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Dutta D, Sharma M, Nagendra L, Bhattacharya S, Mohindra R, Yajnik CS. Long term impact on offspring (5-11 years of age) of metformin use in pregnancy in mothers with diabetes: A systematic review and meta-analysis. Endocr Pract 2024:S1530-891X(24)00559-7. [PMID: 38876183 DOI: 10.1016/j.eprac.2024.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/28/2024] [Accepted: 05/29/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND Data is scant on impact of metformin use in gestational diabetes (GDM)/ diabetes in pregnancy (DIP) on long-term outcomes in children and mothers beyond 5-years of child-birth. This systematic-review and meta-analysis aimed to evaluate the long-term impact of metformin use in pregnancy on children and their mothers. METHODS Electronic databases were searched for studies evaluating metformin as compared to insulin for managing GDM/DIP. Primary outcome was to evaluate changes in body-mass index (BMI) in children at 5-11 years age. Secondary outcomes were to assess alterations in other anthropometric measures, obesity, changes in lipids and adipo-cytokines in children and mothers. RESULTS Children at 9-years age, born to mothers who were treated with metformin during pregnancy had similar BMI [MD1.09kg/m2(95%CI:-0.44-2.62);P=0.16;I2=16%], waist-circumference to height-ratio [MD0.13(95%CI:-0.05-0.30);P=0.16;I2=94%], dual-energy X-ray absorptiometry (DXA) total fat-mass [MD0.68kg(95%CI:-2.39-3.79);P=0.66;I2=70%], DXA-total fat-percent [MD 0.04%(95%CI:-3.44-3.51);P=0.98;I2=56%], DXA-total fat-free mass [MD 0.81kg (95%CI:-0.96-2.58);P=0.37;I2=55%], MRI visceral adipose tissue [MD 80.97cm3(95%CI:-136.47-298.41); P=0.47;I2=78%] and magnetic-resonance spectroscopy liver-fat percentage [MD 0.27%(95% CI:-1.26-1.79);P=0.73;I2=0%], compared to those born to mothers who were treated with insulin. Serum adiponectin, leptin, alanine-aminotransferase and ferritin were comparable among groups. In children between 9-11 years age, occurrence of obesity, diabetes or challenges in motor and social development were comparable between the 2 groups. After 9 years of childbirth, BMI and risk of developing diabetes were similar in the two groups of women. CONCLUSION Metformin use in pregnancy did not show any adverse effects when compared to insulin on long-term outcomes in children and their mothers.
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Affiliation(s)
- Deep Dutta
- Department of Endocrinology, CEDAR Superspeciality Healthcare, Dwarka, New Delhi, India.
| | - Meha Sharma
- Department of Rheumatology, CEDAR Superspeciality Healthcare, Dwarka, New Delhi, India
| | - Lakshmi Nagendra
- Department of Endocrinology, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, India
| | | | - Ritin Mohindra
- Department of Medicine, Post-graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
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Olawore O, Turner LE, Evans MD, Johnson SG, Huling JD, Bramante CT, Buse JB, Stürmer T. Risk of Post-Acute Sequelae of SARS-CoV-2 Infection (PASC) Among Patients with Type 2 Diabetes Mellitus on Anti-Hyperglycemic Medications. Clin Epidemiol 2024; 16:379-393. [PMID: 38836048 PMCID: PMC11149650 DOI: 10.2147/clep.s458901] [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: 02/22/2024] [Accepted: 05/17/2024] [Indexed: 06/06/2024] Open
Abstract
Background Observed activity of metformin in reducing the risk of severe COVID-19 suggests a potential use of the anti-hyperglycemic in the prevention of post-acute sequelae of SARS-CoV-2 infection (PASC). We assessed the 3-month and 6-month risk of PASC among patients with type 2 diabetes mellitus (T2DM) comparing metformin users to sulfonylureas (SU) or dipeptidyl peptidase-4 inhibitors (DPP4i) users. Methods We used de-identified patient level electronic health record data from the National Covid Cohort Collaborative (N3C) between October 2021 and April 2023. Participants were adults ≥ 18 years with T2DM who had at least one outpatient healthcare encounter in health institutions in the United States prior to COVID-19 diagnosis. The outcome of PASC was defined based on the presence of a diagnosis code for the illness or using a predicted probability based on a machine learning algorithm. We estimated the 3-month and 6-month risk of PASC and calculated crude and weighted risk ratios (RR), risk differences (RD), and differences in mean predicted probability. Results We identified 5596 (mean age: 61.1 years; SD: 12.6) and 1451 (mean age: 64.9 years; SD 12.5) eligible prevalent users of metformin and SU/DPP4i respectively. We did not find a significant difference in risk of PASC at 3 months (RR = 0.86 [0.56; 1.32], RD = -3.06 per 1000 [-12.14; 6.01]), or at 6 months (RR = 0.81 [0.55; 1.20], RD = -4.91 per 1000 [-14.75, 4.93]) comparing prevalent users of metformin to prevalent users of SU/ DPP4i. Similar observations were made for the outcome definition using the ML algorithm. Conclusion The observed estimates in our study are consistent with a reduced risk of PASC among prevalent users of metformin, however the uncertainty of our confidence intervals warrants cautious interpretations of the results. A standardized clinical definition of PASC is warranted for thorough evaluation of the effectiveness of therapies under assessment for the prevention of PASC.
