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Yland JJ, Huybrechts KF, Wesselink AK, Straub L, Chiu YH, Seely EW, Patorno E, Bateman BT, Mogun H, Wise LA, Hernández-Díaz S. Perinatal Outcomes Associated With Metformin Use During Pregnancy in Women With Pregestational Type 2 Diabetes Mellitus. Diabetes Care 2024; 47:1688-1695. [PMID: 39042587 PMCID: PMC11362109 DOI: 10.2337/dc23-2056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 06/27/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVE We emulated a modified randomized trial (Metformin in Women With Type 2 Diabetes in Pregnancy [MiTy]) to compare the perinatal outcomes in women continuing versus discontinuing metformin during pregnancy among those with type 2 diabetes treated with metformin plus insulin before pregnancy. RESEARCH DESIGN AND METHODS This study used two health care claims databases (U.S., 2000-2020). Pregnant women age 18-45 years with type 2 diabetes who were treated with metformin plus insulin at conception were eligible. The primary outcome was a composite of preterm birth, birth injury, neonatal respiratory distress, neonatal hypoglycemia, and neonatal intensive care unit admission. Secondary outcomes included the components of the primary composite outcome, gestational hypertension, preeclampsia, maternal hypoglycemia, cesarean delivery, infants large for gestational age, infants small for gestational age (SGA), sepsis, and hyperbilirubinemia. We adjusted for potential baseline confounders, including demographic characteristics, comorbidities, and proxies for diabetes progression. RESULTS Of 2,983 eligible patients, 72% discontinued use of metformin during pregnancy. The average age at conception was 32 years, and the prevalence of several comorbidities was higher among continuers. The risk of the composite outcome was 46% for continuers and 48% for discontinuers. The adjusted risk ratio was 0.92 (95% CI 0.81, 1.03). Risks were similar between treatments and consistent between databases for most secondary outcomes, except for SGA, which was elevated in continuers only in the commercially insured population. CONCLUSIONS Our findings were consistent with those reported in the MiTy randomized trial. Continuing metformin during pregnancy was not associated with increased risk of a neonatal composite adverse outcome. However, a possible metformin-associated risk of SGA warrants further consideration.
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Affiliation(s)
- Jennifer J. Yland
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Krista F. Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Amelia K. Wesselink
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Loreen Straub
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Yu-Han Chiu
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Ellen W. Seely
- Endocrinology, Diabetes and Hypertension Division, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | | | - Helen Mogun
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Lauren A. Wise
- Department of Epidemiology, Boston University School of Public Health, Boston, MA
| | - Sonia Hernández-Díaz
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
- CAUSALab, Harvard T.H. Chan School of Public Health, Boston, MA
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Sheng B, Ni J, Lv B, Jiang G, Lin X, Li H. Short-term neonatal outcomes in women with gestational diabetes treated using metformin versus insulin: a systematic review and meta-analysis of randomized controlled trials. Acta Diabetol 2023; 60:595-608. [PMID: 36593391 PMCID: PMC10063481 DOI: 10.1007/s00592-022-02016-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Accepted: 12/08/2022] [Indexed: 01/04/2023]
Abstract
AIMS To expand the evidence base for the clinical use of metformin, we conducted a meta-analysis of randomized controlled trials (RCTs) comparing the efficacy and safety of metformin versus insulin with respect to short-term neonatal outcomes. METHODS A comprehensive search of electronic databases (PubMed, Embase, Cochrane Library, and Web of Science) was performed. Two reviewers extracted the data and calculated pooled estimates by use of a random-effects model. In total, 24 studies involving 4355 participants met the eligibility criteria and were included in the quantitative analyses. RESULTS Unlike insulin, metformin lowered neonatal birth weights (mean difference - 122.76 g; 95% confidence interval [CI] - 178.31, - 67.21; p < 0.0001), the risk of macrosomia (risk ratio [RR] 0.68; 95% CI 0.54, 0.86; p = 0.001), the incidence of neonatal intensive care unit admission (RR 0.73; 95% CI 0.61, 0.88; p = 0.0009), and the incidence of neonatal hypoglycemia (RR 0.65; 95% CI 0.52, 0.81; p = 0.0001). Subgroup analysis based on the maximum daily oral dose of metformin indicated that metformin-induced neonatal birth weight loss was independent of the oral dose. CONCLUSIONS Our meta-analysis provides further evidence that metformin is a safe oral antihyperglycemic drug and has some benefits over insulin when used for the treatment of gestational diabetes, without an increased risk of short-term neonatal adverse outcomes. Metformin may be particularly useful in women with gestational diabetes at high risk for neonatal hypoglycemia, women who want to limit maternal and fetal weight gain, and women with an inability to afford or use insulin safely.
