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Ait-Chikh C, Page G, Thoreau V. Physiologically-based pharmacokinetic models to predict drug exposure during pregnancy. ANNALES PHARMACEUTIQUES FRANÇAISES 2024; 82:236-242. [PMID: 37739215 DOI: 10.1016/j.pharma.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 09/15/2023] [Accepted: 09/16/2023] [Indexed: 09/24/2023]
Abstract
As pregnant women are constantly exposed to drugs during pregnancy, either to treat long-term conditions or acute illnesses, drug safety is a major concern for the fetus and the mother. Clinical trials are rarely made in this population due to strict regulation and ethical reasons. However, drug pharmacokinetic (PK) parameters vary during pregnancy with an increase in distribution volume, renal clearance and more. In addition, the fetal distribution should be evaluated with the importance of placental diffusion, both active and passive. Therefore, there is a recent interest in the use of physiologically-based pharmacokinetic (PBPK) modeling to characterize these changes and complete the sparse data available on drug PK during pregnancy. Indeed, PBPK models integrate drug physicochemical and physiological parameters corresponding to each compartment of the body to estimate drug concentrations. This review establishes an overview on the current use of PBPK models in drug dosage determination for the pregnant woman, fetal exposure and drug interactions in the fetal compartment.
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Affiliation(s)
- Celia Ait-Chikh
- Faculté de médecine et pharmacie, université de Poitiers, UFR médecine et pharmacie, bâtiment D1, 6, rue de la Milétrie, TSA 51115, 86073 Poitiers cedex 9, France.
| | - Guylène Page
- Faculté de médecine et pharmacie, université de Poitiers, UFR médecine et pharmacie, bâtiment D1, 6, rue de la Milétrie, TSA 51115, 86073 Poitiers cedex 9, France; Neurovascular Unit and Cognitive Disorders (NEUVACOD), pôle Biologie santé, université de Poitiers, Poitiers, France
| | - Vincent Thoreau
- Faculté de médecine et pharmacie, université de Poitiers, UFR médecine et pharmacie, bâtiment D1, 6, rue de la Milétrie, TSA 51115, 86073 Poitiers cedex 9, France; Neurovascular Unit and Cognitive Disorders (NEUVACOD), pôle Biologie santé, université de Poitiers, Poitiers, France
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2
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Jeeyavudeen MS, Murray SR, Strachan MWJ. Management of monogenic diabetes in pregnancy: A narrative review. World J Diabetes 2024; 15:15-23. [PMID: 38313847 PMCID: PMC10835499 DOI: 10.4239/wjd.v15.i1.15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/13/2023] [Accepted: 12/08/2023] [Indexed: 01/12/2024] Open
Abstract
Pregnancy in women with monogenic diabetes is potentially complex, with significant implications for both maternal and fetal health. Among these, maturity-onset diabetes of the young (MODY) stands out as a prevalent monogenic diabetes subtype frequently encountered in clinical practice. Each subtype of MODY requires a distinct approach tailored to the pregnancy, diverging from management strategies in non-pregnant individuals. Glucokinase MODY (GCK-MODY) typically does not require treatment outside of pregnancy, but special considerations arise when a woman with GCK-MODY becomes pregnant. The glycemic targets in GCK-MODY pregnancies are not exclusively dictated by the maternal/paternal MODY genotype but are also influenced by the genotype of the developing fetus. During pregnancy, the choice between sulfonylurea or insulin for treating hepatocyte nuclear factor 1-alpha (HNF1A)-MODY and HNF4A-MODY depends on the mother's specific circumstances and the available expertise. Management of other rarer MODY subtypes is individualized, with decisions made on a case-by-case basis. Therefore, a collaborative approach involving expert diabetes and obstetric teams is crucial for the comprehensive management of MODY pregnancies.
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Affiliation(s)
| | - Sarah R Murray
- MRC Centre for Reproductive Health, University of Edinburgh Queen’s Medical Research Institute, Edinburgh EH16 4TJ, United Kingdom
| | - Mark W J Strachan
- Metabolic Unit, Western General Hospital, Edinburgh EH4 2XU, United Kingdom
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3
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Wang T, Jing Y, Guo H, Xu J, Wang M, Huang L, Chen H, Cui W, Song L, Liu X, Sun B, Wang N. Efficacy and safety of hypoglycemic agents on gestational diabetes mellitus in women: A Bayesian network analysis of randomized controlled trials. Front Public Health 2022; 10:980578. [PMID: 36530712 PMCID: PMC9757606 DOI: 10.3389/fpubh.2022.980578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 11/08/2022] [Indexed: 12/05/2022] Open
Abstract
Objective To compare the efficacy and safety of metformin, glyburide, and insulin for GDM, we conducted a subgroup analysis of outcomes for women with GDM according to the International Association of Diabetes and Pregnancy Study Groups (IADPSG) diagnostic criteria. Methods We searched the NCBI, Embase, and Web of Science databases from inception to March 2022. Randomized controlled trials (RCTs) that compared the outcomes of hypoglycemic agents in women with GDM were included. Bayesian network analysis was employed. Results A total of 29 RCTs were included. Metformin was estimated to lead to a slight improvement in total gestational weight gain (WMD - 1.24 kg, 95% CI -2.38, -0.09), a risk of unmet treatment target in the sensitivity analysis (OR 34.50, 95% CI 1.18-791.37) than insulin. The estimated effect of metformin showed improvements in birth weight than insulin (WMD - 102.58 g, 95% CI -180.45 to -25.49) and glyburide (WMD - 137.84 g, 95% CI -255.31 to -25.45), for hypoglycemia within 1 h of birth than insulin (OR 0.65, 95% CI 0.47 to 0.84). The improvement in the estimated effect of metformin for hypoglycemia within 1 h of birth still existed when compared with glyburide (OR 0.41, 95% CI 0.26 to 0.66), whether in the IADPSG group (OR 0.33, 95% CI 0.12 to 0.92) or not (OR 0.43, 95% CI 0.20 to 0.98). Conclusion Metformin is beneficial for GDM women to control total GWG compared with insulin, regulate fetal birth weight more than insulin and glyburide, and increase the risk of unmet treatment targets compared with insulin. Compared to metformin, glyburide is associated with neonatal hypoglycemia.