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Affiliation(s)
- Oluwasolape Olawore
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lindsey E Turner
- Division of Biostatistics and Health Data Science, University of Minnesota School of Public Health, Minneapolis, MN, USA
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Michael D Evans
- Clinical and Translational Science Institute, University of Minnesota, Minneapolis, MN, USA
| | - Steven G Johnson
- Institute for Health Informatics, University of Minnesota, Minneapolis, MN, USA
| | - Jared D Huling
- Division of Biostatistics and Health Data Science, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Carolyn T Bramante
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - John B Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Bailey CJ. Metformin: Therapeutic profile in the treatment of type 2 diabetes. Diabetes Obes Metab 2024. [PMID: 38784991 DOI: 10.1111/dom.15663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2024] [Revised: 05/02/2024] [Accepted: 05/05/2024] [Indexed: 05/25/2024]
Abstract
Metformin (dimethyl-biguanide) can claim its origins in the use of Galega officinalis as a plant treatment for symptoms ascribed to diabetes. Since the first clinical use of metformin as a glucose-lowering agent in 1957, this medicine has emerged as a first-line pharmacological option to support lifestyle interventions in the management of type 2 diabetes (T2D). It acts through multiple cellular pathways, principally in the gut, liver and muscle, to counter insulin resistance and lower blood glucose without weight gain or risk of overt hypoglycaemia. Other effects include improvements in lipid metabolism, decreased inflammation and lower long-term cardiovascular risk. Metformin is conveniently combined with other diabetes medications, can be prescribed in prediabetes to reduce the risk of progression to T2D, and is used in some regions to assist glycaemic control in pregnancy. Consistent with its diversity of actions, established safety profile and cost-effectiveness, metformin is being assessed for further possible clinical applications. The use of metformin requires adequate renal function for drug elimination, and may cause initial gastrointestinal side effects, which can be moderated by taking with meals or using an extended-release formulation. Thus, metformin serves as a valuable therapeutic resource for use throughout the natural history of T2D.
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Molin J, Domellöf M, Häggström C, Vanky E, Zamir I, Östlund E, Bixo M. Neonatal outcome following metformin-treated gestational diabetes mellitus: A population-based cohort study. Acta Obstet Gynecol Scand 2024; 103:992-1007. [PMID: 38288656 PMCID: PMC11019529 DOI: 10.1111/aogs.14787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/03/2024] [Accepted: 01/08/2024] [Indexed: 04/17/2024]
Abstract
INTRODUCTION Neonatal hypoglycemia is a common complication associated with gestational diabetes and therefore relevant to consider in evaluations of maternal treatment. We aimed to investigate the risk of neonatal hypoglycemia in offspring exposed to metformin treatment alone (MT) or combined with insulin (MIT) in comparison with nutrition therapy alone (NT), and insulin treatment alone (IT). In addition, we investigated MT in comparison with MIT. Secondary outcomes included neonatal anthropometrics, respiratory morbidity, hyperbilirubinemia, 5-min Apgar score, and preterm birth. MATERIAL AND METHODS This Swedish population-based cohort included 16 181 women diagnosed with gestational diabetes, and their singleton offspring born in 2019-2021. We estimated risk as adjusted odds ratio (aOR) with 95% confidence interval (CI), using individual-level, linkage register-data in multivariable logistic regression models. RESULTS In the main analysis, MT was associated with a lower risk of neonatal hypoglycemia vs NT (aOR 0.85, 95% CI: 0.74-0.96), vs MIT (0.74 [0.64-0.87]), and vs IT (0.47 [0.40-0.55]), whereas MIT was associated with a similar risk of neonatal hypoglycemia vs NT (1.14 [0.99-1.30]) and with lower risk vs IT (0.63 [0.53-0.75]). However, supplemental feeding rates were lower for NT vs pharmacological treatments (p < 0.001). In post hoc subgroup analyses including only exclusively breastfed offspring, the risk of neonatal hypoglycemia was modified and similar among MT and NT, and higher in MIT vs NT. Insulin exposure, alone or combined with metformin, was associated with increased risk of being large for gestational age. Compared with NT, exposure to any pharmacological treatment was associated with significantly lower risk of 5-min Apgar score < 4. All other secondary outcomes were comparable among the treatment categories. CONCLUSIONS The risk of neonatal hypoglycemia appears to be comparable among offspring exposed to single metformin treatment and nutrition therapy alone, and the lower risk that we observed in favor of metformin is probably explained by a difference in supplemental feeding practices rather than metformin per se. By contrast, the lower risk favoring metformin exposure over insulin exposure was not explained by supplemental feeding. However, further investigations are required to determine whether the difference is an effect of metformin per se or mediated by other external factors.
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Affiliation(s)
- Johanna Molin
- Department of Clinical SciencesUmeå UniversityUmeåSweden
| | | | - Christel Häggström
- Northern Registry Center, Department of Public Health and Clinical MedicineUmeå UniversityUmeåSweden
| | - Eszter Vanky
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health SciencesNorwegian University of Science and TechnologyTrondheimNorway
- Department of Obstetrics and GynecologySt. Olav's Hospital, Trondheim University HospitalTrondheimNorway
| | - Itay Zamir
- Department of Clinical SciencesUmeå UniversityUmeåSweden
| | - Eva Östlund
- Department of Clinical Sciences and EducationSödersjukhuset, Karolinska InstituteStockholmSweden
| | - Marie Bixo
- Department of Clinical SciencesUmeå UniversityUmeåSweden
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Paschou SA, Shalit A, Gerontiti E, Athanasiadou KI, Kalampokas T, Psaltopoulou T, Lambrinoudaki I, Anastasiou E, Wolffenbuttel BHR, Goulis DG. Efficacy and safety of metformin during pregnancy: an update. Endocrine 2024; 83:259-269. [PMID: 37798604 PMCID: PMC10850184 DOI: 10.1007/s12020-023-03550-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/23/2023] [Indexed: 10/07/2023]
Abstract
During the last decades, gestational diabetes mellitus (GDM) prevalence has been on the rise. While insulin remains the gold standard treatment for GDM, metformin use during pregnancy is controversial. This review aimed to comprehensively assess the available data on the efficacy and safety of metformin during pregnancy, both for the mother and the offspring. Metformin has been validated for maternal efficacy and safety, achieving comparable glycemic control with insulin. Additionally, it reduces maternal weight gain and possibly the occurrence of hypertensive disorders. During the early neonatal period, metformin administration does not increase the risk of congenital anomalies or other major adverse effects, including lower APGAR score at 5 min, neonatal intensive care unit admissions, and respiratory distress syndrome. Several studies have demonstrated a reduction in neonatal hypoglycemia. Metformin has been associated with an increase in preterm births and lower birth weight, although this effect is controversial and depends on the indication for which it was administered. Evidence indicates possible altered fetal programming and predisposition to childhood obesity and metabolic syndrome during adulthood after use of metformin in pregnancy. With critical questions still requiring a final verdict, ongoing research on the field must be conducted.
