62 to 0.99, p = 0.04) were lower following maternal treatment with metformin compared to insulin. There was no difference in neonatal height or incidence of small for gestational age between groups. Two studies (n = 411 infants) reported measures of infant growth (18-24 months of age). In contrast to the neonatal phase, metformin-exposed infants were significantly heavier than those in the insulin-exposed group (mean difference 440 g, 95% CI 50 to 830, I2 = 4%, p = 0.03). Three studies (n = 520 children) reported mid-childhood growth parameters (5-9 years). In mid-childhood, BMI was significantly higher (mean difference 0.78 kg/m2, 95% CI 0.23 to 1.33, I2 = 7%, p = 0.005) following metformin exposure than following insulin exposure, although the difference in absolute weights between the groups was not significantly different (p = 0.09). Limited evidence (1 study with data treated as 2 cohorts) suggested that adiposity indices (abdominal [p = 0.02] and visceral [p = 0.03] fat volumes) may be higher in children born to metformin-treated compared to insulin-treated mothers. Study limitations include heterogeneity in metformin dosing, heterogeneity in diagnostic criteria for GDM, and the scarcity of reporting of childhood outcomes. CONCLUSIONS Following intrauterine exposure to metformin for treatment of maternal GDM, neonates are significantly smaller than neonates whose mothers were treated with insulin during pregnancy. Despite lower average birth weight, metformin-exposed children appear to experience accelerated postnatal growth, resulting in heavier infants and higher BMI by mid-childhood compared to children whose mothers were treated with insulin. Such patterns of low birth weight and postnatal catch-up growth have been reported to be associated with adverse long-term cardio-metabolic outcomes. This suggests a need for further studies examining longitudinal perinatal and childhood outcomes following intrauterine metformin exposure. This review protocol was registered with PROSPERO under registration number CRD42018117503.
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Affiliation(s)
- Jane L. Tarry-Adkins
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust–MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Catherine E. Aiken
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust–MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Obstetrics and Gynaecology, Rosie Hospital and NIHR Cambridge Comprehensive Biomedical Research Centre, University of Cambridge, Cambridge, United Kingdom
| | - Susan E. Ozanne
- Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust–MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
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78
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Obesity and abnormal glucose tolerance in the offspring of mothers with diabetes. Curr Opin Obstet Gynecol 2019; 30:361-368. [PMID: 30102607 DOI: 10.1097/gco.0000000000000479] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Type 2 diabetes and obesity during childhood, puberty, and adulthood have become more common. This trend presents a global problem in terms of public health and health economics. Associations between intrauterine exposure to hyperglycemia, obesity, and abnormal glucose tolerance (AGT) in offspring have been reported in populations at high risk of diabetes such as Pima Indians, but these associations have not been established in other groups. In this review, we summarize the evidence on obesity and AGT in the offspring of mothers with diabetes. RECENT FINDINGS Although there are many reports indicating that the incidence of obesity or overweight is higher in the offspring of mothers with gestational diabetes, there is no consensus on whether maternal prepregnancy obesity has a larger impact than intrauterine exposure to hyperglycemia. While the risk of AGT or type 2 diabetes in the offspring of mothers with gestational diabetes is thought to increase after puberty, the incidence of AGT is elevated by the age of 7 years in the offspring of mothers with untreated gestational diabetes. Maternal gestational diabetes is a risk factor for AGT or type 2 diabetes independent of maternal prepregnancy BMI. When the offspring of women who had gestational diabetes and received therapeutic intervention in two randomized controlled studies were followed, the prevalence of obesity and impaired fasting glucose was lower in some 7-year-old girls, but the effect of maternal intervention was limited. The risk of obesity or overweight is higher in the offspring of mothers with type 1 diabetes, even after adjustment for maternal prepregnancy BMI. The risk of type 2 diabetes in such offspring is also higher. Although the offspring of mothers with type 2 diabetes are likely to be at high risk for type 2 diabetes, there are only limited reports supporting this hypothesis. SUMMARY Intrauterine exposure to hyperglycemia is associated with obesity and AGT among offspring. The present review suggests that these associations might depend on the type of maternal diabetes, that is, the timing and degree of exposure to hyperglycemia. There are only a small number of studies on the effect of therapeutic interventions for maternal diabetes on metabolism in the offspring.
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79
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McIntyre HD, Catalano P, Zhang C, Desoye G, Mathiesen ER, Damm P. Gestational diabetes mellitus. Nat Rev Dis Primers 2019; 5:47. [PMID: 31296866 DOI: 10.1038/s41572-019-0098-8] [Citation(s) in RCA: 726] [Impact Index Per Article: 145.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/29/2019] [Indexed: 12/11/2022]
Abstract
Hyperglycaemia that develops during pregnancy and resolves after birth has been recognized for over 50 years, but uniform worldwide consensus is lacking about threshold hyperglycaemic levels that merit a diagnosis of 'gestational diabetes mellitus' (GDM) and thus treatment during pregnancy. GDM is currently the most common medical complication of pregnancy, and prevalence of undiagnosed hyperglycaemia and even overt diabetes in young women is increasing. Maternal overweight and obesity, later age at childbearing, previous history of GDM, family history of type 2 diabetes mellitus and ethnicity are major GDM risk factors. Diagnosis is usually performed using an oral glucose tolerance test (OGTT), although a non-fasting, glucose challenge test (GCT) is used in some parts of the world to screen women for those requiring a full OGTT. Dietary modification and increased physical activity are the primary treatments for GDM, but pharmacotherapy, usually insulin, is used when normoglycaemia is not achieved. Oral hypoglycaemic agents, principally metformin and glibenclamide (glyburide), are also used in some countries. Treatment improves immediate pregnancy outcomes, reducing excess fetal growth and adiposity and pregnancy-related hypertensive disorders. GDM increases the risk of long-term complications, including obesity, impaired glucose metabolism and cardiovascular disease, in both the mother and infant. Optimal management of mother and infant during long-term follow-up remains challenging, with very limited implementation of preventive strategies in most parts of the world.