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Affiliation(s)
- Ting Wang
- Department of Endocrinology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China,Department of Respiratory Medicine, Xi'an People's Hospital (Xi'an No. 4 Hospital), Xi'an, China
| | - Yingyu Jing
- Department of Endocrinology and Second Department of Geriatrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Haonan Guo
- Department of Endocrinology and Second Department of Geriatrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Jing Xu
- Department of Endocrinology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Man Wang
- Department of Cardiovascular Medicine, Xi'an People's Hospital (Xi'an No. 4 Hospital), Xi'an, China
| | - Lili Huang
- Department of Medical Ultrasound, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Huan Chen
- Department of Endocrinology and Second Department of Geriatrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wei Cui
- Department of Endocrinology and Second Department of Geriatrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Lin Song
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China
| | - Xiang Liu
- Chinese Journal of Woman and Child Health Research, Xi'an, China
| | - Bo Sun
- Department of Physiology and Pathophysiology, School of Basic Medical Sciences, Xi'an Jiaotong University Health Science Center, Xi'an, China,*Correspondence: Bo Sun
| | - Ning Wang
- Department of Endocrinology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China,Postdoctoral Research Station, School of Nursing, Health Science Center, Xi'an Jiaotong University, Xi'an, China,Ning Wang
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4
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Abstract
Gestational diabetes mellitus (GDM) traditionally refers to abnormal glucose tolerance with onset or first recognition during pregnancy. GDM has long been associated with obstetric and neonatal complications primarily relating to higher infant birthweight and is increasingly recognized as a risk factor for future maternal and offspring cardiometabolic disease. The prevalence of GDM continues to rise internationally due to epidemiological factors including the increase in background rates of obesity in women of reproductive age and rising maternal age and the implementation of the revised International Association of the Diabetes and Pregnancy Study Groups' criteria and diagnostic procedures for GDM. The current lack of international consensus for the diagnosis of GDM reflects its complex historical evolution and pragmatic antenatal resource considerations given GDM is now 1 of the most common complications of pregnancy. Regardless, the contemporary clinical approach to GDM should be informed not only by its short-term complications but also by its longer term prognosis. Recent data demonstrate the effect of early in utero exposure to maternal hyperglycemia, with evidence for fetal overgrowth present prior to the traditional diagnosis of GDM from 24 weeks' gestation, as well as the durable adverse impact of maternal hyperglycemia on child and adolescent metabolism. The major contribution of GDM to the global epidemic of intergenerational cardiometabolic disease highlights the importance of identifying GDM as an early risk factor for type 2 diabetes and cardiovascular disease, broadening the prevailing clinical approach to address longer term maternal and offspring complications following a diagnosis of GDM.
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Affiliation(s)
- Arianne Sweeting
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Jencia Wong
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - Helen R Murphy
- Diabetes in Pregnancy Team, Cambridge University Hospitals, Cambridge, UK
- Norwich Medical School, Bob Champion Research and Education Building, University of East Anglia, Norwich, UK
- Division of Women’s Health, Kings College London, London, UK
| | - Glynis P Ross
- Department of Endocrinology, Royal Prince Alfred Hospital, Sydney, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
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5
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Size-dependent placental retention effect of liposomes in ICR pregnant mice: Potential superiority in placenta-derived disease therapy. Int J Pharm 2022; 625:122121. [PMID: 35987320 DOI: 10.1016/j.ijpharm.2022.122121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 08/10/2022] [Accepted: 08/13/2022] [Indexed: 11/23/2022]
Abstract
The great challenge in developing safe medications for placenta-derived diseases is to reduce or eliminate fetal drug exposure while still providing the necessary therapeutic effect. Rapid advances in nanotechnology have brought opportunities for the therapy of placenta-derived disease through accumulating the drug in the placenta while reducing its placental penetration. Among various nanocarriers, liposomes are regarded as an ideal type of carrier for placental drug delivery due to their biosafety and biodegradability. However, their placental retention effect with different particle sizes has not been studied. This research aimed to explore a suitable size of liposomes for placenta drug delivery. Cy 5 dye was chosen as a model molecule for tracing the distribution of three different-sized liposomes (∼80 nm, 200 nm, and 500 nm) in ICR pregnant mice. The stability, cytotoxicity, and cellular uptake study of Cy 5-loaded liposomes were performed. The in vivo fluorescence studies on ICR pregnant mice suggested that the particle size of liposomes was positively correlated with the degree of liposome aggregation in the placenta. The ratio of fluorescence in the placenta and fetus section (P/F value) was proposed to evaluate the placental retention effect of different-sized liposomes. The results showed that the liposomes with 500 nm had the highest P/F value and thus exhibited the strongest placental retention effect and the weakest placental penetration ability. Moreover, liquid chromatography-mass spectrometry analysis confirmed the reliability of the fluorescence section analysis in exploring the placental retention effect of nanovehicles. In general, this study introduced a simple and intuitive method to evaluate the placental retention effect of nanoplatforms and defined a suitable size of liposomes for placenta-derived disease drug delivery.
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Harrison RK, Saravanan V, Davitt C, Cruz M, Palatnik A. Antenatal maternal hypoglycemia in women with gestational diabetes mellitus and neonatal outcomes. J Perinatol 2022; 42:1091-1096. [PMID: 35194160 DOI: 10.1038/s41372-022-01350-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Revised: 01/26/2022] [Accepted: 02/08/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To examine the prevalence of antenatal maternal hypoglycemia after initiation of pharmacotherapy for gestational diabetes mellitus (GDMA2) and its association with pregnancy outcomes. STUDY DESIGN Retrospective cohort of GDMA2 women receiving either insulin or oral hypoglycemic agents. Composite neonatal outcome included macrosomia, jaundice, respiratory distress syndrome, large for gestational age, shoulder dystocia, birth trauma, 5-minute Apgar < 7, and neonatal hypoglycemia, and was compared between women with and without hypoglycemia using bivariate and multivariate analyses. RESULTS Of 489 women included in the study, 95 (19.4%) had at least one episode of hypoglycemia, most often in the setting of glyburide. Newborns exposed to maternal hypoglycemia had higher rates of the composite neonatal outcome (54.7% vs. 38.3%, p = 0.004). After controlling for confounding factors, maternal hypoglycemia remained independently associated with the composite neonatal outcome (aOR = 1.69, 95% CI 1.04-2.72). CONCLUSION Maternal hypoglycemia in GDMA2 was associated with higher rates of adverse neonatal outcomes.
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Affiliation(s)
- Rachel K Harrison
- Maternal Fetal Medicine, Advocate Medical Group, 4400W. 95th St, Suite 207, Chicago, IL, 60453, USA
| | - Vishmayaa Saravanan
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, 9200W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Caroline Davitt
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, 9200W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Meredith Cruz
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, 9200W. Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Anna Palatnik
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, 9200W. Wisconsin Ave, Milwaukee, WI, 53226, USA.
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7
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van Hove H, Mathiesen L, Freriksen J, Vähäkangas K, Colbers A, Brownbill P, Greupink R. Placental transfer and vascular effects of pharmaceutical drugs in the human placenta ex vivo: A review. Placenta 2022; 122:29-45. [DOI: 10.1016/j.placenta.2022.03.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/15/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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8
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Yu DQ, Xu GX, Teng XY, Xu JW, Tang LF, Feng C, Rao JP, Jin M, Wang LQ. Glycemic control and neonatal outcomes in women with gestational diabetes mellitus treated using glyburide, metformin, or insulin: a pairwise and network meta-analysis. BMC Endocr Disord 2021; 21:199. [PMID: 34641848 PMCID: PMC8513183 DOI: 10.1186/s12902-021-00865-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 09/24/2021] [Indexed: 02/06/2023] Open
Abstract
AIMS We aimed to assess the comparative efficiency and safety of the use of glyburide, metformin, and insulin in gestational diabetes mellitus (GDM). METHODS We searched for randomized controlled trials that compared glyburide, metformin, and insulin in GDM. Data regarding glycemic control and neonatal safety were collected and analyzed in pairwise and network meta-analyses. RESULTS A total of 4533 individuals from 23 trials were included. Compared with glyburide, metformin reduced 2-h postprandial blood glucose (2HPG) to a greater extent (standard mean difference (SMD) 0.18; 95% credible interval (CI) 0.01, 0.34). There were significantly lower prevalence of neonatal hypoglycemia (risk difference (RD) - 0.07; 95%CI - 0.11, - 0.02) and preeclampsia (RD - 0.03; 95%CI - 0.06, 0) in the metformin group than in the insulin group. The metformin group had significantly lower birth weight (SMD - 0.17; 95%CI - 0.25, - 0.08) and maternal weight gain (SMD - 0.61; 95%CI - 0.86,- 0.35) compared with the insulin group. Network meta-analysis suggested that metformin had the highest probability of successfully controlling glycemia and preventing neonatal complications. CONCLUSIONS The present meta-analysis suggests that metformin may be as effective as insulin for glycemic control and is the most promising drug for the prevention of neonatal and maternal complications.