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Affiliation(s)
- Stavroula A Paschou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Almog Shalit
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Gerontiti
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Kleoniki I Athanasiadou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodoros Kalampokas
- Second Department of Obstetrics and Gynecology, Aretaieion University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Theodora Psaltopoulou
- Endocrine Unit and Diabetes Center, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Irene Lambrinoudaki
- Second Department of Obstetrics and Gynecology, Aretaieion University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Bruce H R Wolffenbuttel
- Department of Endocrinology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, First Department of Obstetrics and Gynecology, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Cantacorps L, Zhu J, Yagoub S, Coull BM, Falck J, Chesters RA, Ritter K, Serrano-Lope M, Tscherepentschuk K, Kasch LS, Paterson M, Täger P, Baidoe-Ansah D, Pandey S, Igual-Gil C, Braune A, Lippert RN. Developmental metformin exposure does not rescue physiological impairments derived from early exposure to altered maternal metabolic state in offspring mice. Mol Metab 2024; 79:101860. [PMID: 38142972 PMCID: PMC10792763 DOI: 10.1016/j.molmet.2023.101860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 12/26/2023] Open
Abstract
OBJECTIVE The incidence of gestational diabetes mellitus (GDM) and metabolic disorders during pregnancy are increasing globally. This has resulted in increased use of therapeutic interventions such as metformin to aid in glycemic control during pregnancy. Even though metformin can cross the placental barrier, its impact on offspring brain development remains poorly understood. As metformin promotes AMPK signaling, which plays a key role in axonal growth during development, we hypothesized that it may have an impact on hypothalamic signaling and the formation of neuronal projections in the hypothalamus, the key regulator of energy homeostasis. We further hypothesized that this is dependent on the metabolic and nutritional status of the mother at the time of metformin intervention. Using mouse models of maternal overnutrition, we aimed to assess the effects of metformin exposure on offspring physiology and hypothalamic neuronal circuits during key periods of development. METHODS Female C57BL/6N mice received either a control diet or a high-fat diet (HFD) during pregnancy and lactation periods. A subset of dams was fed a HFD exclusively during the lactation. Anti-diabetic treatments were given during the first postnatal weeks. Body weights of male and female offspring were monitored daily until weaning. Circulating metabolic factors and molecular changes in the hypothalamus were assessed at postnatal day 16 using ELISA and Western Blot, respectively. Hypothalamic innervation was assessed by immunostaining at postnatal days 16 and 21. RESULTS We identified alterations in weight gain and circulating hormones in male and female offspring induced by anti-diabetic treatment during the early postnatal period, which were critically dependent on the maternal metabolic state. Furthermore, hypothalamic agouti-related peptide (AgRP) and proopiomelanocortin (POMC) neuronal innervation outcomes in response to anti-diabetic treatment were also modulated by maternal metabolic state. We also identified sex-specific changes in hypothalamic AMPK signaling in response to metformin exposure. CONCLUSION We demonstrate a unique interaction between anti-diabetic treatment and maternal metabolic state, resulting in sex-specific effects on offspring brain development and physiological outcomes. Overall, based on our findings, no positive effect of metformin intervention was observed in the offspring, despite ameliorating effects on maternal metabolic outcomes. In fact, the metabolic state of the mother drives the most dramatic differences in offspring physiology and metformin had no rescuing effect. Our results therefore highlight the need for a deeper understanding of how maternal metabolic state (excessive weight gain versus stable weight during GDM treatment) affects the developing offspring. Further, these results emphasize that the interventions to treat alterations in maternal metabolism during pregnancy need to be reassessed from the perspective of the offspring physiology.
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Affiliation(s)
- Lídia Cantacorps
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany; German Center for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Jiajie Zhu
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Selma Yagoub
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Bethany M Coull
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Joanne Falck
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Robert A Chesters
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Katrin Ritter
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Miguel Serrano-Lope
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Katharina Tscherepentschuk
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Lea-Sophie Kasch
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Maya Paterson
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Paula Täger
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - David Baidoe-Ansah
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Shuchita Pandey
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Carla Igual-Gil
- Department of Physiology of Energy Metabolism, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Nuthetal, Germany
| | - Annett Braune
- Research Group Intestinal Microbiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany
| | - Rachel N Lippert
- Department of Neurocircuit Development and Function, German Institute of Human Nutrition Potsdam-Rehbruecke, Nuthetal, Germany; German Center for Diabetes Research (DZD), München-Neuherberg, Germany; NeuroCure Cluster of Excellence, Charité-Universitätsmedizin, Berlin, Germany.