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Affiliation(s)
- H David McIntyre
- Mater Research and University of Queensland, Brisbane, Queensland, Australia.
| | - Patrick Catalano
- Mother Infant Research Institute, Department of Obstetrics and Gynecology, Tufts University School of Medicine, Friedman School of Nutrition Science and Policy, Boston, MA, USA
| | - Cuilin Zhang
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD, USA
| | - Gernot Desoye
- Department of Obstetrics and Gynecology, Medical University of Graz, Graz, Austria
| | - Elisabeth R Mathiesen
- Department of Endocrinology, Center for Pregnant Women with Diabetes, Rigshospitalet and The Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Peter Damm
- Department of Obstetrics, Center for Pregnant Women with Diabetes, Rigshospitalet and The Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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80
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Ringholm L, Damm P, Mathiesen ER. Improving pregnancy outcomes in women with diabetes mellitus: modern management. Nat Rev Endocrinol 2019; 15:406-416. [PMID: 30948803 DOI: 10.1038/s41574-019-0197-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Women with pre-existing (type 1 or type 2) diabetes mellitus are at increased risk of pregnancy complications, such as congenital malformations, preeclampsia and preterm delivery, compared with women who do not have diabetes mellitus. Approximately half of pregnancies in women with pre-existing diabetes mellitus are complicated by fetal overgrowth, which results in infants who are overweight at birth and at risk of birth trauma and, later in life, the metabolic syndrome, cardiovascular disease and type 2 diabetes mellitus. Strict glycaemic control with appropriate diet, use of insulin and, if necessary, antihypertensive treatment is the cornerstone of diabetes mellitus management to prevent pregnancy complications. New technology for managing diabetes mellitus is evolving and is changing the management of these conditions in pregnancy. For instance, in Europe, most women with pre-existing diabetes mellitus are treated with insulin analogues before and during pregnancy. Furthermore, many women are on insulin pumps during pregnancy, and the use of continuous glucose monitoring is becoming more frequent. In addition, smartphone application technology is a promising educational tool for pregnant women with diabetes mellitus and their caregivers. This Review covers how modern diabetes mellitus management with appropriate diet, insulin and antihypertensive treatment in patients with pre-existing diabetes mellitus can contribute to reducing the risk of pregnancy complications such as congenital malformations, fetal overgrowth, preeclampsia and preterm delivery.
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Affiliation(s)
- Lene Ringholm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark.
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark.
- Steno Diabetes Center Copenhagen, Gentofte, Denmark.
| | - Peter Damm
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Obstetrics, Rigshospitalet, Copenhagen, Denmark
| | - Elisabeth R Mathiesen
- Center for Pregnant Women with Diabetes, Rigshospitalet, Copenhagen, Denmark
- Department of Endocrinology, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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81
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Kassab BM, Hussein HH, Mahmoud OM, Abdel-Alrahman G. Effects of insulin and metformin on fetal kidney development of streptozotocin-induced gestational diabetic albino rats. Anat Cell Biol 2019; 52:161-175. [PMID: 31338233 PMCID: PMC6624335 DOI: 10.5115/acb.2019.52.2.161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/12/2018] [Accepted: 12/14/2018] [Indexed: 02/06/2023] Open
Abstract
Gestational diabetes mellitus is one of common medical complications of pregnancy. Hyperglycemia in utero impairs renal development and produces renal anomalies. Metformin has antioxidant properties and better glycemic control. Aim: assessment insulin and metformin effects on renal development of streptozotocin-induced gestational diabetic albino rats. Sixty virgin female albino rats were used. Once pregnancy confirmed, animals were randomly assigned into control, metformin, diabetic, diabetic plus insulin, diabetic plus metformin and diabetic plus insulin and metformin treated groups. Rats were sacrificed on the 20th day of gestation; fetuses were extracted and weighted. Fetal kidneys were extracted prepared for light, morphometric and electron microscopic examination. Diabetic followed by diabetic plus metformin treated groups revealed retardation of glomerular development in the cortical and Juxtaglomerular zones with a significant increase in the early immature glomerular stages and immature to mature glomerular ratio compared to other groups. Diabetic group also showed morphometric changes, shrunken and empty glomeruli, vacuolar degeneration and hemorrhage. Diabetic plus metformin group showed minimal improvement while diabetic plus insulin and diabetic plus insulin and metformin groups showed developmental, histopathological and morphometric improvement with best results in the combination group. Gestational diabetes mellitus (GDM) possess deleterious effects on fetal kidney development. Insulin improves the glycemic state and decreases GDM effects on fetal kidneys. Metformin produces mild protection while the combination of insulin and metformin produces the best glycemic control and protect fetal kidneys.
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Affiliation(s)
- Ban M Kassab
- Department of Anatomy, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Hoda H Hussein
- Department of Anatomy, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Omayma M Mahmoud
- Department of Anatomy, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Gamal Abdel-Alrahman
- Department of Anatomy, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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82
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Abstract
Diabetes is a common complication of pregnancy associated with both short- and long-term adverse maternal and offspring effects. All types of diabetes in pregnancy are increasing in prevalence. Treatment of diabetes in pregnancy, targeting glycemic control, improves both maternal and offspring outcomes, albeit imperfectly for many women. Pharmacologic treatment recommendations differ between pregestational and gestational diabetes. Improved treatment of diabetes in pregnancy will need to consider maternal disease heterogeneity and comorbidities as well as long-term offspring outcomes. In this review, the authors summarize recent clinical studies to highlight established pharmacologic treatments for diabetes in pregnancy and provide suggestions for further research.