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Affiliation(s)
- Dan-Qing Yu
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Guan-Xin Xu
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Xin-Yuan Teng
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Jing-Wei Xu
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Liang-Fang Tang
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Chun Feng
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Jin-Peng Rao
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Min Jin
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China
| | - Li-Quan Wang
- The Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Rd, Zhejiang, 310009, Hangzhou, China.
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9
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Rodenstein MS, Bianco ME, Ramchal MU, Murias M, Silton RL, Josefson JL. Long-term follow-up of children with in utero exposure to sulfonylurea medications. Obes Sci Pract 2021; 7:487-493. [PMID: 34401206 PMCID: PMC8346368 DOI: 10.1002/osp4.488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/06/2021] [Accepted: 01/31/2021] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Offspring born to mothers with gestational diabetes mellitus (GDM) are more likely to have negative neurodevelopmental health outcomes, early obesity, type 2 diabetes, and metabolic syndrome in childhood, adolescence, and adulthood. Standard of care management for GDM and type 2 diabetes mellitus during pregnancy is insulin, but oral sulfonylurea use is increasing, and these medications cross the placenta. Literature on treatment with sulfonylureas for maternal GDM has focused on maternal glycemic control and neonatal outcomes. Studies that have evaluated the long-term outcomes of children exposed to sulfonylureas in utero are limited. OBJECTIVE This study evaluated anthropometric and neurodevelopmental outcomes of 55 children (ages 5-10) born to mothers with diabetes during pregnancy treated with sulfonylurea or insulin. METHODS AND RESULTS A group of 25 sulfonylurea-exposed and 30 insulin-exposed participants were age- and sex-matched between groups. No significant differences were identified in z-scores for body mass index (BMI), waist circumference, skinfold measurements, and body fat or rates of overweight/obese BMI between groups. On performance-based cognitive assessment, the sulfonylurea-exposed group had significantly lower scores on inhibition (p = 0.043). CONCLUSION In summary, children with in utero sulfonylurea exposure had similar physical measurements compared to children with insulin exposure and lower performance on a measure of executive function (inhibition), which is associated with adverse health outcomes.
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Affiliation(s)
- Marissa S. Rodenstein
- Department of Medical EducationNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Monica E. Bianco
- Department of PediatricsNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Maegan U. Ramchal
- Institute for Innovations in Developmental SciencesNorthwestern UniversityChicagoIllinoisUSA
| | - Michael Murias
- Institute for Innovations in Developmental SciencesNorthwestern UniversityChicagoIllinoisUSA
| | | | - Jami L. Josefson
- Department of PediatricsNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
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10
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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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11
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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: 39] [Impact Index Per Article: 9.8] [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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12
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Lofthouse EM, Cleal JK, Hudson G, Lewis RM, Sengers BG. Glibenclamide transfer across the perfused human placenta is determined by albumin binding not transporter activity. Eur J Pharm Sci 2020; 152:105436. [PMID: 32592753 DOI: 10.1016/j.ejps.2020.105436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/29/2020] [Accepted: 06/23/2020] [Indexed: 12/16/2022]
Abstract
The placenta mediates the transfer of maternal nutrients into the fetal circulation while removing fetal waste products, drugs and environmental toxins that may otherwise be detrimental to fetal development. This study investigated the role of drug transporters and protein binding in the transfer of the antidiabetic drug glibenclamide across the human placental syncytiotrophoblast using placental perfusion experiments and computational modeling. In the absence of albumin, placental glibenclamide uptake from the fetal circulation was not affected by competitive inhibition with bromosulphothalein (BSP), indicating that OATP2B1 does not mediate placental glibenclamide uptake from the fetus. In the presence of maternal and fetal albumin, BSP increased placental glibenclamide uptake from the fetal circulation by displacing glibenclamide from BSA, increasing the free fraction of glibenclamide driving diffusive transport. The P-gp and BCRP inhibitor GF120918 did not affect placental glibenclamide uptake from the maternal circulation and as such this study did not find any evidence for the apical efflux transporters in placental glibenclamide transfer. Computational modeling confirmed that albumin binding and not transporter activity, is the dominant factor in the transfer of glibenclamide across the human placenta. The effect of BSP binding to albumin on promoting the diffusive transfer of glibenclamide highlights the importance of drug-protein binding interactions and their interpretation using computational modeling.
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Affiliation(s)
- Emma M Lofthouse
- Faculty of Medicine, University of Southampton, UK; Institute for Life Sciences, University of Southampton, UK
| | - Jane K Cleal
- Faculty of Medicine, University of Southampton, UK; Institute for Life Sciences, University of Southampton, UK
| | | | - Rohan M Lewis
- Faculty of Medicine, University of Southampton, UK; Institute for Life Sciences, University of Southampton, UK
| | - Bram G Sengers
- Faculty of Engineering and Physical Sciences, University of Southampton, UK; Institute for Life Sciences, University of Southampton, UK.
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13
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Bouchghoul H, Alvarez JC, Verstuyft C, Bouyer J, Senat MV. Transplacental transfer of glyburide in women with gestational diabetes and neonatal hypoglycemia risk. PLoS One 2020; 15:e0232002. [PMID: 32379777 PMCID: PMC7205195 DOI: 10.1371/journal.pone.0232002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Accepted: 04/03/2020] [Indexed: 11/28/2022] Open
Abstract
Background In pregnant women with gestational diabetes, glyburide can be an alternative to insulin despite concerns about its transplacental transfer. However, transplacental transfer of glyburide is poorly quantified and the relationship between cord blood glyburide concentration and hypoglycemia has not been studied. Our objective was to quantify the transplacental transfer of glyburide at delivery and to study the association between the cord blood glyburide concentration and the risk of neonatal hypoglycemia in patients with gestational diabetes treated with glyburide. Methods and findings INDAO was a multicenter, noninferiority, randomized trial conducted between May 2012 and November 2016 in 914 women with singleton pregnancies and gestational diabetes. An ancillary study was conducted in the 87 patients of the Bicêtre University Hospital Center. The sample consisted of 46 patients with utilizable assays at delivery. The relationships between glyburide concentration and the time since the last intake of glyburide and between fetal glyburide concentration and neonatal hypoglycemia were modeled with linear or logistic regressions using fractional polynomials. There was placental transfer of glyburide at a fetal to maternal ratio of 62% (95% CI [50; 74]). Umbilical cord blood glyburide concentration decreased steeply after the last maternal glyburide intake. After 24 hours, the mean umbilical cord blood concentration was less than 5 ng/mL. Neonatal hypoglycemia risk was increased with an odds ratio of hypoglycemia equal to 3.70 [1.40–9.77] for each 10 ng/mL increase in the cord blood glyburide concentration. However, no newborns were admitted to the NICU because of clinical signs of hypoglycemia or for treatment of hypoglycemia. Conclusion Considering that neonatal glyburide exposure may be limited by stopping treatment a sufficient time before labor, there may still be a place for glyburide in the management of gestational diabetes.