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Locatelli A, Ornaghi S, Terzaghi A, Belleudi V, Fortinguerra F, Poggi FR, Perna S, Trotta F. Antidiabetic Therapy during Pregnancy: The Prescription Pattern in Italy. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7139. [PMID: 38063570 PMCID: PMC10706431 DOI: 10.3390/ijerph20237139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 11/26/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023]
Abstract
Pregestational and gestational diabetes mellitus are relevant complications of pregnancy, and antidiabetic drugs are prescribed to obtain glycemic control and improve perinatal outcomes. The objective of this study was to describe the prescription pattern of antidiabetics before, during and after pregnancy in Italy and to evaluate its concordance with the Italian guideline on treatment of diabetes mellitus. A multi-database cross-sectional population study using a Common Data Model was performed. In a cohort of about 450,000 women, the prescribing profile of antidiabetics seemed to be in line with the Italian guideline, which currently does not recommend the use of oral antidiabetics and non-insulin injection, even if practice is still heterogeneous (up to 3.8% in the third trimester used oral antidiabetics). A substantial variability in the prescription pattern was observed among the Italian regions considered: the highest increase was registered in Tuscany (4.2%) while the lowest was in Lombardy (1.5%). Women with multiple births had a higher proportion of antidiabetic prescriptions than women with singleton births both in the preconception period and during pregnancy (1.3% vs. 0.7%; 3.4% vs. 2.6%) and used metformin more frequently. The consumption of antidiabetics in foreign women was higher than Italians (second trimester: 1.8% vs. 0.9%, third trimester: 3.6% vs. 1.8%).
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Affiliation(s)
- Anna Locatelli
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900 Monza, Italy; (A.L.); (A.T.)
| | - Sara Ornaghi
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900 Monza, Italy; (A.L.); (A.T.)
| | - Alessandra Terzaghi
- School of Medicine and Surgery, University of Milano-Bicocca, Via Pergolesi 33, 20900 Monza, Italy; (A.L.); (A.T.)
| | - Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health Service, ASL Roma 1, 00147 Rome, Italy; (V.B.); (F.R.P.)
| | | | - Francesca Romana Poggi
- Department of Epidemiology, Lazio Regional Health Service, ASL Roma 1, 00147 Rome, Italy; (V.B.); (F.R.P.)
| | - Serena Perna
- Italian Medicines Agency (AIFA), 00187 Rome, Italy; (F.F.); (S.P.); (F.T.)
| | - Francesco Trotta
- Italian Medicines Agency (AIFA), 00187 Rome, Italy; (F.F.); (S.P.); (F.T.)
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Paavilainen E, Nyman A, Niinikoski H, Nikkinen H, Veijola R, Vääräsmäki M, Tossavainen P, Rönnemaa T, Tertti K. Metformin Versus Insulin for Gestational Diabetes: Cognitive and Neuropsychological Profiles of Children Aged 9 years. J Dev Behav Pediatr 2023; 44:e642-e650. [PMID: 38019468 PMCID: PMC10686276 DOI: 10.1097/dbp.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/18/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVE We compared cognitive profile and neuropsychological performance in 9-year-old offspring of mothers who were treated with metformin or insulin for gestational diabetes mellitus (GDM). METHODS A total of 172 children whose mothers were randomly assigned to receive either metformin or insulin for GDM were studied at the age of 9 years. Of these children, 127 were from Turku, Finland (63 metformin and 64 insulin), and 45 from Oulu, Finland (19 metformin and 26 insulin). Clinical and demographic background characteristics were obtained at enrolment, birth, and 9-year follow-up. Cognitive profiles were examined at age 9 years with the Wechsler Intelligence Scale for Children. Neuropsychological functions were examined with 2 subtests of the Developmental Neuropsychological Assessment test battery assessing comprehension of instructions and narrative memory, Trail Making Test assessing attention and with Behavioral Rating Inventory of Executive Functioning, including parent-rated and teacher-rated evaluations. Academic functioning was studied with reading fluency subtest of the Screening test for reading, writing, and calculus for first to sixth grades and information about educational support received at school reported by parents. RESULTS The cognitive profiles, including indexes of verbal comprehension, perceptual reasoning, working memory, and processing speed, did not differ significantly between metformin-treated and insulin-treated groups. Significant differences were not found between the treatment groups in assessed neuropsychological functions, reading fluency, or received level of support at school. CONCLUSION Cognitive and neuropsychological outcomes were similar in 9-year-old children whose mothers had either metformin or insulin treatment of GDM.
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Affiliation(s)
- Elisa Paavilainen
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Anna Nyman
- Department of Psychology and Speech-Language Pathology, University of Turku, Turku, Finland
| | - Harri Niinikoski
- Department of Pediatrics and Adolescent Medicine, University of Turku and Turku University Hospital, Turku, Finland
| | - Hilkka Nikkinen
- Department of Obstetrics and Gynecology, Research Unit of Clinical Medicine, Medical Research Center, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Riitta Veijola
- Department of Pediatrics, Research Unit of Clinical Medicine, Medical Research Center, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Marja Vääräsmäki
- Department of Obstetrics and Gynecology, Research Unit of Clinical Medicine, Medical Research Center, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Päivi Tossavainen
- Department of Pediatrics, Research Unit of Clinical Medicine, Medical Research Center, University of Oulu and Oulu University Hospital, Oulu, Finland
| | - Tapani Rönnemaa
- Department of Medicine, University of Turku and Division of Medicine, Turku University Hospital, Turku, Finland; and
| | - Kristiina Tertti
- Department of Obstetrics and Gynecology, University of Turku and Turku University Hospital, Turku, Finland
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9
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Martine‐Edith G, Johnson W, Petherick ES. Associations between maternal gestational diabetes metformin or insulin treatment and offspring growth trajectories from birth to 60 months of age: Findings from the Born in Bradford (BiB) study. Diabet Med 2023; 40:e15204. [PMID: 37597238 PMCID: PMC10946820 DOI: 10.1111/dme.15204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/19/2023] [Accepted: 08/12/2023] [Indexed: 08/21/2023]
Abstract
AIM To investigate the associations between gestational diabetes mellitus (GDM) metformin or insulin treatment and offspring growth trajectories from 0 to 60 months. METHODS Participants were from the Born in Bradford birth cohort study. Using covariate-adjusted multilevel linear spline models (4 splines: 0-1.6, 1.6-6, 6-17 and 17-60 months), we compared weight, height and body mass index (BMI) z-score trajectories of: (1) 76 offspring exposed to metformin (OGDM-Metformin) and 420 offspring exposed to insulin (OGDM-Insulin); (2) OGDM-Metformin and 9171 offspring not exposed to GDM (No-GDM); (3) OGDM-Insulin and No-GDM. RESULTS (1) OGDM-Metformin had comparable growth trajectories to OGDM-Insulin from 0 to 60 months. (2) OGDM-Metformin had a lower mean birthweight z-score than No-GDM. OGDM-Metformin had faster changes in height z-score (0.13 [95% CI 0.026, 0.24]) from 17 to 60 months and by 60 months, had comparable mean BMI z-score to No-GDM. (3) OGDM-insulin had lower mean birthweight and height z-scores than No-GDM. OGDM-Insulin had faster changes in weight (0.32 [0.021, 0.62]) and height (0.50 [0.087, 0.91]) from 1.6 to 6 months and by 60 months, had comparable mean BMI z-score to No-GDM. CONCLUSIONS GDM metformin treatment was not associated with differences in offspring growth trajectories compared to insulin treatment. Both metformin and insulin-exposed offspring had comparable BMI z-score to No-GDM by 60 months.