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Affiliation(s)
- Maisa N Feghali
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee Women's Research Institute, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213, USA.
| | - Jason G Umans
- Department of Medicine, Georgetown-Howard Universities Center for Clinical and Translational Science, Georgetown University, 3800 Reservoir Rd NW, Washington, DC 20007, USA; Department of Obstetrics and Gynecology, Georgetown-Howard Universities Center for Clinical and Translational Science, Georgetown University, 3800 Reservoir Rd NW, Washington, DC 20007, USA
| | - Patrick M Catalano
- Maternal Infant Research Institute, Obstetrics and Gynecology Research, Tufts University School of Medicine, Friedman School of Nutrition Science and Policy, 800 Washington Street, Box 394, Boston, MA 02111, USA
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83
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Griffith RJ, Alsweiler J, Moore AE, Brown S, Middleton P, Shepherd E, Crowther CA. Interventions to prevent women developing gestational diabetes mellitus: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2019; 2019:CD012394. [PMCID: PMC6515838 DOI: 10.1002/14651858.cd012394.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/30/2023]
Abstract
This is a protocol for a Cochrane Review (Overview). The objectives are as follows: To summarise the evidence from Cochrane systematic reviews regarding the effects of interventions to prevent women developing gestational diabetes mellitus (GDM).
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Affiliation(s)
- Rebecca J Griffith
- University of AucklandDepartment of Paediatrics: Child and Youth HealthAucklandNew Zealand
| | - Jane Alsweiler
- University of AucklandDepartment of Paediatrics: Child and Youth HealthAucklandNew Zealand
| | - Abigail E Moore
- The University of AucklandLiggins Institute85 Park RoadAucklandNew Zealand1023
| | - Stephen Brown
- Auckland University of TechnologySchool of Interprofessional Health Studies90 Akoranga DriveAucklandNew Zealand0627
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideAustralia5006
| | - Emily Shepherd
- The University of AdelaideRobinson Research Institute, Discipline of Obstetrics and Gynaecology, Adelaide Medical SchoolAdelaideAustralia
| | - Caroline A Crowther
- The University of AucklandLiggins Institute85 Park RoadAucklandNew Zealand1023
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84
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Abstract
IMPORTANCE The presence of preexisting type 1 or type 2 diabetes in pregnancy increases the risk of adverse maternal and neonatal outcomes, such as preeclampsia, cesarean delivery, preterm delivery, macrosomia, and congenital defects. Approximately 0.9% of the 4 million births in the United States annually are complicated by preexisting diabetes. OBSERVATIONS Women with diabetes have increased risk for adverse maternal and neonatal outcomes, and similar risks are present with type 1 and type 2 diabetes. Both forms of diabetes require similar intensity of diabetes care. Preconception planning is very important to avoid unintended pregnancies and to minimize risk of congenital defects. Hemoglobin A1c goals are less than 6.5% at conception and less than 6.0% during pregnancy. It is also critical to screen for and manage comorbid illnesses, such as retinopathy and nephropathy. Medications known to be unsafe in pregnancy, such as angiotensin-converting enzyme inhibitors and statins, should be discontinued. Women with obesity should be screened for obstructive sleep apnea, which is often undiagnosed and can result in poor outcomes. Blood pressure goals must be considered carefully because lower treatment thresholds may be required for women with nephropathy. During pregnancy, continuous glucose monitoring can improve glycemic control and neonatal outcomes in women with type 1 diabetes. Insulin is first-line therapy for all women with preexisting diabetes; injections and insulin pump therapy are both effective approaches. Rates of severe hypoglycemia are increased during pregnancy; therefore, glucagon should be available to the patient and close contacts should be trained in its use. Low-dose aspirin is recommended soon after 12 weeks' gestation to minimize the risk of preeclampsia. The importance of discussing long-acting reversible contraception before and after pregnancy, to allow for appropriate preconception planning, cannot be overstated. CONCLUSIONS AND RELEVANCE Preexisting diabetes in pregnancy is complex and is associated with significant maternal and neonatal risk. Optimization of glycemic control, medication regimens, and careful attention to comorbid conditions can help mitigate these risks and ensure quality diabetes care before, during, and after pregnancy.
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Affiliation(s)
| | - Rachel Blair
- Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Anne L. Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, California, United States
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85
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Abstract
Gestational and pre-gestational diabetes are frequent problems encountered in obstetrical practice and their complications may influence both the mother (such as hypertension, pre-eclampsia, increased caesarean rates) and the foetus (such as macrosomia, shoulder dystocia, respiratory distress, hypoglycaemia, or childhood obesity and diabetes). Given the important implications for mothers and their offspring, screening and appropriate management of diabetes during pregnancy are essential. This is a review of articles published between 2015 and 2018 on Medline via Ovid that focus on advances in the management of diabetes in pregnancy. Recent data have concentrated predominantly on optimising glycaemic control, which is key for minimising the burden of maternal and foetal complications. Lifestyle changes, notably physical exercise and diet adjustments, appear to have beneficial effects. However, data are inconclusive with respect to which diet and form of exercise provide optimal benefits. Oral glycaemic agents-in particular, metformin-are gaining acceptance as more data indicating their long-term safety for the foetus and newborn emerge. Recent reviews present inconclusive data on the efficacy and safety of insulin analogues. New technologies such as continuous insulin pumps for type 1 diabetes and telemedicine-guided management of diabetes are significantly appreciated by patients and represent promising clinical tools. There are few new data addressing the areas of antenatal foetal surveillance, the timing and need for induction of delivery, and the indications for planned caesarean section birth.