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Affiliation(s)
- Bo Sheng
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
| | - Juan Ni
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
| | - Bin Lv
- Department of Gynecology and Obstetrics, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
| | - Guoguo Jiang
- Department of Hospital Infection Management, The Second Hospital of Chengdu City, Chengdu, 610041 Sichuan China
| | - Xuemei Lin
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
| | - Hao Li
- Department of Anesthesiology, West China Second University Hospital, Sichuan University, Chengdu, 610041 Sichuan China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Ministry of Education, Sichuan University, Chengdu, 610041 Sichuan China
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Feig DS, Sanchez JJ, Murphy KE, Asztalos E, Zinman B, Simmons D, Haqq AM, Fantus IG, Lipscombe L, Armson A, Barrett J, Donovan L, Karanicolas P, Tobin S, Mangoff K, Klein G, Jiang Y, Tomlinson G, Hamilton J. Outcomes in children of women with type 2 diabetes exposed to metformin versus placebo during pregnancy (MiTy Kids): a 24-month follow-up of the MiTy randomised controlled trial. Lancet Diabetes Endocrinol 2023; 11:191-202. [PMID: 36746160 DOI: 10.1016/s2213-8587(23)00004-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 12/19/2022] [Accepted: 12/30/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Metformin is increasingly being used during pregnancy, with potentially adverse long-term effects on children. We aimed to examine adiposity in children of women with type 2 diabetes from the Metformin in Women with Type 2 Diabetes in Pregnancy (MiTy) trial, with and without in-utero exposure to metformin, up to 24 months of age. METHODS MiTy Kids is a follow-up study that included infants of women who participated in the MiTy randomised controlled trial, receiving either oral 1000 mg metformin twice daily or placebo. Caregivers and researchers remained masked to the type of medication (metformin or placebo) mothers received during their pregnancy. Anthropometric measurements, including weight, height, and skinfold thicknesses, were taken at 3, 6, 12, 18, and 24 months. At 24 months, linear regression was used to compare the BMI Z score and sum of skinfolds in the metformin versus placebo groups, adjusted for confounders. Fractional polynomials were used to assess growth trajectories. This study is registered with ClinicalTrials.gov, NCT01832181. FINDINGS Of the 465 eligible children, 283 (61%) were included from 19 centres in Canada and Australia. At 24 months, there was no difference between groups in mean BMI Z score (0·84 [SD 1·52] with metformin vs 0·91 [1·38] with placebo; mean difference 0·07 [95% CI -0·31 to 0·45], p=0·72) or mean sum of skinfolds (23·0 mm [5·2] vs 23·8 mm [5·4]; mean difference 0·8 mm [-0·7 to 2·3], p=0·31). Metformin was not a predictor of BMI Z score at 24 months of age (mean difference -0·01 [95% CI -0·42 to 0·37], p=0·92). There was no overall difference in BMI trajectory but, in males, trajectories were significantly different by treatment (p=0·048); BMI in the metformin group was higher between 6 and 24 months. Children of women with type 2 diabetes were approximately 1 SD heavier than the WHO reference population. INTERPRETATION Anthropometrics were similar in children exposed and those not exposed to metformin in utero; hence, overall, data are reassuring with regard to the use of metformin during pregnancy in women with type 2 diabetes and the long-term health of their children. FUNDING Canadian Institute for Health Research.