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Affiliation(s)
| | - William Johnson
- School of Sport, Exercise and Health SciencesLoughborough UniversityLoughboroughUK
| | - Emily S. Petherick
- School of Sport, Exercise and Health SciencesLoughborough UniversityLoughboroughUK
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Muller DRP, Stenvers DJ, Malekzadeh A, Holleman F, Painter RC, Siegelaar SE. Effects of GLP-1 agonists and SGLT2 inhibitors during pregnancy and lactation on offspring outcomes: a systematic review of the evidence. Front Endocrinol (Lausanne) 2023; 14:1215356. [PMID: 37881498 PMCID: PMC10597691 DOI: 10.3389/fendo.2023.1215356] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/25/2023] [Indexed: 10/27/2023] Open
Abstract
Aims/hypothesis Glucagon-like peptide 1 (GLP-1) agonists and sodium-glucose co-transporter-2 (SGLT2) inhibitors are novel drugs which have recently seen rapid uptake in the treatment of type 2 diabetes and obesity. The paucity of data regarding their safety during pregnancy and lactation causes a dilemma for the physician. The aim of the present study was to systematically review all available data on the offspring effects of GLP-1 agonists and SGLT2 inhibitors during pregnancy and lactation. Methods We systematically searched PubMed, clinicaltrials.gov, FDA and EMA product information on GLP-1 agonists and SGLT2 inhibitors in pregnancy and lactation from inception up to 19 April 2022 without language restrictions. We approached both the Netherlands Pharmacovigilance Centre Lareb on January 17th 2023 and the Teratology Information Service (TIS) of Switzerland on February 6th 2023. Eligible studies investigating the safety (including congenital anomalies, fetal growth, perinatal demise) in animals or humans, or reporting the degree of transfer of these drugs to the fetus, breast milk or breastfed neonate. Two reviewers independently assessed and selected studies for inclusion and subsequently resolved discrepancies by discussion. Results We included 39 records (n=9 theoretical; based on drug properties, n=7 human; n=23 animal, including 76 human offspring, and an unknown number of animal offspring as these numbers could not be retrieved from the FDA and EMA product information). In animal studies, GLP1-agonists were associated with reduced fetal weight and/or growth, delayed ossification and skeletal variants, usually associated with a reduction in maternal weight gain and decreased food consumption. Exendin-4 (GLP1-agonist) was not transported across the maternal-fetal placental interface. In human studies, exenatide (GLP1-agonist) showed a fetal-to-maternal peptide concentration ratio of ≤ 0.017 in ex vivo human placental perfusion in a single placenta. Liraglutide (GLP1-agonist) showed no significant maternal to fetal transfer at least 3.5 hours after maternal exposure in a human study with one subject. In animal studies, GLP-1 agonists were excreted in breast milk; human data on excretion were not available. In animal studies, SGLT2 inhibitors were generally safe during the first trimester but exposure during postnatal day 21 to 90 in juvenile rats, a period coinciding with the late second and third trimester of human renal development, caused dilatation of the renal pelvis and tubules. Human data consisted of a pharmaceutical database of inadvertent pregnancies during SGLT2 inhibitor use, which found an increase in miscarriages and congenital malformations. In animal studies SGLT2 inhibitors were excreted in breast milk and affected neonatal growth, but human data are not available. Conclusion/interpretation We found evidence for adverse offspring effects of GLP-1 agonists and SGLT2 inhibitors also in human studies. Our findings broadly support the advice to discontinue GLP-1 agonists and SGLT2 inhibitors during pregnancy and lactation, and also support the ongoing registration of pregnancy outcomes in pharmacological databases since the amount of available data is scarce and mostly limited to animal studies. Registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=219877.