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Affiliation(s)
- Cristina Mitric
- Obstetrics & Gynaecology, McGill University, Montreal, Quebec, H4A 3J1, Canada
| | - Jade Desilets
- Obstetrics & Gynaecology, McGill University, Montreal, Quebec, H4A 3J1, Canada
| | - Richard N Brown
- Obstetrics & Gynaecology, McGill University, Montreal, Quebec, H4A 3J1, Canada
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86
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Xu Q, Xie Q. Long-term effects of prenatal exposure to metformin on the health of children based on follow-up studies of randomized controlled trials: a systematic review and meta-analysis. Arch Gynecol Obstet 2019; 299:1295-1303. [PMID: 30953188 DOI: 10.1007/s00404-019-05124-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 03/16/2019] [Indexed: 01/11/2023]
Abstract
PURPOSE Oral antidiabetic medication of metformin is increasingly used in pregnant women with gestational diabetes mellitus (GDM), polycystic ovary syndrome (PCOS) and obesity. The drug passes through the placenta and can potentially influence the fetus. The aim of the study is to investigate the possible long-term effects of prenatal exposure to metformin on growth and development of the offspring. METHODS A systematic review and meta-analysis was conducted to examine the longer term outcomes by the follow-up studies of the already published RCTs focusing on the body composition, metabolic parameters and neurophysiological development of the children prenatally exposed to metformin. The primary sources of the reviewed studies through August 2018, with restriction on the language of English, were Pubmed and Embase. RESULTS 11 follow-up studies were included, with a maximal age of children being 13 years, comprising 823 children of mothers with GDM or PCOS who were randomized to either metformin or insulin/placebo during pregnancy. From the pooled meta-analysis we found that children prenatal exposure to metformin were associated with a significantly heavier weight (MD = 0.48 kg, 95% CI 0.24 kg, 0.73 kg; P = 0.0001, I2 = 0). As for other parameters of body composition, metabolic parameters and neurophysiological development, the results were similar between metformin and placebo/insulin use. CONCLUSION Increased offspring weight was more observed in children prenatal exposure to metformin. Heathcare providers and patients should be aware that metformin is increasingly prescribed in pregnancy based on the relatively limited evidences but nonetheless encouraging long-term offspring data are available.
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Affiliation(s)
- Qing Xu
- Department of Gynaecology and Obstetrics, Affiliated Hospital of Putian College, No. 181 East Meiyuan Road, Lichen District, Putian City, 351100, Fujian, China.
| | - Qinglian Xie
- Health Evaluation Center, Affiliated Hospital of Putian College, Putian City, 351100, Fujian, China
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87
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Liu Z, Yu X, Tong C, Qi H. Renal dysfunction in a mouse model of GDM is prevented by metformin through MAPKs. Mol Med Rep 2019; 19:4491-4499. [PMID: 30896853 DOI: 10.3892/mmr.2019.10060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 02/15/2019] [Indexed: 11/06/2022] Open
Abstract
Gestational diabetes mellitus (GDM) incidence is increasing worldwide. In the present study, the effects of metformin on high fat diet (HFD)‑induced renal dysfunction were investigated in GDM mice. In addition, the molecular mechanisms underlying metformin function were examined. GDM was induced by feeding pregnant mice a HFD, and mice were treated with two different doses of metformin (300 and 600 mg/kg/day) or PBS between embryonic day 11.5 (E11.5) and E17.5. The pregnant mice at E18.5 were utilized to analyze the effects of metformin on renal dysfunction. Renal function and the protein expression levels of inflammatory cytokines and factors of the mitogen‑activated protein kinase (MAPK) signaling pathway in the kidneys of pregnant mice were assessed by ELISA and western blotting. Data obtained during late pregnancy suggested that metformin significantly decreased body weight and the levels of blood glucose in GDM mice, as assessed by the glucose tolerance test and the homeostatic model assessment for insulin resistance. The levels of microalbumin and serum β2‑microglobulin in GDM mice during late pregnancy were decreased following treatment with metformin. Furthermore, serum levels of interleukin (IL)‑6 and tumor necrosis factor (TNF)‑α, and phosphorylation of MAPK1/3, MAPK14 and MAPK8 in the kidneys were decreased in GDM mice following metformin treatment at E18.5, compared with the untreated GDM group. The present study suggested that inflammation may be associated with renal dysfunction in GDM mice, and that the MAPK signaling pathway may be involved in the protective effect of metformin on renal dysfunction in GDM mice.
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Affiliation(s)
- Zhengfei Liu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Xinyang Yu
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Chao Tong
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
| | - Hongbo Qi
- Department of Obstetrics and Gynecology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, P.R. China
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Barbour LA, Feig DS. Metformin for Gestational Diabetes Mellitus: Progeny, Perspective, and a Personalized Approach. Diabetes Care 2019; 42:396-399. [PMID: 30787061 DOI: 10.2337/dci18-0055] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Linda A Barbour
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Denice S Feig
- Department of Medicine, Division of Endocrinology and Metabolism, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
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Anti-inflammatory Action of Metformin with Respect to CX3CL1/CX3CR1 Signaling in Human Placental Circulation in Normal-Glucose Versus High-Glucose Environments. Inflammation 2019; 41:2246-2264. [PMID: 30097812 DOI: 10.1007/s10753-018-0867-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Upregulation of chemokine CX3CL1 and its receptor CX3CR1 occurs in the diabetic human placenta. Metformin, an insulin-sensitizing biguanide, is used in the therapy of diabetic pregnancy. By preventing the activation of NF-κB, metformin exhibits anti-inflammatory properties. We examined the influence of hyperglycemia (25 mmol/L glucose; HG group; N = 36) on metformin-mediated effects on CX3CL1 and TNF-α production by placental lobules perfused extracorporeally. Additionally, CX3CR1 expression and contents of CX3CR1, TNF-α receptor 1 (TNFR1), and NF-κB proteins in the placental tissue were evaluated. Placentae perfused under normoglycemia (5 mmol/L glucose; NG group; N = 36) served as the control. Metformin (2.5 and 5.0 mg/L; subgroups B and C) lowered the production of CX3CL1 and TNF-α in a dose-dependent and time-dependent manner. Hyperglycemia did not weaken the strength of these metformin effects. Moreover, CX3CL1 levels after perfusion with 5.0 mg/L metformin were reduced by 33.28 and 33.83% (at 120 and 150 min, respectively) in the HG-C subgroup versus 24.98 and 23.66% in the NG-C subgroup, which indicated an augmentation of the metformin action over time in hyperglycemia. CX3CR1 expression was significantly higher in the HG-B and HG-C subgroups compared to that in the NG-B and NG-C subgroups. Increased CX3CR1 protein content in the placental lysates was observed in subgroups B and C. The two higher metformin concentrations significantly decreased the levels of NF-κBp65 protein content in both groups. However, the decrease was significantly stronger in hyperglycemia. TNFR1 upregulation in the HG group was not affected by metformin. Further studies on metformin therapy during pregnancy are needed, including safety issues.