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Affiliation(s)
- Hanane Bouchghoul
- Department of Gynecology-Obstetrics, Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, UVSQ, Inserm, CESP, Villejuif, France
- * E-mail:
| | - Jean-Claude Alvarez
- Département de Pharmacologie-Toxicologie, Assistance Publique-Hôpitaux de Paris, Hôpital Raymond Poincaré, MasSpecLab, Plateforme de spectrométrie de masse, Inserm U-1173, UFR PIFO, Université Versailles Saint Quentin-en-Yvelines, Garches, France
| | - Céline Verstuyft
- Assistance Publique-Hôpitaux de Paris, Hôpital Bicêtre, Service de Génétique moléculaire, Pharmacogénétique et Hormonologie, Inserm U 1178 équipe Dépression, CESP, Université Paris-Sud, Le Kremlin-Bicêtre, France
| | - Jean Bouyer
- Université Paris-Saclay, UVSQ, Inserm, CESP, Villejuif, France
| | - Marie-Victoire Senat
- Department of Gynecology-Obstetrics, Assistance Publique-Hôpitaux de Paris, Bicêtre Hospital, Le Kremlin-Bicêtre, France
- Université Paris-Saclay, UVSQ, Inserm, CESP, Villejuif, France
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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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15
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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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16
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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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17
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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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18
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Abstract
Although it has been accepted for decades that women with gestational diabetes mellitus (GDM) are at high risk for future development of type 2 diabetes, vigorous debate regarding the value of detecting and treating GDM has persisted into the twenty-first century. Although results from 2 randomized trials provide strong evidence that treating GDM reduces adverse perinatal outcomes, it remains to be determined whether treatment impacts long-term offspring outcomes. Insulin is the first-line pharmacologic treatment and is added when glycemic goals are not met with nutritional modifications. Oral agent use is controversial, as data on long-term offspring outcomes are lacking.
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Affiliation(s)
- Emily D Szmuilowicz
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, 645 North Michigan Avenue, 530-24, Chicago, IL 60611, USA
| | - Jami L Josefson
- Division of Endocrinology, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, 225 East Chicago Avenue, Box 54, Chicago, IL 60611, USA
| | - Boyd E Metzger
- Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Tarry Building, Room 12-703, 300 East Superior, Chicago, IL 60611, USA.
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19
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Dallmann A, Liu XI, Burckart GJ, van den Anker J. Drug Transporters Expressed in the Human Placenta and Models for Studying Maternal-Fetal Drug Transfer. J Clin Pharmacol 2019; 59 Suppl 1:S70-S81. [PMID: 31502693 PMCID: PMC7304533 DOI: 10.1002/jcph.1491] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 06/25/2019] [Indexed: 12/30/2022]
Abstract
Tremendous efforts have been directed to investigate the ontogeny of drug transporters in fetuses, neonates, infants, and children based on their importance for understanding drug pharmacokinetics. During development (ie, in the fetus and newborn infant), there is special interest in transporters expressed in the placenta that modulate placental drug transfer. Many of these transporters can decrease or increase drug concentrations in the fetus and at birth, stressing the relevance of elucidating expression in the placenta and potential gestational age-dependent changes therein. Hence, the main objective of this review was to summarize the current knowledge about expression and ontogeny of transporters in the human placenta in healthy pregnant women. In addition, various in vitro, ex vivo, and in silico models that can be used to investigate placental drug transfer, namely, placental cancer cell lines, ex vivo cotyledon perfusion experiments, and physiologically based pharmacokinetic (PBPK) models, are discussed together with their advantages and shortcomings. A particular focus was placed on PBPK models because these models can integrate different types of information, such as expression data, ontogeny information, and observations obtained from the ex vivo cotyledon perfusion experiment. Such a mechanistic modeling framework may leverage the available information and ultimately help to improve knowledge about the adequacy and safety of pharmacotherapy in pregnant women and their fetuses.
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Affiliation(s)
- André Dallmann
- Pediatric Pharmacology and Pharmacometrics Research Center, University Children’s Hospital Basel (UKBB), Switzerland
| | - Xiaomei I. Liu
- Division of Clinical Pharmacology, Children’s National Medical Center, Washington, DC, USA
| | - Gilbert J. Burckart
- US Food and Drug Administration, Office of Clinical Pharmacology, Silver Spring, MD, USA
| | - John van den Anker
- Pediatric Pharmacology and Pharmacometrics Research Center, University Children’s Hospital Basel (UKBB), Switzerland
- Division of Clinical Pharmacology, Children’s National Medical Center, Washington, DC, USA
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20
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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: 777] [Impact Index Per Article: 155.4] [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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21
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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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22
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Abstract
PURPOSE OF REVIEW Gestational diabetes (GDM) is associated with adverse pregnancy and neonatal outcomes and increased maternal risk for subsequent type 2 diabetes. The best diagnostic strategy for GDM is debated and the role of oral antidiabetic medications (OAD) for treatment is unclear. In this paper, we review methods of GDM diagnosis, updates in GDM therapy, and interventions to reduce future type 2 diabetes in women with a history of GDM. RECENT FINDINGS A "one-step" screening protocol for GDM using 75-g, 2-h oral glucose tolerance testing at 24-28 weeks gestation is recommended by the International Association of the Diabetes and Pregnancy Study Groups, the American Diabetes Association, and the Endocrine Society. This strategy identifies a milder degree of hyperglycemia and thus increases GDM prevalence. Studies indicate that in these cases of mild hyperglycemia, treatment decreases pregnancy and neonatal complications. Insulin analogues including detemir, aspart, and lispro have been shown to be safe in pregnancy with a pregnancy category B classification. Growing literature suggests that sulfonylureas cross the placenta and are associated with increased incidence of macrosomia and neonatal hypoglycemia. Telephone or online diabetes prevention program (DPP)-based interventions for women with GDM have shown encouraging results in pilot studies. Insurance coverage remains a barrier. Additional studies are needed to determine the safety of OAD in pregnancy. Public policy supporting DPP could help improve patient access to these proven interventions.
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Affiliation(s)
- Laura T Dickens
- Department of Medicine, Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago, 5841 S. Maryland Ave., MC 1027, Chicago, IL, 60637, USA.