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Affiliation(s)
- Dion R. P. Muller
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers (UMC) Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, Netherlands
| | - Dirk J. Stenvers
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers (UMC) Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, Netherlands
| | - Arjan Malekzadeh
- Medical Library, Amsterdam University Medical Centers (UMC) Location University of Amsterdam, Amsterdam, Netherlands
| | - Frederik Holleman
- Department of Internal Medicine, Amsterdam University Medical Centers (UMC) Location University of Amsterdam, Amsterdam, Netherlands
| | - Rebecca C. Painter
- Department of Gynaecology and Obstetrics, Amsterdam University Medical Centers (UMC) Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
- Amsterdam Reproduction and Development, Amsterdam, Netherlands
| | - Sarah E. Siegelaar
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers (UMC) Location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, Netherlands
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11
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Sciacca L, Bianchi C, Burlina S, Formoso G, Manicardi E, Sculli MA, Resi V. Position paper of the Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), and the Italian Study Group of Diabetes in pregnancy: Metformin use in pregnancy. Acta Diabetol 2023; 60:1421-1437. [PMID: 37401946 PMCID: PMC10442287 DOI: 10.1007/s00592-023-02137-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/12/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE This document purpose is to create an evidence-based position statement on the role of metformin therapy in pregnancy complicated by obesity, gestational diabetes (GDM), type 2 diabetes mellitus (T2DM), polycystic ovary syndrome (PCOS) and in women undergoing assisted reproductive technology (ART). METHODS A comprehensive review of international diabetes guidelines and a search of medical literature was performed to identify studies presenting data on the use of metformin in pregnancy. The document was approved by the councils of the two scientific societies. RESULTS In condition affecting the fertility, as PCOS, metformin use in pre-conception or early in pregnancy may be beneficial for clinical pregnancy, even in ART treatment, and in obese-PCOS women may reduce preterm delivery. In obese women, even in the presence of GDM or T2DM, metformin use in pregnancy is associated with a lower gestational weight gain. In pregnancy complicated by diabetes (GDM or T2DM), metformin improves maternal glycemic control and may reduce insulin dose. Neonatal and infant outcomes related to metformin exposure in utero are lacking. Metformin use in women with GDM or T2DM is associated with lower birth weight. However, an increased tendency to overweight-obesity has been observed in children, later in life. CONCLUSIONS Metformin may represent a therapeutic option in selected women with obesity, PCOS, GDM, T2DM, and in women undergoing ART. However, more research is required specifically on the long-term effects of in utero exposition to metformin.
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Affiliation(s)
- Laura Sciacca
- Interassociative Diabetes and Pregnancy Study Group, Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Rome, Italy.
- Department of Clinical and Experimental Medicine, Endocrinology Section, University of Catania, Catania, Italy.
| | - Cristina Bianchi
- Interassociative Diabetes and Pregnancy Study Group, Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Rome, Italy
- Metabolic Diseases and Diabetes Unit, University Hospital of Pisa, Pisa, Italy
| | - Silvia Burlina
- Interassociative Diabetes and Pregnancy Study Group, Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Rome, Italy
- Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Gloria Formoso
- Interassociative Diabetes and Pregnancy Study Group, Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Rome, Italy
- Department of Medicine and Aging Sciences, Center for Advanced Studies and Technology (CAST, Ex CeSIMet) G. d'Annunzio University Chieti-Pescara, Chieti, Italy
| | - Elisa Manicardi
- Interassociative Diabetes and Pregnancy Study Group, Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Rome, Italy
- Diabetes Unit, Primary Health Care, Local Health Authority of Reggio Emilia-IRCCS, Reggio Emilia, Italy
| | - Maria Angela Sculli
- Interassociative Diabetes and Pregnancy Study Group, Italian Association of Medical Diabetologists (AMD), Italian Society of Diabetology (SID), Rome, Italy
- Endocrinology and Diabetes, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | - Veronica Resi
- Endocrinology Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
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12
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Lofthouse EM, Cleal J, Lewis RM, Sengers BG. Computational Modelling of Paracellular Diffusion and OCT3 Mediated Transport of Metformin in the Perfused Human Placenta. J Pharm Sci 2023; 112:2570-2580. [PMID: 37211316 DOI: 10.1016/j.xphs.2023.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 05/15/2023] [Accepted: 05/15/2023] [Indexed: 05/23/2023]
Abstract
Metformin is an antidiabetic drug, increasingly prescribed in pregnancy and has been shown to cross the human placenta. The mechanisms underlying placental metformin transfer remain unclear. This study investigated the roles of drug transporters and paracellular diffusion in the bidirectional transfer of metformin across the human placental syncytiotrophoblast using placental perfusion experiments and computational modelling. 14C-metformin transfer was observed in the maternal to fetal and fetal to maternal directions and was not competitively inhibited by 5 mM unlabelled metformin. Computational modelling of the data was consistent with overall placental transfer via paracellular diffusion. Interestingly, the model also predicted a transient peak in fetal 14C-metformin release due to trans-stimulation of OCT3 by unlabelled metformin at the basal membrane. To test this hypothesis a second experiment was designed. OCT3 substrates (5 mM metformin, 5 mM verapamil and 10 mM decynium-22) added to the fetal artery trans-stimulated release of 14C-metformin from the placenta into the fetal circulation, while 5 mM corticosterone did not. This study demonstrated activity of OCT3 transporters on the basal membrane of the human syncytiotrophoblast. However, we did not detect a contribution of either OCT3 or apical membrane transporters to overall materno-fetal transfer, which could be represented adequately by paracellular diffusion in our system.
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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 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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Newman C, Rabbitt L, Ero A, Dunne FP. Focus on Metformin: Its Role and Safety in Pregnancy and Beyond. Drugs 2023:10.1007/s40265-023-01899-0. [PMID: 37354354 PMCID: PMC10322786 DOI: 10.1007/s40265-023-01899-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2023] [Indexed: 06/26/2023]
Abstract
Metformin is used worldwide in the treatment of type 2 diabetes and has been used in the treatment of diabetes in pregnancy since the 1970s. It is highly acceptable to patients due to its ease of administration, cost and adverse effect profile. It is effective in reducing macrosomia, large-for-gestational-age infants and reduces maternal weight gain. Despite its many advantages, metformin has been associated with reductions in foetal size and has been associated with an increase in infants born small-for-gestational-age in certain cohorts. In this article, we review its efficacy, adverse effects and long-term follow-up before, during and after pregnancy for both mother and infant. We also evaluate the other forms of treatment for gestational diabetes, including oral therapies, insulin therapy and emerging treatments.
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Affiliation(s)
- Christine Newman
- Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospital, Galway, Ireland.