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90
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Landi SN, Radke S, Engel SM, Boggess K, Stürmer T, Howe AS, Funk MJ. Association of Long-term Child Growth and Developmental Outcomes With Metformin vs Insulin Treatment for Gestational Diabetes. JAMA Pediatr 2019; 173:160-168. [PMID: 30508164 PMCID: PMC6439608 DOI: 10.1001/jamapediatrics.2018.4214] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
IMPORTANCE Metformin is an emerging option for treating gestational diabetes (GDM). However, because metformin crosses the placenta, patients and clinicians are concerned with its long-term effect on child health. OBJECTIVE To estimate the association of treating GDM with metformin vs insulin with child growth and development. DESIGN, SETTING, AND PARTICIPANTS Population-based cohort study of New Zealand women treated with metformin or insulin for GDM from 2005 to 2012 and their children. This study linked national health care data to create a cohort of mothers and their children, including data from maternity care, pharmaceutical dispensing, hospitalizations, demographic records, and the B4 School Check (B4SC) preschool health assessment. Women treated pharmacologically with metformin or insulin during pregnancy were included. We excluded pregnancies with evidence of diabetes and deliveries prior to 2013. Liveborn infants were linked to their B4SC results. Data were analyzed between January 2017 and May 2018. EXPOSURES Pharmacologic treatment for GDM with metformin or insulin, measured using pharmaceutical claims data. MAIN OUTCOMES AND MEASURES Child growth (weight and height) and Strengths and Difficulties Questionnaire (SDQ) scores for behavioral development. All outcomes were derived from the B4SC screening program. Linear and log-binomial regression with inverse probability of treatment weighting was used to estimate the association of child growth and psychosocial outcomes with metformin vs insulin treatment for GDM. RESULTS In both treatment groups, the mean (SD) maternal age was 32 (5) years. A large proportion of mothers who were treated with insulin identified as New Zealand European (867 [44.9%]) while 576 mothers who were treated with metformin (28.9%) identified as New Zealand European. Approximately one-third of mothers who were treated with metformin (n = 639) identified as Asian. We identified 3928 pregnancies treated with metformin (n = 1996) or insulin (n = 1932). After adjustment, we observed no meaningful difference in weight for height z scores between children exposed to metformin compared with insulin (mean difference, -0.10; 95% CI, -0.20 to 0.01). Risk of being 85th percentile or greater for weight for height was similar between treatment groups (adjusted risk ratio, 0.92; 95% CI, 0.83-1.02). Mean SDQ scores were not meaningfully different between the treatment groups, Children of metformin-treated mothers were not significantly more likely to have parent-reported SDQ scores of 14 or more (adjusted risk ratio, 1.13; 95% CI, 0.88-1.46) than those of insulin-treated mothers. CONCLUSIONS AND RELEVANCE Our study compares long-term outcomes among school-aged children following maternal use of metformin vs insulin treatment for GDM. Children of metformin-treated mothers were indistinguishable on growth and developmental assessments from those of insulin-treated mothers. These results will help inform future GDM treatment guidelines.
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Affiliation(s)
- Suzanne N. Landi
- Department of Epidemiology, Gillings School of Global
Public Health, University of North Carolina at Chapel Hill
| | - Sarah Radke
- National Institute of Health Innovation, University of
Auckland, Auckland, New Zealand
| | - Stephanie M. Engel
- Department of Epidemiology, Gillings School of Global
Public Health, University of North Carolina at Chapel Hill
| | - Kim Boggess
- Department of Obstetrics and Gynecology, School of
Medicine, University of North Carolina at Chapel Hill
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global
Public Health, University of North Carolina at Chapel Hill
| | - Anna S. Howe
- Department of General Practice and Primary Health
Care, University of Auckland, Auckland, New Zealand
| | - Michele Jonsson Funk
- Department of Epidemiology, Gillings School of Global
Public Health, University of North Carolina at Chapel Hill
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91
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Hanem LGE, Salvesen Ø, Juliusson PB, Carlsen SM, Nossum MCF, Vaage MØ, Ødegård R, Vanky E. Intrauterine metformin exposure and offspring cardiometabolic risk factors (PedMet study): a 5-10 year follow-up of the PregMet randomised controlled trial. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 3:166-174. [PMID: 30704873 DOI: 10.1016/s2352-4642(18)30385-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 11/22/2018] [Accepted: 11/26/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Metformin is increasingly used to treat gestational diabetes and type 2 diabetes in pregnancy, and in attempts to improve pregnancy outcomes in polycystic ovary syndrome and obesity. It passes across the placenta with possible long-term consequences for the offspring. We previously explored the effect of metformin, given to women with polycystic ovary syndrome during pregnancy, on children's growth up to 4 years of age. In this 5-10 year follow-up, we examined the cardiometabolic risk factors in these children. METHODS This is a follow-up of children from the PregMet study, a double-blind, randomised controlled trial comparing metformin with placebo in polycystic ovary syndrome pregnancies. In the PregMet study, between Feb 4, 2005, and Jan 27, 2009, 257 pregnant women aged 18-45 years with polycystic ovary syndrome according to the Rotterdam criteria were included with 274 singleton pregnancies at 5-12 weeks of gestation at 11 study centres in Norway. 17 women participated twice. Pregnant women were randomised to metformin (2000 mg/day) or placebo from inclusion in the first trimester to birth. Randomisation was stratified according to metformin use at conception. In this follow-up, the primary endpoint was body-mass index (BMI) in the offspring at 5-10 years of age assessed by the standard deviation score (Z score). The primary endpoint was analysed with independent sample t tests. ClinicalTrials.gov number NCT00159536. FINDINGS Of the 255 invited children from the PregMet study, 141 (55%) consented to participate and were included between April 29, 2014, and July 12, 2016. Maternal baseline characteristics in the first trimester were similar between groups. Children in the metformin group had a higher BMI Z score than those in the placebo group (difference in means=0·41, 95% CI 0·03-0·78, p=0·03). INTERPRETATION The increased BMI in metformin-exposed children might indicate a potential risk of inferior cardiometabolic health. Implications for adult health cannot be excluded. FUNDING The Research Council of Norway, Novo Nordisk Foundation, St Olavs University Hospital, and the Norwegian University of Science and Technology.
