Can glyburide be advocated over subcutaneous insulin for perinatal outcomes of women with gestational diabetes? A systematic review and meta-analysis

Epidemiology and management of gestational diabetes

Gestational diabetes is defined as hyperglycaemia first detected during pregnancy at glucose concentrations that are less than those of overt diabetes. Around 14% of pregnancies globally are affected by gestational diabetes; its prevalence varies with differences in risk factors and approaches to screening and diagnosis; and it is increasing in parallel with obesity and type 2 diabetes. Gestational diabetes direct costs are US$1·6 billion in the USA alone, largely due to complications including hypertensive disorders, preterm delivery, and neonatal metabolic and respiratory consequences. Between 30% and 70% of gestational diabetes is diagnosed in early pregnancy (ie, early gestational diabetes defined by hyperglycaemia before 20 weeks of gestation). Early gestational diabetes is associated with worse pregnancy outcomes compared with women diagnosed with late gestational diabetes (hyperglycaemia from 24 weeks to 28 weeks of gestation). Randomised controlled trials show benefits of treating gestational diabetes from 24 weeks to 28 weeks of gestation. The WHO 2013 recommendations for diagnosing gestational diabetes (one-step 75 gm 2-h oral glucose tolerance test at 24-28 weeks of gestation) are largely based on the Hyperglycemia and Adverse Pregnancy Outcomes Study, which confirmed the linear association between pregnancy complications and late-pregnancy maternal glycaemia: a phenomenon that has now also been shown in early pregnancy. Recently, the Treatment of Booking Gestational Diabetes Mellitus (TOBOGM) trial showed benefit in diagnosis and treatment of early gestational diabetes for women with risk factors. Given the diabesity epidemic, evidence for gestational diabetes heterogeneity by timing and subtype, and advances in technology, a life course precision medicine approach is urgently needed, using evidence-based prevention, diagnostic, and treatment strategies.

Unraveling the Role of the NLRP3 Inflammasome in Lymphoma: Implications in Pathogenesis and Therapeutic Strategies

Inflammasomes are multimeric protein complexes, sensors of intracellular danger signals, and crucial components of the innate immune system, with the NLRP3 inflammasome being the best characterized among them. The increasing scientific interest in the mechanisms interconnecting inflammation and tumorigenesis has led to the study of the NLRP3 inflammasome in the setting of various neoplasms. Despite a plethora of data regarding solid tumors, NLRP3 inflammasome's implication in the pathogenesis of hematological malignancies only recently gained attention. In this review, we investigate its role in normal lymphopoiesis and lymphomagenesis. Considering that lymphomas comprise a heterogeneous group of hematologic neoplasms, both tumor-promoting and tumor-suppressing properties were attributed to the NLRP3 inflammasome, affecting neoplastic cells and immune cells in the tumor microenvironment. NLRP3 inflammasome-related proteins were associated with disease characteristics, response to treatment, and prognosis. Few studies assess the efficacy of NLRP3 inflammasome therapeutic targeting with encouraging results, though most are still at the preclinical level. Further understanding of the mechanisms regulating NLRP3 inflammasome activation during lymphoma development and progression can contribute to the investigation of novel treatment approaches to cover unmet needs in lymphoma therapeutics.

Effects of oral glibenclamide versus subcutaneous insulin on perinatal outcome of patients with gestational diabetes mellitus: A randomized clinical trial

Background

The first-line treatment for gestational diabetes mellitus remains insulin, but oral hypoglycemic agents are easier and cheaper to use. The aim of the current study was to compare the efficacy and safety of oral glibenclamide and subcutaneous insulin on the serum glucose control and perinatal outcome of patients with gestational diabetes mellitus.

Materials and methods

This randomized clinical trial was conducted during a 2-year period from 2017 to 2019 in two tertiary healthcare centers in Shiraz, Iran. We included 84 singleton pregnancies between 24 and 34 weeks of gestation diagnosed with gestational diabetes mellitus. Patients were randomly assigned to oral glibenclamide (n = 44) or subcutaneous insulin (n = 40) according to a standard protocol and followed until delivery. The primary endpoint was to compare the glycemic level of patients, and the secondary outcomes included pregnancy adverse events and neonatal complications such as preeclampsia, preterm and premature rupture of membranes, preterm labor, placental abruption, maternal hypoglycemia, birth weight, neonatal hypoglycemia, hyperbilirubinemia, respiratory distress syndrome, and neonatal intensive care unit admission.

Results

The two study groups had comparable baseline characteristics. After treatment, the two study groups were comparable regarding fasting blood glucose (p = 0.398) and 2 h postprandial glucose (p = 0.085). There was no significant difference between the two groups regarding the rate of preeclampsia (p = 0.250), preterm rupture of membranes (p = 0.998), preterm labor (p = 0.495), hypoglycemia (p = 0.476), and abruption (p = 0.815). There was no significant difference between the two study groups in birth weight (p = 0.863) and the Apgar score at 1 (p = 0.190) and 5 min (p = 0.055). The rates of neonatal adverse events including hypoglycemia (p = 0.999), hyperbilirubinemia (p = 0.160), neonatal intensive care unit admission (p = 0.852), and respiratory distress syndrome (p = 0.665) were comparable between the two groups.