- Diabetes Collaborative Clinical Trial Network, Clinical Research Facility, University of Galway, Galway, Ireland.
| | - Louise Rabbitt
- Department of Clinical Pharmacology and Therapeutics, Galway University Hospital, Galway, Ireland
- Discipline of Pharmacology and Therapeutics, School of Medicine, University of Galway, Galway, Ireland
| | - Adesuwa Ero
- Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospital, Galway, Ireland
| | - Fidelma P Dunne
- Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospital, Galway, Ireland
- Diabetes Collaborative Clinical Trial Network, Clinical Research Facility, University of Galway, Galway, Ireland
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Tosti G, Barberio A, Tartaglione L, Rizzi A, Di Leo M, Viti L, Sirico A, De Carolis S, Pontecorvi A, Lanzone A, Pitocco D. Lights and shadows on the use of metformin in pregnancy: from the preconception phase to breastfeeding and beyond. Front Endocrinol (Lausanne) 2023; 14:1176623. [PMID: 37409227 PMCID: PMC10319127 DOI: 10.3389/fendo.2023.1176623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/17/2023] [Indexed: 07/07/2023] Open
Abstract
During pregnancy, the complex hormonal changes lead to a progressive decrease of insulin sensitivity that can drive the onset of gestational diabetes (GDM) or worsen an already-known condition of insulin resistance like type 2 diabetes, polycystic ovarian syndrome (PCOS), and obesity, with complications for the mother and the fetus. Metformin during pregnancy is proving to be safe in a growing number of studies, although it freely crosses the placenta, leading to a fetal level similar to maternal concentration. The aim of this literature review is to analyze the main available evidence on the use of metformin during, throughout, and beyond pregnancy, including fertilization, lactation, and medium-term effects on offspring. Analyzed studies support the safety and efficacy of metformin during pregnancy. In pregnant women with GDM and type 2 diabetes, metformin improves obstetric and perinatal outcomes. There is no evidence that it prevents GDM in women with pregestational insulin resistance or improves lipid profile and risk of GDM in pregnant women with PCOS or obesity. Metformin could have a role in reducing the risk of preeclampsia in pregnant women with severe obesity, the risk of late miscarriages and preterm delivery in women with PCOS, and the risk of ovarian hyperstimulation syndrome, increasing the clinical pregnancy rate in women with PCOS undergoing in vitro fertilization (IVF/FIVET). Offspring of mothers with GDM exposed to metformin have no significant differences in body composition compared with insulin treatment, while it appears to be protective for metabolic and cardiovascular risk.
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Affiliation(s)
- Giulia Tosti
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Annarita Barberio
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Linda Tartaglione
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Alessandro Rizzi
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Mauro Di Leo
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Luca Viti
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Angelo Sirico
- Catholic University School of Medicine, Rome, Italy
- Department of Woman and Child Health, Woman Health Area Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Sara De Carolis
- Catholic University School of Medicine, Rome, Italy
- Department of Woman and Child Health, Woman Health Area Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Alfredo Pontecorvi
- Catholic University School of Medicine, Rome, Italy
- Department of Endocrinology, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Antonio Lanzone
- Catholic University School of Medicine, Rome, Italy
- Department of Woman and Child Health, Woman Health Area Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Dario Pitocco
- Diabetes Care Unit, Fondazione Policlinico Universitario A. Gemelli Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS), Rome, Italy
- Catholic University School of Medicine, Rome, Italy
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15
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Bramante CT, Buse JB, Liebovitz D, Nicklas J, Puskarich MA, Cohen K, Belani H, Anderson B, Huling JD, Tignanelli C, Thompson J, Pullen M, Siegel L, Proper J, Odde DJ, Klatt N, Sherwood N, Lindberg S, Wirtz EL, Karger A, Beckman K, Erickson S, Fenno S, Hartman K, Rose M, Patel B, Griffiths G, Bhat N, Murray TA, Boulware DR. Outpatient treatment of Covid-19 with metformin, ivermectin, and fluvoxamine and the development of Long Covid over 10-month follow-up. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.12.21.22283753. [PMID: 36597543 PMCID: PMC9810227 DOI: 10.1101/2022.12.21.22283753] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Long Covid is an emerging chronic illness potentially affecting millions, sometimes preventing the ability to work or participate in normal daily activities. COVID-OUT was an investigator-initiated, multi-site, phase 3, randomized, quadruple-blinded placebo-controlled clinical trial (NCT04510194). The design simultaneously assessed three oral medications (metformin, ivermectin, fluvoxamine) using two by three parallel treatment factorial assignment to efficiently share placebo controls and assessed Long Covid outcomes for 10 months to understand whether early outpatient treatment of SARS-CoV-2 with metformin, ivermectin, or fluvoxamine prevents Long Covid. Methods This was a decentralized, remotely delivered trial in the US of 1,125 adults age 30 to 85 with overweight or obesity, fewer than 7 days of symptoms, and enrolled within three days of a documented SARS-CoV-2 infection. Immediate release metformin titrated over 6 days to 1,500mg per day 14 days total; ivermectin 430mcg/kg/day for 3 days; fluvoxamine, 50mg on day one then 50mg twice daily through 14 days. Medical-provider diagnosis of Long Covid, reported by participant by day 300 after randomization was a pre-specified secondary outcome; the primary outcome of the trial was severe Covid by day 14. Result The median age was 45 years (IQR 37 to 54), 56% female of whom 7% were pregnant. Two percent identified as Native American; 3.7% as Asian; 7.4% as Black/African American; 82.8% as white; and 12.7% as Hispanic/Latino. The median BMI was 29.8 kg/m2 (IQR 27 to 34); 51% had a BMI >30kg/m2. Overall, 8.4% reported having received a diagnosis of Long Covid from a medical provider: 6.3% in the metformin group and 10.6% in the metformin control; 8.0% in the ivermectin group and 8.1% in the ivermectin control; and 10.1% in the fluvoxamine group and 7.5% in the fluvoxamine control. The Hazard Ratio (HR) for Long Covid in the metformin group versus control was 0.58 (95% CI 0.38 to 0.88); 0.99 (95% CI 0.592 to 1.643) in the ivermectin group; and 1.36 in the fluvoxamine group (95% CI 0.785 to 2.385). Conclusions There was a 42% relative decrease in the incidence of Long Covid in the metformin group compared to its blinded control in a secondary outcome of this randomized phase 3 trial.