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Affiliation(s)
- Liv Guro Engen Hanem
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
| | - Øyvind Salvesen
- Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Petur B Juliusson
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Department of Health Registries, Norwegian Institute of Public Health, Sentrum, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway; Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Sven M Carlsen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Department of Endocrinology, St. Olavs Hospital, Trondheim University Hospital, Torgarden, Trondheim, Norway
| | - Marit Cecilie Fonn Nossum
- Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Marte Øye Vaage
- Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway
| | - Rønnaug Ødegård
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Centre for Obesity Research, St. Olavs Hospital, Trondheim University Hospital, Torgarden, Trondheim, Norway
| | - Eszter Vanky
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Trondheim, Norway; Department of Obstetrics and Gynecology, St. Olavs Hospital, Trondheim University Hospital, Torgarden, Trondheim, Norway
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92
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Berry DC, Thomas SD, Dorman KF, Ivins AR, de los Angeles Abreu M, Young L, Boggess K. Rationale, design, and methods for the Medical Optimization and Management of Pregnancies with Overt Type 2 Diabetes (MOMPOD) study. BMC Pregnancy Childbirth 2018; 18:488. [PMID: 30541506 PMCID: PMC6292086 DOI: 10.1186/s12884-018-2108-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 11/20/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Annually in the US, over 100,000 pregnant women with overt type 2 diabetes give birth. Strict maternal glycemic control is the key to optimizing infant outcomes. Medical treatment of type 2 diabetes in pregnancy is generally restricted to insulin, as data on the safety and efficacy of oral hypoglycemic agents in pregnancy are limited. However, over one-third of infants born to women with type 2 diabetes experience an adverse outcome, such as premature delivery, large-for-gestational age, hypoglycemia, hyperbilirubinemia, or birth trauma, suggesting that current treatment regimens fall short of optimizing outcomes. Metformin is the pharmacologic treatment of choice for type 2 diabetes outside of pregnancy. Metformin is favored over insulin because it results in less weight gain, fewer hypoglycemic episodes, and is administered orally rather than injected. However, metformin is not typically used for treatment of type 2 diabetes complicating pregnancy, mainly because no large clinical studies have been conducted to examine its use in this context. METHODS/DESIGN This is a randomized double-blind multi-center clinical trial of insulin plus metformin versus insulin plus placebo for the treatment of type 2 diabetes complicating pregnancy. A total of 1200 women with type 2 diabetes will be randomized between 10 weeks 0 days' and 20 weeks 6 days' gestation and followed until 30 days after delivery. Neonate outcomes will be followed until 30 days of age. The primary aim is to compare the effect of insulin and metformin versus insulin and placebo on composite adverse neonatal outcomes, comprising perinatal mortality, preterm delivery, neonatal hypoglycemia, hyperbilirubinemia, large-for-gestational age small for gestational age, low birth weight, and/or birth trauma. Key secondary aims are to compare treatment groups for neonatal fat mass and rate of maternal hypoglycemia. Additional aims are to assess the side effects and safety of insulin and metformin among pregnant women with overt type 2 diabetes and to compare gestational weight gain among women treated with metformin plus insulin versus insulin alone. DISCUSSION Successful completion of this study will result in high-quality, contemporary evidence for management of overt type 2 diabetes complicating pregnancy to improve neonatal outcomes. TRIAL REGISTRATION NCT02932475 (05/17/2016).
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Affiliation(s)
- Diane C. Berry
- The University of North Carolina at Chapel Hill School of Nursing, Campus Box 7460, Chapel Hill, NC 27599-7460 USA
| | - Sonia Davis Thomas
- Department of Biostatistics, University of North Carolina, 137 E Rosemary St Suite 203, Chapel Hill, NC 27514 USA
| | - Karen F. Dorman
- The University of North Carolina at Chapel Hill School of Medicine, Campus Box 7516, Chapel Hill, NC 27599-7516 USA
| | - Amber Rose Ivins
- The University of North Carolina at Chapel Hill School of Medicine, Campus Box 7516, Chapel Hill, NC 27599-7516 USA
| | - Maria de los Angeles Abreu
- Department of Biostatistics, University of North Carolina, 137 E Rosemary St Suite 203, Chapel Hill, NC 27514 USA
| | - Laura Young
- The University of North Carolina at Chapel Hill School of Medicine, Campus Box 7516, Chapel Hill, NC 27599-7516 USA
| | - Kim Boggess
- The University of North Carolina at Chapel Hill School of Medicine, Campus Box 7516, Chapel Hill, NC 27599-7516 USA
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93
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Paschou SA, Wolffenbuttel BHR. Metformin use during pregnancy: Is it really safe? J Diabetes 2018; 10:984-985. [PMID: 29987873 DOI: 10.1111/1753-0407.12813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 06/11/2018] [Indexed: 12/11/2022] Open
Affiliation(s)
- Stavroula A Paschou
- Division of Endocrinology and Diabetes, "Aghia Sophia" Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Bruce H R Wolffenbuttel
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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94
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Faure M, Bertoldo MJ, Khoueiry R, Bongrani A, Brion F, Giulivi C, Dupont J, Froment P. Metformin in Reproductive Biology. Front Endocrinol (Lausanne) 2018; 9:675. [PMID: 30524372 PMCID: PMC6262031 DOI: 10.3389/fendo.2018.00675] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Accepted: 10/29/2018] [Indexed: 12/19/2022] Open
Abstract
Initially produced in Europe in 1958, metformin is still one of the most widely prescribed drugs to treat type II diabetes and other comorbidities associated with insulin resistance. Metformin has been shown to improve fertility outcomes in females with insulin resistance associated with polycystic ovary syndrome (PCOS) and in obese males with reduced fertility. Metformin treatment reinstates menstrual cyclicity, decreases the incidence of cesareans, and limits the number of premature births. Notably, metformin reduces steroid levels in conditions associated with hyperandrogenism (e.g., PCOS and precocious puberty) in females and improves fertility of adult men with metabolic syndrome through increased testosterone production. While the therapeutical use of metformin is considered to be safe, in the last 10 years some epidemiological studies have described phenotypic differences after prenatal exposure to metformin. The goals of this review are to briefly summarize the current knowledge on metformin focusing on its effects on the female and male reproductive organs, safety concerns, including the potential for modulating fetal imprinting via epigenetics.