Conclusion

The results of the current study demonstrate that oral glibenclamide is as effective and safe as subcutaneous insulin in glycemic control and maternal and neonatal outcomes in women with gestational diabetes mellitus. Thus, it could be used as first-line treatment of gestational diabetes mellitus.

Effect of Evidence-Based Diet Nursing on Intestinal Flora and Maternal and Infant Prognosis in Patients with Gestational Diabetes

Background. Gestational diabetes mellitus (GDM) refers to the diabetes first discovered or occurring during pregnancy. The incidence of gestational diabetes in China is about 1%–5%, with an increasing trend in recent years. Objective. To observe the effect of evidence-based diet nursing on intestinal flora and maternal and infant prognosis in patients with gestational diabetes. Methods. One hundred and thirty patients with GDM admitted to our hospital from January 2020 to January 2022 were selected and divided into two groups according to the intervention method, with 65 cases in each group. The control group was given routine nursing plus diet nursing, while the observation group was given evidence-based nursing plus diet nursing. The changes of blood glucose index and intestinal flora before and after intervention in the two groups were detected, and the compliance behavior, pregnancy outcome, and perinatal outcome in the two groups were statistically analyzed. Results. After the intervention, the fasting blood glucose, 2 h postprandial blood glucose, and HbA1c in the two groups gradually decreased ( $P<0.05$ ). Further comparison between the groups showed that the fasting blood glucose, 2 h postprandial blood glucose, and HbA1c in the observation group were lower than those in the control group ( $P<0.05$ ). After intervention, the ratios of Bifidobacterium, Lactobacillus, and Bifidobacterium to E. coli in the two groups gradually increased ( $P<0.05$ ). Furthermore, comparison between the groups showed that the ratios of Bifidobacterium, Lactobacillus, and Bifidobacterium to E. coli in the observation group were higher than those in the control group ( $P<0.05$ ). The blood glucose rate, regular prenatal examination rate, and diet control rate of the observation group were 100.00%, 100.00%, and 95.38%, respectively, which were higher than 89.23%, 92.31%, and 84.62% of the control group, and the difference was significant ( $P<0.05$ ). The pregnancy infection rate and cesarean section rate in the observation group were 0.00% and 33.85%, respectively, which were lower than 6.15% and 60.00% in the control group, and the difference was significant ( $P<0.05$ ).The premature delivery rate and polyhydramnios rate in the observation group were 3.08% and 1.54%, respectively, which were not significantly different from 6.15% to 7.69% in the control group ( $P>0.05$ ). The rates of macrosomia, neonatal hypoglycemia, and neonatal hyperbilirubinemia in the observation group were 1.54%, 3.08%, and 9.23%, respectively, which were lower than those in the control group (10.77%, 13.85%, and 23.08%), and the differences were significant ( $P<0.05$ ). The fetal malformation rate and neonatal asphyxia rate in the observation group were 0.00% and 1.54%, respectively, which were not significantly different from 1.54% to 7.69% in the control group ( $P>0.05$ ). Conclusion. The application of evidence-based care combined with dietary care in GDM patients can improve intestinal flora, control blood glucose, improve patient compliance behavior, and improve maternal and infant outcomes.

Association of Glyburide and Subcutaneous Insulin With Perinatal Complications Among Women With Gestational Diabetes

IMPORTANCE

Nearly 30% of individuals with gestational diabetes (GDM) do not achieve glycemic control with lifestyle modification alone and require medication treatment. Oral agents, such as glyburide, have several advantages over insulin for the treatment of GDM, including greater patient acceptance; however, the effectiveness of glyburide for the treatment of GDM remains controversial.

OBJECTIVE

To compare the perinatal and neonatal outcomes associated with glyburide vs insulin using causal inference methods in a clinical setting with information on glycemic control.

DESIGN, SETTING, AND PARTICIPANTS

The population-based cohort study included patients with GDM who required medication treatment from 2007 to 2017 in Kaiser Permanente Northern California. Machine learning and rigorous casual inference methods with time-varying exposures were used to evaluate associations of exposure to glyburide vs insulin with perinatal outcomes. Data analysis was conducted from March 2018 to July 2017.

EXPOSURES

Time-varying exposure to glyburide vs insulin during pregnancy.

MAIN OUTCOMES AND MEASURES

Outcomes evaluated separately included neonatal hypoglycemia, jaundice, shoulder dystocia, respiratory distress syndrome (RDS), neonatal intensive care unit (NICU) admission, size-for-gestational age, and cesarean delivery. Inverse probability weighting (IPW) estimation was used to separately compare perinatal outcomes between those initiating glyburide and insulin. This approach was combined with Super Learning for propensity score estimation to account for both baseline and time-dependent confounding in both per-protocol (primary) and intention-to-treat (secondary) analyses to evaluate sustained exposure to the same therapy.