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Affiliation(s)
| | - John B Buse
- Endocrinology, University of North Carolina, Chapel Hill, ND
| | - David Liebovitz
- General Internal Medicine, Northwestern University, Chicago, IL
| | - Jacinda Nicklas
- General Internal Medicine, University of Colorado, Denver, CO
| | | | - Ken Cohen
- UnitedHealth Group, Optum Labs, Minnetonka, MN
| | - Hrishikesh Belani
- Department of Medicine, Olive View - University of California, Los Angeles, CA
| | - Blake Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | | | - Jennifer Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew Pullen
- Infectious Diseases, University of Minnesota Medical School, Minneapolis, MN
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Jennifer Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David J Odde
- Department of Biomedical Engineering University of Minnesota, Minneapolis, MN
| | - Nichole Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN
| | - Nancy Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Sarah Lindberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Esteban Lemus Wirtz
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Amy Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN
| | - Kenny Beckman
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN
| | - Spencer Erickson
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Sarah Fenno
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Katrina Hartman
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Michael Rose
- General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Barkha Patel
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | | | - Neeta Bhat
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David R Boulware
- Infectious Diseases, University of Minnesota Medical School, Minneapolis, MN
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Brand KM, Thoren R, Sõnajalg J, Boutmy E, Foch C, Schlachter J, Hakkarainen KM, Saarelainen L. Metformin in pregnancy and risk of abnormal growth outcomes at birth: a register-based cohort study. BMJ Open Diabetes Res Care 2022; 10:10/6/e003056. [PMID: 36460329 PMCID: PMC9723823 DOI: 10.1136/bmjdrc-2022-003056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/17/2022] [Indexed: 12/03/2022] Open
Abstract
We previously reported an increased risk of being small for gestational age (SGA) and a decreased risk of being large for gestational age (LGA) after in utero exposure to metformin compared with insulin exposure. This follow-up study investigated if these observations remain when metformin exposure (henceforth, metformin cohort) is compared with non-pharmacological antidiabetic treatment of gestational diabetes mellitus (GDM; naïve cohort), instead of insulin. RESEARCH DESIGN AND METHODS : This was a Finnish population register-based cohort study from singleton children born during 2004-2016. Birth outcomes from metformin cohort (n=3964) and the naïve cohort (n=82 675) were used in the main analyses. Additional analyses were conducted in a subcohort, restricting the metformin cohort to children of mothers with GDM only (n=2361). Results were reported as inverse probability of treatment weighted OR (wOR), with the naïve cohort as reference. RESULTS : No difference was found for the outcome of SGA between the cohorts in the main analyses (wOR 0.97, 95% CI 0.73 to 1.27) or in the additional analyses (wOR 1.01, 95% CI 0.75 to 1.37). No difference between the cohorts was found for the risk of LGA (wOR 0.91, 95% CI 0.75 to 1.11) in the main analyses but a decreased risk was observed in the additional analyses (wOR 0.72, 95% CI 0.56 to 0.92). CONCLUSIONS : This follow-up study found no increase in the risk of SGA or LGA after in utero exposure to metformin, compared with drug-naïve GDM. The decreased risk of LGA in mothers with GDM may suggest residual confounding. The lack of increased SGA risk aligns with findings from studies using metformin in non-diabetic pregnancies. In contrast, lower birth weight and increased SGA birth risk were observed in GDM pregnancies for metformin versus insulin. Metformin should be avoided with emerging growth restriction in utero. The interplay of intrauterine hyperglycemia and pharmacological treatments needs further assessment.
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Seshiah V, Bronson SC, Balaji V, Jain R, Anjalakshi C. Prediction and Prevention of Gestational Diabetes Mellitus and Its Sequelae by Administering Metformin in the Early Weeks of Pregnancy. Cureus 2022; 14:e31532. [DOI: 10.7759/cureus.31532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 11/16/2022] Open
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Diabetes und Schwangerschaft – Update 2022. DIE DIABETOLOGIE 2022. [PMCID: PMC9122083 DOI: 10.1007/s11428-022-00900-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Gestationsdiabetes mellitus (GDM) ist mit einem Anteil von 80 % die häufigste Form der Hyperglykämie in der Schwangerschaft. Stillen reduziert das Risiko für Typ-2-Diabetes, je länger die Stilldauer, umso größer ist der Effekt. Bei Frauen, die eine Früh- oder eine Totgeburt durchgemacht haben, besteht ein erhöhtes Risiko, selbst frühzeitig zu versterben. Das Potenzial einer Präeklampsieprävention durch niedrig dosierte Azetylsalizylsäuregabe bei Frauen mit Diabetes mellitus wird bei weitem nicht ausgeschöpft. Schwangere reduzieren durch eine COVID-19-Impfung (COVID-19: „coronavirus disease 2019“) ihr Risiko für einen schweren Krankheitsverlauf. Die nach wie vor hohe Rate an perinataler Mortalität bei Schwangerschaften mit Typ-1- und Typ-2-Diabetes kann in erster Linie durch eine Verbesserung von Basisfaktoren bei der perikonzeptionellen Betreuung reduziert werden. Zweizeitiges Screening auf GDM reduziert im Vergleich zum einzeitigen Screening die GDM-Prävalenz und die Medikalisierung ohne Nachteile für die Mütter und ihre Neugeborenen. Die Zulassung von Metformin für Schwangere seit Februar 2022 bedeutet nicht, dass dieses Arzneimittel als primäre Pharmakotherapie für schwangere Frauen empfohlen wird.
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Abstract
Overview of: Medicines and Healthcare products Regulatory Agency. Metformin in pregnancy: study shows no safety concerns. Drug Safety Update 2022;15:3.
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