| | - Celeste C Thomas
- Department of Medicine, Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago, 5841 S. Maryland Ave., MC 1027, Chicago, IL, 60637, USA
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23
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Affiliation(s)
- Shiqiao Peng
- Department of Endocrinology and Metabolism, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Chenyan Li
- Department of Endocrinology and Metabolism, First Affiliated Hospital of China Medical University, Shenyang, China
| | - Xuren Sun
- Department of Gastroenterology, First Affiliated Hospital of China Medical University, Shenyang, China
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24
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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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25
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van Weelden W, Wekker V, de Wit L, Limpens J, Ijäs H, van Wassenaer-Leemhuis AG, Roseboom TJ, van Rijn BB, DeVries JH, Painter RC. Long-Term Effects of Oral Antidiabetic Drugs During Pregnancy on Offspring: A Systematic Review and Meta-analysis of Follow-up Studies of RCTs. Diabetes Ther 2018; 9:1811-1829. [PMID: 30168045 PMCID: PMC6167305 DOI: 10.1007/s13300-018-0479-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Antidiabetic drugs (OADs) are increasingly prescribed to treat hyperglycaemia during pregnancy in women with gestational diabetes mellitus (GDM) or polycystic ovary syndrome (PCOS), even though long-term effects on offspring are unknown. This systematic review summarises the evidence of follow-up studies of randomised controlled trials (RCTs) reporting on long-term effects of prenatal exposure to OADs on offspring. METHODS The MEDLINE, EMBASE and CENTRAL databases were searched from inception to April 2018 for the concepts antidiabetic agents and prenatal exposure (or pregnancy and offspring/child) in combination with an RCT search filter. RCTs evaluating post-neonatal health effects in offspring and comparing maternal treatment with an OAD with no treatment, placebo, an alternative OAD or insulin during pregnancy were eligible for inclusion. Two independent researchers selected, extracted and assessed the data. Meta-analyses were performed using a random effects model and the Cochrane Collaboration's risk of bias tool was used for quality assessment. RESULTS Ten studies were included, with a maximal follow-up duration of 9 years, comprising 778 children of mothers with GDM or PCOS who were randomised to either metformin or insulin/placebo during pregnancy. Meta-analysis showed that children prenatally exposed to metformin were heavier compared to controls (standardised mean difference (SMD) 0.26 [95% CI 0.11-0.41]), but not taller (SMD 0.10 [95% CI -0.14-0.33]). Additionally, offspring body mass index (BMI) z scores did not differ according to metformin exposure (mean difference 0.30 [95% CI -0.01-0.61]). Individual small studies reported that prenatal exposure to metformin was associated with greater mid-upper arm, head and waist circumferences, biceps skinfolds, waist-to-height ratio, more arm fat, higher fasting glucose, ferritin and lower LDL cholesterol in offspring. CONCLUSION Prenatal exposure to metformin is associated with increased offspring weight, but not with height or BMI. Larger follow-up studies are needed to confirm and look into the implications of these findings. Plain language summary available for this article.
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Affiliation(s)
- Wenneke van Weelden
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Vincent Wekker
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Leon de Wit
- Department of Gynaecology and Obstetrics, Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jacqueline Limpens
- Medical Library, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hilkka Ijäs
- Department of Obstetrics and Gynaecology, Oulu University Hospital, Oulu, Finland
| | - Aleid G van Wassenaer-Leemhuis
- Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Tessa J Roseboom
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Bas B van Rijn
- Department of Gynaecology and Obstetrics, Wilhelmina Children's Hospital Birth Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Rebecca C Painter
- Department of Obstetrics and Gynaecology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
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Langer O. Pharmacological treatment of gestational diabetes mellitus: point/counterpoint. Am J Obstet Gynecol 2018; 218:490-499. [PMID: 29499921 DOI: 10.1016/j.ajog.2018.01.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/22/2018] [Accepted: 01/22/2018] [Indexed: 12/25/2022]
Abstract
Controversies persist over the most efficacious pharmacologic treatment for gestational diabetes mellitus. For purposes of accuracy in this article, the individual American College of Obstetricians and Gynecologists Practice Bulletin and American Diabetes Association Standards of Medical Care positions on each issue are quoted and then deliberated with evidence of counter claims presented in point/counterpoint. This is a review of all the relevant evidence for the most holistic picture possible. The main issues are (1) which diabetic drugs cross the placenta, (2) the quality of evidence and data source validity, (3) the rationale for the designation of glucose control as the primary outcome in gestational diabetes mellitus, and (4) which drugs (metformin, glyburide, or insulin) are most effective in improving secondary outcomes. The concept that 1 drug fits all, whether it be insulin, glyburide, or metformin, is a fallacy. Different drugs provide certain benefits but not all the benefits and not to all patients. In addition, the steps in the gestational diabetes mellitus management decision path and the current cost of the use of insulin, glyburide, or metformin are addressed. In the future, we must consider studying the potential of diabetic drugs that currently are used in nonpregnancy and incorporating the concept of precision medicine in the decision tree to maximize pregnancy outcomes.
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Feghali MN, Abebe KZ, Comer DM, Caritis S, Catov JM, Scifres CM. Pregnancy outcomes in women with an early diagnosis of gestational diabetes mellitus. Diabetes Res Clin Pract 2018; 138:177-186. [PMID: 29427694 PMCID: PMC5910191 DOI: 10.1016/j.diabres.2018.02.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/16/2018] [Accepted: 02/01/2018] [Indexed: 01/08/2023]
Abstract
AIM To examine pregnancy outcomes in women with gestational diabetes mellitus (GDM) based on the timing of diagnosis. METHOD We compared demographics, blood sugars and outcomes between women diagnosed before (n = 167) or after 24 weeks' gestation (n = 1202) in a single hospital between 2009 and 2012. Because early screening is risk-based we used propensity score modelling and conditional logistic regression to account for systematic differences. RESULTS Women diagnosed with GDM before 24 weeks were more likely to be obese and they were less likely to have excess gestational weight gain (35 vs. 45%, p = 0.04). Early diagnosis was associated with more frequent therapy including glyburide (65 vs. 56%, p < 0.001) and insulin (19 vs 6%, p < 0.001). After propensity score modelling and accounting for covariates, early diagnosis was associated with an increased risk for macrosomia (OR 2, 95% 1-4.15, p = 0.0498). Early diagnosis was not associated with other adverse outcomes. In a subgroup analysis comparing women treated with glyburide prior to 24 weeks compared to those diagnosed after 24 weeks, early diagnosis in women treated with glyburide was associated with an increased risk for macrosomia (OR 2.3, 95% CI 1.1-5.4, P = 0.04). CONCLUSION Women diagnosed with GDM before 24 weeks have unique features, are at risk for adverse outcomes, and require targeted approaches to therapy.
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Affiliation(s)
- Maisa N Feghali
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, United States.
| | - Kaleab Z Abebe
- Department of Medicine, University of Pittsburgh School of Medicine, United States
| | - Diane M Comer
- Department of Medicine, University of Pittsburgh School of Medicine, United States
| | - Steve Caritis
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, United States
| | - Janet M Catov
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, United States
| | - Christina M Scifres
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh School of Medicine, United States; Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, United States
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Abstract
PURPOSE OF REVIEW Monogenic diabetes accounts for 1-2% of all diabetes cases, but is frequently misdiagnosed as type 1, type 2, or gestational diabetes. Accurate genetic diagnosis directs management, such as no pharmacologic treatment for GCK-MODY, low-dose sulfonylureas for HNF1A-MODY and HNF4A-MODY, and high-dose sulfonylureas for KATP channel-related diabetes. While diabetes treatment is defined for the most common causes of monogenic diabetes, pregnancy poses a challenge to management. Here, we discuss the key issues in pregnancy affected by monogenic diabetes. RECENT FINDINGS General recommendations for pregnancy affected by GCK-MODY determine need for maternal insulin treatment based on fetal mutation status. However, a recent study suggests macrosomia and miscarriage rates may be increased with this strategy. Recent demonstration of transplacental transfer of sulfonylureas also raises questions as to when insulin should be initiated in sulfonylurea-responsive forms of monogenic diabetes. Pregnancy represents a challenge in management of monogenic diabetes, where factors of maternal glycemic control, fetal mutation status, and transplacental transfer of medication must all be taken into consideration. Guidelines for pregnancy affected by monogenic diabetes will benefit from large, prospective studies to better define the need for and timing of initiation of insulin treatment.