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Affiliation(s)
- Melanie Faure
- Unité de Physiologie de la Reproduction et des Comportements, Centre Val de Loire, Institut National de la Recherche Agronomique, UMR85, Nouzilly, France
| | - Michael J Bertoldo
- Discipline of Obstetrics and Gynaecology, School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Rita Khoueiry
- Department of Development and Regeneration, Stem Cell Institute, KU Leuven, Leuven, Belgium
| | - Alice Bongrani
- Unité de Physiologie de la Reproduction et des Comportements, Centre Val de Loire, Institut National de la Recherche Agronomique, UMR85, Nouzilly, France
| | - François Brion
- INERIS, Direction des Risques Chroniques, Pole VIVA, Unite d'ecotoxicologie in vitro et in vivo, BP2, Verneuil-en-Halatte, France
| | - Cecilia Giulivi
- Department of Molecular Biosciences, School of Veterinary Medicine, University of California, Davis, Davis, CA, United States
- Medical Investigations of Neurodevelopmental Disorders Institute, University of California, Davis, Davis, CA, United States
| | - Joelle Dupont
- Unité de Physiologie de la Reproduction et des Comportements, Centre Val de Loire, Institut National de la Recherche Agronomique, UMR85, Nouzilly, France
| | - Pascal Froment
- Unité de Physiologie de la Reproduction et des Comportements, Centre Val de Loire, Institut National de la Recherche Agronomique, UMR85, Nouzilly, France
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95
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Prenatal metformin exposure or organic cation transporter 3 knock-out curbs social interaction preference in male mice. Pharmacol Res 2018; 140:21-32. [PMID: 30423430 DOI: 10.1016/j.phrs.2018.11.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Revised: 09/21/2018] [Accepted: 11/07/2018] [Indexed: 12/15/2022]
Abstract
Poorly managed gestational diabetes can lead to severe complications for mother and child including fetal overgrowth, neonatal hypoglycemia and increased autism risk. Use of metformin to control it is relatively new and promising. Yet safety concerns regarding gestational metformin use remain, as its long-term effects in offspring are unclear. In light of beneficial findings with metformin for adult mouse social behavior, we hypothesized gestational metformin treatment might also promote offspring sociability. To test this, metformin was administered to non-diabetic, lean C57BL/6 J female mice at mating, with treatment discontinued at birth or wean. Male offspring exposed to metformin through birth lost social interaction preference relative to controls by time in chambers, but not by sniffing measures. Further, prenatal metformin exposure appeared to enhance social novelty preference only in females. However due to unbalanced litters and lack of statistical power, firm establishment of any sex-dependency of metformin's effects on sociability was not possible. Since organic cation transporter 3 (OCT3) transports metformin and is dense in placenta, social preferences of OCT3 knock-out males were measured. Relative to wild-type, OCT3 knock-outs had reduced interaction preference. Our data indicate gestational metformin exposure under non-diabetic conditions, or lack of OCT3, can impair social behavior in male C57BL6/J mice. Since OCT3 transports serotonin and tryptophan, impaired placental OCT3 function is one common mechanism that could persistently impact central serotonin systems and social behavior. Yet no gross alterations in serotonergic function were evident by measure of serotonin transporter density in OCT3, or serotonin turnover in metformin-exposed offspring brains. Mechanisms underlying the behavioral outcomes, and if with gestational diabetes the same would occur, remain unclear. Metformin's impacts on placental transporters and serotonin metabolism or AMPK activity in fetal brain need further investigation to clarify benefits and risks to offspring sociability from use of metformin to treat gestational diabetes.
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96
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Corcoy R, Balsells M, García-Patterson A, Shmueli A, Hadar E. Pharmacotherapy for hyperglycemia in pregnancy - Do oral agents have a place? Diabetes Res Clin Pract 2018; 145:51-58. [PMID: 29679622 DOI: 10.1016/j.diabres.2018.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 04/06/2018] [Indexed: 12/13/2022]
Abstract
Diabetes is a frequent condition in pregnancy and achieving adequate glycemic control is of paramount importance. Insulin treatment is the gold standard, oral agents are more attractive, but their safety and efficiency should be a prerequisite for their use. We have more information regarding treatment of women with gestational diabetes mellitus where glyburide can induce a picture of fetal hyperinsulinism (higher birthweight and more neonatal hypoglycemia) whereas metformin requires supplemental insulin in a larger proportion of women but achieves satisfactory perinatal outcomes with the exception of preterm birth. Information in patients with Type 2 Diabetes Mellitus is much more limited but also favors metformin. Combinations provide additional possibilities. However, as to long-term outcomes, we have no information on the impact of exposure to glyburide and it is still unclear if in utero exposure to metformin will have any effect on the offspring and the direction of this effect. Women prefer oral agents, indicating the need of additional studies.
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Affiliation(s)
- Rosa Corcoy
- Servei d'Endocrinologia i Nutrició, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain; CIBER-BBN, Madrid, Spain
| | - Montserrat Balsells
- Servei d'Endocrinologia i Nutrició, Hospital de la Mútua de Terrassa, Terrassa, Spain
| | | | - Anat Shmueli
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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97
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Zhen XM, Li X, Chen C. Longer-term outcomes in offspring of GDM mothers treated with metformin versus insulin. Diabetes Res Clin Pract 2018; 144:82-92. [PMID: 30031048 DOI: 10.1016/j.diabres.2018.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/30/2018] [Accepted: 07/02/2018] [Indexed: 01/12/2023]
Abstract
Insulin has traditionally been the gold standard pharmacological treatment for gestational diabetes mellitus (GDM). Insulin requires multiple injections a day, can cause frequent hypoglycaemia, requires careful handling, and is generally more expensive compared to oral agents. Metformin has been increasingly popular in recent years. Based on the short-term data available, metformin appears to be safe and effective for the treatment of GDM but existing studies have all stressed the lack of longer-term offspring data. This article will analyse the evidence available on the longer-term outcomes in the offspring of women with GDM treated with metformin versus insulin. Pubmed, EMBASE, CENTRAL, and CNKI were searched for follow-up studies of randomised controlled trials that compared metformin with insulin for the treatment of GDM. Existing follow-up studies did not find any significant increase in the risk of adverse effects in terms of growth and development in the offspring of GDM mothers managed with metformin versus insulin.