RESULTS

From 2007 to 2017, 11 321 patients with GDM (mean [SD] age, 32.9 [4.9] years) initiated glyburide or insulin during pregnancy. In multivariate models, the risk of neonatal respiratory distress was 2.03 (95% CI, 0.13-3.92) per 100 births lower and the risk of NICU admission was 3.32 (95% CI, 0.20-6.45) per 100 births lower after continuous exposure to glyburide compared with insulin. There were no statistically significant differences in glyburide vs insulin initiation in risk for neonatal hypoglycemia (0.85 [95% CI, -1.17 to 2.86] per 100 births), jaundice (0.02 [95% CI, -1.46 to 1.51] per 100 births), shoulder dystocia (-1.05 [95% CI, -2.71 to 0.62] per 100 births), or large-for-gestational age categories (-2.75 [95% CI, -6.31 to 0.80] per 100 births).

CONCLUSIONS AND RELEVANCE

Using data from a clinical setting and contemporary causal inference methods, our findings do not provide evidence of a difference in the outcomes examined between patients with GDM initiating glyburide compared with those initiating insulin.

Effectiveness of antidiabetic agents for treatment of gestational diabetes: A methodological quality assessment of meta-analyses and network meta-analysis

AIMS/INTRODUCTION

Despite there being several meta-analyses on the effects of antidiabetic agents in patients with gestational diabetes mellitus, the reliability of their findings is a concern, mainly due to undetermined methodological quality of these studies. This study aimed to assess the methodological quality of available meta-analyses and provide a summary estimation of the effectiveness of treatments modalities.

MATERIALS AND METHODS

PubMed, Web of Science and Scopus databases were comprehensively searched for retrieving relevant meta-analyses published in English up to May 2020. A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) was applied to evaluate methodological quality of eligible meta-analyses. A network meta-analysis was used to calculate the pooled odds ratio of maternal and neonatal outcomes in gestational diabetes mellitus patients treated with metformin or glyburide compared with those treated with insulin. The rank network analysis was carried out for ranking of the treatments and reporting the most efficient treatment.

RESULTS

A total of 27 and 17 studies were included for qualitative and quantitative syntheses, respectively; of these, just four studies were classified as high quality. The results showed that metformin had the highest probability of being the best treatment, compared with insulin and glyburide, for the majority of adverse neonatal outcomes, whereas glyburide was the best treatment in reducing the risk of adverse maternal outcomes. The results were not significantly changed after excluding low-quality studies.

CONCLUSIONS

This review study of available literature shows that metformin can be a superior option in most neonatal and maternal adverse pregnancy outcomes in women with gestational diabetes mellitus; the results need to be further updated by including future more qualified studies.

Improvement Effect of Metformin on Female and Male Reproduction in Endocrine Pathologies and Its Mechanisms

Metformin (MF), a first-line drug to treat type 2 diabetes mellitus (T2DM), alone and in combination with other drugs, restores the ovarian function in women with polycystic ovary syndrome (PCOS) and improves fetal development, pregnancy outcomes and offspring health in gestational diabetes mellitus (GDM) and T2DM. MF treatment is demonstrated to improve the efficiency of in vitro fertilization and is considered a supplementary drug in assisted reproductive technologies. MF administration shows positive effect on steroidogenesis and spermatogenesis in men with metabolic disorders, thus MF treatment indicates prospective use for improvement of male reproductive functions and fertility. MF lacks teratogenic effects and has positive health effect in newborns. The review is focused on use of MF therapy for restoration of female and male reproductive functions and improvement of pregnancy outcomes in metabolic and endocrine disorders. The mechanisms of MF action are discussed, including normalization of metabolic and hormonal status in PCOS, GDM, T2DM and metabolic syndrome and restoration of functional activity and hormonal regulation of the gonadal axis.

Current Resources for Evidence-Based Practice, November 2020

An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of diversity in the maternity care workforce and commentaries on reviews focused on burnout in midwifery and a cross-national comparison of guidelines for uncomplicated childbirth.

Interleukin-1β and Cancer

Within a tumor, IL-1β is produced and secreted by various cell types, such as immune cells, fibroblasts, or cancer cells. The IL1B gene is induced after "priming" of the cells and a second signal is required to allow IL-1β maturation by inflammasome-activated caspase-1. IL-1β is then released and leads to transcription of target genes through its ligation with IL-1R1 on target cells. IL-1β expression and maturation are guided by gene polymorphisms and by the cellular context. In cancer, IL-1β has pleiotropic effects on immune cells, angiogenesis, cancer cell proliferation, migration, and metastasis. Moreover, anti-cancer treatments are able to promote IL-1β production by cancer or immune cells, with opposite effects on cancer progression. This raises the question of whether or not to use IL-1β inhibitors in cancer treatment.