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Affiliation(s)
- Laura T Dickens
- Department of Medicine, Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago, 5841 S. Maryland Ave., MC 1027, Chicago, IL, 60637, USA.
| | - Rochelle N Naylor
- Department of Medicine, Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago, 5841 S. Maryland Ave., MC 1027, Chicago, IL, 60637, USA
- Department of Pediatrics, Section of Adult and Pediatric Endocrinology, Diabetes, and Metabolism, University of Chicago, Chicago, IL, USA
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Therapies for gestational diabetes and their implications for maternal and offspring health: Evidence from human and animal studies. Pharmacol Res 2018; 130:52-73. [PMID: 29421161 DOI: 10.1016/j.phrs.2018.02.002] [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: 10/23/2017] [Revised: 01/05/2018] [Accepted: 02/01/2018] [Indexed: 01/21/2023]
Abstract
Obesity prior to and during pregnancy is associated with an increased risk of complications during pregnancy. One of the most common complications of pregnancy is gestational diabetes mellitus (GDM), a condition characterized by hyperglycemia and insulin resistance that is diagnosed in the third trimester of pregnancy. GDM predisposes both mothers and their children to increased obesity and cardiometabolic disorders, namely type 2 diabetes and cardiovascular disease. Current treatments include lifestyle changes and insulin injections, but oral anti-diabetic drugs such as metformin and glyburide are increasingly prescribed as they do not require injections. However, the long-term implications of therapies for diabetes during pregnancy on mothers and their offspring are not fully understood. In this review, we describe current treatments for GDM, including the first line lifestyle interventions such as exercise as well as insulin, glyburides and metformin. We also review selected natural health products that are sometimes used by individuals during pregnancy that could also be an effective therapeutic in pregnancies characterized by obesity or GDM. We focus on both the short- and long-term effects of treatments on the health of mothers and their offspring. We review the current literature from clinical research and animal studies.
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Koren G, Ornoy A. The role of the placenta in drug transport and fetal drug exposure. Expert Rev Clin Pharmacol 2018; 11:373-385. [DOI: 10.1080/17512433.2018.1425615] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Gideon Koren
- Institute of Research and Innovation, Maccabi Health Services, Israel
| | - Asher Ornoy
- Department of Pediatrics, Hebrew University, Israel
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Shepherd M, Brook AJ, Chakera AJ, Hattersley AT. Management of sulfonylurea-treated monogenic diabetes in pregnancy: implications of placental glibenclamide transfer. Diabet Med 2017; 34:1332-1339. [PMID: 28556992 PMCID: PMC5612398 DOI: 10.1111/dme.13388] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2017] [Indexed: 01/05/2023]
Abstract
The optimum treatment for HNF1A/HNF4A maturity-onset diabetes of the young and ATP-sensitive potassium (KATP ) channel neonatal diabetes, outside pregnancy, is sulfonylureas, but there is little evidence regarding the most appropriate treatment during pregnancy. Glibenclamide has been widely used in the treatment of gestational diabetes, but recent data have established that glibenclamide crosses the placenta and increases risk of macrosomia and neonatal hypoglycaemia. This raises questions about its use in pregnancy. We review the available evidence and make recommendations for the management of monogenic diabetes in pregnancy. Due to the risk of stimulating increased insulin secretion in utero, we recommend that in women with HNF1A/ HNF4A maturity-onset diabetes of the young, those with good glycaemic control who are on a sulfonylurea per conception either transfer to insulin before conception (at the risk of a short-term deterioration of glycaemic control) or continue with sulfonylurea (glibenclamide) treatment in the first trimester and transfer to insulin in the second trimester. Early delivery is needed if the fetus inherits an HNF4A mutation from either parent because increased insulin secretion results in ~800-g weight gain in utero, and prolonged severe neonatal hypoglycaemia can occur post-delivery. If the fetus inherits a KATP neonatal diabetes mutation from their mother they have greatly reduced insulin secretion in utero that reduces fetal growth by ~900 g. Treating the mother with glibenclamide in the third trimester treats the affected fetus in utero, normalising fetal growth, but is not desirable, especially in the high doses used in this condition, if the fetus is unaffected. Prospective studies of pregnancy in monogenic diabetes are needed.
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Affiliation(s)
- M. Shepherd
- Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
- Exeter NIHR Clinical Research FacilityRoyal Devon and Exeter NHS Foundation TrustExeterUK
| | - A. J. Brook
- Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
- Lancashire Women and Newborn CentreBurnley General Hospital, East Lancashire NHS Hospitals TrustBurnleyUK
- University of ManchesterManchesterUK
| | - A. J. Chakera
- Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
- Royal Sussex County Hospital, Brighton and Sussex University HospitalsBrightonUK
| | - A. T. Hattersley
- Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
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Díaz P, Dimasuay KG, Koele-Schmidt L, Jang B, Barbour LA, Jansson T, Powell TL. Glyburide treatment in gestational diabetes is associated with increased placental glucose transporter 1 expression and higher birth weight. Placenta 2017; 57:52-59. [PMID: 28864019 PMCID: PMC10881120 DOI: 10.1016/j.placenta.2017.05.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/12/2017] [Accepted: 05/27/2017] [Indexed: 12/31/2022]
Abstract
Use of glyburide in gestational diabetes (GDM) has raised concerns about fetal and neonatal side effects, including increased birth weight. Placental nutrient transport is a key determinant of fetal growth, however the effect of glyburide on placental nutrient transporters is largely unknown. We hypothesized that glyburide treatment in GDM pregnancies is associated with increased expression of nutrient transporters in the syncytiotrophoblast plasma membranes. We collected placentas from GDM pregnancies who delivered at term and were treated with either diet modification (n = 15) or glyburide (n = 8). Syncytiotrophoblast microvillous (MVM) and basal (BM) plasma membranes were isolated and expression of glucose (glucose transporter 1; GLUT1), amino acid (sodium-coupled neutral amino acid transporter 2; SNAT2 and L-type amino acid transporter 1; LAT1) and fatty acid (fatty acid translocase; FAT/CD36, fatty acid transporter 2 and 4; FATP2, FATP4) transporters was determined by Western blot. Additionally, we determined GLUT1 expression by confocal microscopy in cultured primary human trophoblasts (PHT) after exposure to glyburide. Birth weight was higher in the glyburide-treated group as compared to diet-treated GDM women (3764 ± 126 g vs. 3386 ± 75 g; p < 0.05). GLUT1 expression was increased in both MVM (+50%; p < 0.01) and BM (+75%; p < 0.01). In contrast, MVM FAT/CD36 (-65%; p = 0.01) and FATP2 (-65%; p = 0.02) protein expression was reduced in mothers treated with glyburide. Glyburide increased membrane expression of GLUT1 in a dose-dependent manner in cultured PHT. This data is the first to show that glyburide increases GLUT1 expression in syncytiotrophoblast MVM and BM in GDM pregnancies, and may promote transplacental glucose delivery contributing to fetal overgrowth.
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Affiliation(s)
- Paula Díaz
- Department of Pediatrics, Section of Neonatology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Obstetrics and Gynecology, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA.
| | - Kris Genelyn Dimasuay
- Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Medicine at Royal Melbourne Hospital, University of Melbourne, Parkville 3050, Victoria, Australia
| | - Lindsey Koele-Schmidt
- Department of Obstetrics and Gynecology, University of Texas Health Science Center San Antonio, San Antonio, TX 78229, USA
| | - Brian Jang
- Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Linda A Barbour
- Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Medicine, Division of Endocrinology, Metabolism, and Diabetes, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Thomas Jansson
- Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Theresa L Powell
- Department of Pediatrics, Section of Neonatology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA.