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Affiliation(s)
- Xi May Zhen
- School of Medicine, The University of Queensland, Brisbane 4072, Australia; Royal Prince Alfred Hospital, Sydney 2050, Australia.
| | - Xue Li
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Queensland 4072, Australia
| | - Chen Chen
- School of Biomedical Sciences, The University of Queensland, Brisbane, Queensland 4072, Australia.
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98
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Benhalima K, Mathiesen ER, Paldanius PM, Mathieu C. The need for appropriate registration of pregnancy outcomes under newer oral glucose-lowering therapies. Diabetes Obes Metab 2018; 20:2477-2480. [PMID: 29806119 DOI: 10.1111/dom.13386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 05/24/2018] [Accepted: 05/24/2018] [Indexed: 11/26/2022]
Abstract
Because of the increase in type 2 diabetes (T2DM) in young adults, women of childbearing age are frequently treated with newer glucose-lowering therapies, and an increase in unintentional exposure to therapies unapproved for use during pregnancy is expected. The clinician is left with the dilemma of deciding between discontinuation of a novel agent that is providing excellent glycaemic control, while switching to other agents may cause deterioration of glycaemia, and continued use of novel agents that may have uncertain effects on the unborn child. For T2DM, pregnancy data are collected only via spontaneous reporting systems. Therefore, we evaluated the available data on pregnancy outcomes under newer glucose-lowering agents in pharmaceutical safety databases. We found that data on pregnancy outcomes with new glucose-lowering agents in T2DM are scarce, with a high risk of bias towards negative outcomes, limiting their usefulness in robustly assessing safety. Because of the lack of information at present, these agents are not recommended for use during pregnancy or when planning pregnancy. To better guide clinical practice, structured systems of assessing pregnancy outcomes in women receiving these novel agents are urgently needed.
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Affiliation(s)
- Katrien Benhalima
- Department of Endocrinology, UZ Gasthuisberg KU Leuven, Leuven, Belgium
| | - Elisabeth R Mathiesen
- Department of Endocrinology, Center for Pregnant Women with Diabetes, Rigshospitalet, Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | | | - Chantal Mathieu
- Department of Endocrinology, UZ Gasthuisberg KU Leuven, Leuven, Belgium
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99
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Schäfer-Graf UM. Gestational Diabetes - Major New Clinically Relevant Aspects. Geburtshilfe Frauenheilkd 2018; 78:977-983. [PMID: 30364451 PMCID: PMC6195425 DOI: 10.1055/a-0707-6697] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 12/15/2022] Open
Abstract
The implementation of screening for gestational diabetes (GDM) in the German Prenatal Care guidelines of 2012 and the publication of numerous new studies have led to clinically relevant changes in the care of pregnant women with GDM to whom consideration was given in the new S3 Guideline on the Diagnosis, Management and Follow-up of Gestational Diabetes (AWMF 057/008) published in March this year. Certain aspects are addressed and discussed on the basis of additional background information.
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100
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Barbour LA, Scifres C, Valent AM, Friedman JE, Buchanan TA, Coustan D, Aagaard K, Thornburg KL, Catalano PM, Galan HL, Hay WW, Frias AE, Shankar K, Simmons RA, Moses RG, Sacks DA, Loeken MR. A cautionary response to SMFM statement: pharmacological treatment of gestational diabetes. Am J Obstet Gynecol 2018; 219:367.e1-367.e7. [PMID: 29959933 DOI: 10.1016/j.ajog.2018.06.013] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 06/07/2018] [Accepted: 06/20/2018] [Indexed: 02/07/2023]
Abstract
Use of oral agents to treat gestational diabetes mellitus remains controversial. Recent recommendations from the Society for Maternal-Fetal Medicine assert that metformin may be a safe first-line alternative to insulin for gestational diabetes mellitus treatment and preferable to glyburide. However, several issues should give pause to the widespread adoption of metformin use during pregnancy. Fetal concentrations of metformin are equal to maternal, and metformin can inhibit growth, suppress mitochondrial respiration, have epigenetic modifications on gene expression, mimic fetal nutrient restriction, and alter postnatal gluconeogenic responses. Because both the placenta and fetus express metformin transporters and exhibit high mitochondrial activity, these properties raise important questions about developmental programming of metabolic disease in offspring. Animal studies have demonstrated that prenatal metformin exposure results in adverse long-term outcomes on body weight and metabolism. Two recent clinical randomized controlled trials in women with gestational diabetes mellitus or polycystic ovary syndrome provide evidence that metformin exposure in utero may produce a metabolic phenotype that increases childhood weight or obesity. These developmental programming effects challenge the conclusion that metformin is equivalent to insulin. Although the Society for Maternal-Fetal Medicine statement endorsed metformin over glyburide if oral agents are used, there are few studies directly comparing the 2 agents and it is not clear that metformin alone is superior to glyburide. Moreover, it should be noted that prior clinical studies have dosed glyburide in a manner inconsistent with its pharmacokinetic properties, resulting in poor glycemic control and high rates of maternal hypoglycemia. We concur with the American Diabetes Association and American Congress of Obstetricians and Gynecologists, which recommend insulin as the preferred agent, but we believe that it is premature to embrace metformin as equivalent to insulin or superior to glyburide. Due to the uncertainty of the long-term metabolic risks of either metformin or glyburide, we call for carefully controlled studies that optimize oral medication dosing according to their pharmacodynamic and pharmacokinetic properties in pregnancy, appropriately target medications based on individual patterns of hyperglycemia, and follow the offspring long-term for metabolic risk.
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