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Lindsay RS, Mackin ST, Nelson SM. Gestational diabetes mellitus-right person, right treatment, right time? BMC Med 2017; 15:163. [PMID: 28844206 PMCID: PMC5572161 DOI: 10.1186/s12916-017-0925-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/09/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Personalised treatment that is uniquely tailored to an individual's phenotype has become a key goal of clinical and pharmaceutical development across many, particularly chronic, diseases. For type 2 diabetes, the importance of the underlying clinical heterogeneity of the condition is emphasised and a range of treatments are now available, with personalised approaches being developed. While a close connection between risk factors for type 2 diabetes and gestational diabetes has long been acknowledged, stratification of screening, treatment and obstetric intervention remains in its infancy. CONCLUSIONS Although there have been major advances in our understanding of glucose tolerance in pregnancy and of the benefits of treatment of gestational diabetes, we argue that far more vigorous approaches are needed to enable development of companion diagnostics, and to ensure the efficacious and safe use of novel therapeutic agents and strategies to improve outcomes in this common condition.
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Affiliation(s)
- Robert S Lindsay
- Institute of Cardiovascular & Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, University Place, Glasgow, G12 8TA, UK.
| | - Sharon T Mackin
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
| | - Scott M Nelson
- School of Medicine, University of Glasgow, Glasgow Royal Infirmary, Glasgow, G31 2ER, UK
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Barbour LA, Davies JK. Comment on Nachum et al. Glyburide Versus Metformin and Their Combination for the Treatment of Gestational Diabetes Mellitus: A Randomized Controlled Study. Diabetes Care 2017;40:332-337. Diabetes Care 2017; 40:e115. [PMID: 28733384 DOI: 10.2337/dc17-0554] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Linda A Barbour
- Divisions of Endocrinology, Metabolism, and Diabetes and Maternal-Fetal Medicine, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, CO
| | - Jill K Davies
- Division of Maternal-Fetal Medicine, Denver Health Medical Center, Denver, CO
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Nachum Z, Zafran N, Salim R, Hissin N, Hasanein J, Gam Ze Letova Y, Suleiman A, Yefet E. Glyburide Versus Metformin and Their Combination for the Treatment of Gestational Diabetes Mellitus: A Randomized Controlled Study. Diabetes Care 2017; 40:332-337. [PMID: 28077460 DOI: 10.2337/dc16-2307] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 12/22/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To compare the efficacy and safety of glyburide versus metformin and their combination for the treatment of gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS In this prospective randomized controlled study, we randomly assigned patients with GDM at 13-33 weeks gestation and whose blood glucose was poorly controlled by diet to receive either glyburide or metformin. If optimal glycemic control was not achieved, the other drug was added. If adverse effects occurred, the drug was replaced. If both failed, insulin was given. The primary outcomes were the rate of treatment failure and glycemic control after the first-line medication according to mean daily glucose charts. RESULTS Glyburide was started in 53 patients and metformin in 51. In the glyburide group, the drug failed in 18 (34%) patients due to adverse effects (hypoglycemia) in 6 (11%) and lack of glycemic control in 12 (23%). In the metformin group, the drug failed in 15 (29%) patients, due to adverse effects (gastrointestinal) in 1 (2%) and lack of glycemic control in 14 (28%). Treatment success after second-line therapy was higher in the metformin group than in the glyburide group (13 of 15 [87%] vs. 9 of 18 [50%], respectively; P = 0.03). In the glyburide group, nine (17%) patients were eventually treated with insulin compared with two (4%) in the metformin group (P = 0.03). The combination of the drugs reduced the need for insulin from 33 (32%) to 11 (11%) patients (P = 0.0002). Mean daily blood glucose and other obstetrical and neonatal outcomes were comparable between groups, including macrosomia, neonatal hypoglycemia, and electrolyte imbalance. CONCLUSIONS Glyburide and metformin are comparable oral treatments for GDM regarding glucose control and adverse effects. Their combination demonstrates a high efficacy rate with a significantly reduced need for insulin, with a possible advantage for metformin over glyburide as first-line therapy.
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Affiliation(s)
- Zohar Nachum
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Noah Zafran
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Raed Salim
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Noura Hissin
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
| | - Jamal Hasanein
- Department of Neonatology, Emek Medical Center, Afula, Israel
| | | | - Abeer Suleiman
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
| | - Enav Yefet
- Department of Obstetrics and Gynecology, Emek Medical Center, Afula, Israel
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Bimson BE, Rosenn BM, Morris SA, Sasso EB, Schwartz RA, Brustman LE. Current trends in the diagnosis and management of gestational diabetes mellitus in the United States*. J Matern Fetal Neonatal Med 2016; 30:2607-2612. [PMID: 27819164 DOI: 10.1080/14767058.2016.1257603] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Brianne E. Bimson
- Department of Obstetrics and Gynecology, Mount Sinai West Hospital, Mount Sinai Health System, Icahn School of Medicine, New York, NY, USA
| | - Barak M. Rosenn
- Department of Obstetrics and Gynecology, Mount Sinai West Hospital, Mount Sinai Health System, Icahn School of Medicine, New York, NY, USA
| | - Sara A. Morris
- Department of Obstetrics and Gynecology, Mount Sinai West Hospital, Mount Sinai Health System, Icahn School of Medicine, New York, NY, USA
| | - Elizabeth B. Sasso
- Department of Obstetrics and Gynecology, Mount Sinai West Hospital, Mount Sinai Health System, Icahn School of Medicine, New York, NY, USA
| | - Rachelle A. Schwartz
- Department of Obstetrics and Gynecology, Mount Sinai West Hospital, Mount Sinai Health System, Icahn School of Medicine, New York, NY, USA
| | - Lois E. Brustman
- Department of Obstetrics and Gynecology, Mount Sinai West Hospital, Mount Sinai Health System, Icahn School of Medicine, New York, NY, USA
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Malek R, Davis SN. Pharmacokinetics, efficacy and safety of glyburide for treatment of gestational diabetes mellitus. Expert Opin Drug Metab Toxicol 2016; 12:691-9. [PMID: 27163280 DOI: 10.1080/17425255.2016.1187131] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Gestational diabetes mellitus (GDM) complicates 10% of all pregnancies and is defined as hyperglycemia first noted during pregnancy. Rates of GDM are rising and untreated GDM results in complications for both mother and fetus. GDM is often managed by diet and exercise but 30-40% of women will require pharmacological intervention. Insulin has traditionally been the treatment of choice but since 2007, glyburide, a second generation sulfonylurea has become the most prescribed medication for GDM. AREAS COVERED This review will cover the pharmacokinetics, efficacy, and safety of glyburide for the management of GDM. EXPERT OPINION Management of GDM is challenging secondary to the stringent glycemic goals that mimic the lower glucose levels in pregnancy. Glyburide is generally effective in treating hyperglycemia. However, several studies have raised safety concerns showing higher neonatal intensive care unit (NICU) admissions, higher rates of macrosomia, large for gestational age and pre-eclampsia in the mother. For this reason, insulin should be first-line therapy for GDM. In areas of limited resources where the self-monitoring needed for accurate insulin dosing is not possible, where access to refrigeration for insulin storage is not universal, or severe needle phobia then the benefits of glyburide (controlling hyperglycemia) outweighs the harm of NICU admissions and macrosomia.
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Affiliation(s)
- Rana Malek
- a Department of Internal Medicine, Division of Endocrinology, Diabetes, and Nutrition , University of Maryland School of Medicine , Baltimore , MD , USA
| | - Stephen N Davis
- b Department of Medicine, University of Maryland Medical Center , University of Maryland School of Medicine , Baltimore , MD , USA
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Bircsak KM, Gupta V, Yuen PYS, Gorczyca L, Weinberger BI, Vetrano AM, Aleksunes LM. Genetic and Dietary Regulation of Glyburide Efflux by the Human Placental Breast Cancer Resistance Protein Transporter. J Pharmacol Exp Ther 2016; 357:103-13. [PMID: 26850786 DOI: 10.1124/jpet.115.230185] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2015] [Accepted: 02/02/2016] [Indexed: 12/16/2022] Open
Abstract
Glyburide is frequently used to treat gestational diabetes owing to its low fetal accumulation resulting from placental efflux by the breast cancer resistance protein (BCRP)/ABCG2 transporter. Here we sought to determine how exposure to the dietary phytoestrogen genistein and expression of a loss-of-function polymorphism in the ABCG2 gene (C421A) impacted the transport of glyburide by BCRP using stably transfected human embryonic kidney 293 (HEK) cells, human placental choriocarcinoma BeWo cells, and human placental explants. Genistein competitively inhibited the BCRP-mediated transport of (3)H-glyburide in both wild-type (WT) and C421A-BCRP HEK-expressing cells, with greater accumulation of (3)H-glyburide in cells expressing the C421A variant. In BeWo cells, exposure to genistein for 60 minutes increased the accumulation of (3)H-glyburide 30%-70% at concentrations relevant to dietary exposure (IC50 ∼180 nM). Continuous exposure of BeWo cells to genistein for 48 hours reduced the expression of BCRP mRNA and protein by up to 40%, which impaired BCRP transport activity. Pharmacologic antagonism of the estrogen receptor attenuated the genistein-mediated downregulation of BCRP expression, suggesting that phytoestrogens may reduce BCRP levels through this hormone receptor pathway in BeWo cells. Interestingly, genistein treatment for 48 hours did not alter BCRP protein expression in explants dissected from healthy term placentas. These data suggest that whereas genistein can act as a competitive inhibitor of BCRP-mediated transport, its ability to downregulate placental BCRP expression may only occur in choriocarcinoma cells. Overall, this research provides important mechanistic data regarding how the environment (dietary genistein) and a frequent genetic variant (ABCG2, C421A) may alter the maternal-fetal disposition of glyburide.
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Affiliation(s)
- Kristin M Bircsak
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy (K.M.B., L.M.A., L.G.), and Environmental and Occupational Health Sciences Institute, Rutgers, The State University of New Jersey (L.M.A.), Piscataway, New Jersey; Departments of Obstetrics and Gynecology (V.G.) and Pediatrics (P.Y.S.Y., A.M.V.), Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey; Hofstra North Shore-LIJ School of Medicine, Cohen Children's Medical Center of New York, New Hyde Park, New York (B.I.W.)
| | - Vivek Gupta
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy (K.M.B., L.M.A., L.G.), and Environmental and Occupational Health Sciences Institute, Rutgers, The State University of New Jersey (L.M.A.), Piscataway, New Jersey; Departments of Obstetrics and Gynecology (V.G.) and Pediatrics (P.Y.S.Y., A.M.V.), Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey; Hofstra North Shore-LIJ School of Medicine, Cohen Children's Medical Center of New York, New Hyde Park, New York (B.I.W.)
| | - Poi Yu Sofia Yuen
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy (K.M.B., L.M.A., L.G.), and Environmental and Occupational Health Sciences Institute, Rutgers, The State University of New Jersey (L.M.A.), Piscataway, New Jersey; Departments of Obstetrics and Gynecology (V.G.) and Pediatrics (P.Y.S.Y., A.M.V.), Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey; Hofstra North Shore-LIJ School of Medicine, Cohen Children's Medical Center of New York, New Hyde Park, New York (B.I.W.)
| | - Ludwik Gorczyca
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy (K.M.B., L.M.A., L.G.), and Environmental and Occupational Health Sciences Institute, Rutgers, The State University of New Jersey (L.M.A.), Piscataway, New Jersey; Departments of Obstetrics and Gynecology (V.G.) and Pediatrics (P.Y.S.Y., A.M.V.), Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey; Hofstra North Shore-LIJ School of Medicine, Cohen Children's Medical Center of New York, New Hyde Park, New York (B.I.W.)
| | - Barry I Weinberger
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy (K.M.B., L.M.A., L.G.), and Environmental and Occupational Health Sciences Institute, Rutgers, The State University of New Jersey (L.M.A.), Piscataway, New Jersey; Departments of Obstetrics and Gynecology (V.G.) and Pediatrics (P.Y.S.Y., A.M.V.), Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey; Hofstra North Shore-LIJ School of Medicine, Cohen Children's Medical Center of New York, New Hyde Park, New York (B.I.W.)
| | - Anna M Vetrano
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy (K.M.B., L.M.A., L.G.), and Environmental and Occupational Health Sciences Institute, Rutgers, The State University of New Jersey (L.M.A.), Piscataway, New Jersey; Departments of Obstetrics and Gynecology (V.G.) and Pediatrics (P.Y.S.Y., A.M.V.), Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey; Hofstra North Shore-LIJ School of Medicine, Cohen Children's Medical Center of New York, New Hyde Park, New York (B.I.W.)
| | - Lauren M Aleksunes
- Department of Pharmacology and Toxicology, Ernest Mario School of Pharmacy (K.M.B., L.M.A., L.G.), and Environmental and Occupational Health Sciences Institute, Rutgers, The State University of New Jersey (L.M.A.), Piscataway, New Jersey; Departments of Obstetrics and Gynecology (V.G.) and Pediatrics (P.Y.S.Y., A.M.V.), Rutgers University Robert Wood Johnson Medical School, New Brunswick, New Jersey; Hofstra North Shore-LIJ School of Medicine, Cohen Children's Medical Center of New York, New Hyde Park, New York (B.I.W.)
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Langer O. Oral hypoglycemic agents: do the ends justify the means? Matern Health Neonatol Perinatol 2015; 1:19. [PMID: 27057336 PMCID: PMC4823678 DOI: 10.1186/s40748-015-0021-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 07/16/2015] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Glyburide has replaced insulin as the first line of therapy in the treatment of gestational diabetes in the United States. Glyburide and metformin therapies were reported to be comparable to insulin yet also cost-effective, patient-friendly, and potentially compliance-enhancing. Recently, the efficacy of the use of these oral hypoglycemic drugs has been questioned. In this review, the questionable concerns will be addressed: Which diabetic drug(s) cross the placenta? What is the quality of evidence and the data source validity? Which treatment modalities are most effective in reducing the primary outcome in GDM? Which drug is most effective in improving secondary outcomes? FINDINGS This review documents the methodological issues in study design that have impacted the results for the provision of health care interventions in GDM. The review summarizes the contents of the articles qualitatively and assesses the theoretical and empirical evidence. Multiple types of studies exist and every study design serves a specific purpose. Different study designs addressing the same question can yield varying results. The risk of presenting uncertain results without categorically knowing the direction and magnitude of the effect holds true for both randomized and nonrandomized controlled trials. The review further emphasizes the importance of achieving the targeted levels of glycemic control. CONCLUSION The implications of this review are critical to addressing the current gaps in the literature on the efficacy of the use of oral hypoglycemic agents in GDM. The emphasis needs to be placed on patient treatment in order to manage hyperglycemia to reduce fetal and maternal morbidity. In this regard, we need to delineate proper outcome criteria that will reflect disease severity and treat using appropriate pharmacological therapy.
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