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Affiliation(s)
- Denice S Feig
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada; Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada.
| | | | - Kellie E Murphy
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada; Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada
| | - Elizabeth Asztalos
- Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Bernard Zinman
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada; Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada
| | - David Simmons
- Department of Medicine, Western Sydney University, Sydney, NSW, Australia
| | - Andrea M Haqq
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - I George Fantus
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada; Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada; Department of Medicine and Research Institute, McGill University Health Center, McGill University, Montreal, QC, Canada
| | - Lorraine Lipscombe
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Anthony Armson
- Department of Obstetrics and Gynecology, Dalhousie University, Halifax, NS, Canada
| | - Jon Barrett
- Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Lois Donovan
- Department of Medicine and Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Calgary, AB, Canada
| | - Paul Karanicolas
- Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | | | - Gail Klein
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - Yidi Jiang
- Sunnybrook Research Institute, Toronto, ON, Canada
| | - George Tomlinson
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Jill Hamilton
- Department of Pediatrics, Division of Endocrinology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Abolhassani N, Winterfeld U, Kaplan YC, Jaques C, Minder Wyssmann B, Del Giovane C, Panchaud A. Major malformations risk following early pregnancy exposure to metformin: a systematic review and meta-analysis. BMJ Open Diabetes Res Care 2023; 11:e002919. [PMID: 36720508 PMCID: PMC9890805 DOI: 10.1136/bmjdrc-2022-002919] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 01/20/2023] [Indexed: 02/02/2023] Open
Abstract
Metformin is considered as first-line treatment for type 2 diabetes and an effective treatment for polycystic ovary syndrome (PCOS). However, evidence regarding its safety in pregnancy is limited. We conducted a systematic review and meta-analysis of major congenital malformations (MCMs) risk after first-trimester exposure to metformin in women with PCOS and pregestational diabetes mellitus (PGDM). Randomized controlled trials (RCTs) and observational cohort studies with a control group investigating risk of MCM after first-trimester pregnancy exposure to metformin were searched until December 2021. ORs and 95% CIs were calculated separately according to indications and study type using Mantel-Haenszel method; outcome data were combined using random-effects model. Eleven studies (two RCTs; nine observational cohorts) met the inclusion criteria: four included pregnant women with PCOS, four included those with PGDM and three evaluated both indications separately and were considered in both indication groups. In PCOS group, there were two RCTs (57 exposed, 52 control infants) and five observational studies (472 exposed, 1892 control infants); point estimates for MCM rates in RCTs and observational studies were OR 0.93 (95% CI 0.09 to 9.21) (I2=0%; Q test=0.31; p value=0.58) and OR 1.35 (95% CI 0.37 to 4.90) (I2=65%; Q test=9.43; p value=0.05), respectively. In PGDM group, all seven studies were observational (1122 exposed, 1851 control infants); the point estimate for MCM rates was OR 1.05 (95% CI 0.50 to 2.18) (I2=59%; Q test=16.34; p value=0.01). Metformin use in first-trimester pregnancy in women with PCOS or PGDM do not meaningfully increase the MCM risk overall. However, further studies are needed to characterize residual safety concerns.
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Affiliation(s)
- Nazanin Abolhassani
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- Department of Epidemiology and Health Systems, Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Vaud, Switzerland
| | - Ursula Winterfeld
- Service de Pharmacologie Clinique, Centre Hospitalier Universitaire Vaudois, Lausanne University Hospital, Lausanne, Vaud, Switzerland
| | - Yusuf C Kaplan
- Izmir University of Economics, School of Medicine, Izmir University of Economics, Izmir, Turkey
| | - Cécile Jaques
- Lausanne University Hospital and University of Lausanne, Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Beatrice Minder Wyssmann
- Public Health & Primary Care Library, University Library of Bern, University of Bern, University of Bern, Bern, Switzerland
| | - Cinzia Del Giovane
- Institute of Primary Health Care (BIHAM), University of Bern, University of Bern, Bern, Switzerland
| | - Alice Panchaud
- Primary Care Pharmacy, Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland, University of Bern, Bern, Switzerland
- Materno-fetal and Obstetrics Research Unit, Department "Femme-Mère-Enfant", University Hospital, Lausanne, Switzerland, University of Lausanne, Lausanne, Switzerland
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5
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Wang T, Zhang W. Application of Gestational Blood Glucose Control During Perinatal Period in Parturients with Diabetes Mellitus: Meta-Analysis of Controlled Clinical Studies. Front Surg 2022; 9:893148. [PMID: 35910483 PMCID: PMC9334781 DOI: 10.3389/fsurg.2022.893148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 05/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background Gestational diabetes mellitus (GDM) is a common metabolic disorder. Hyperglycemia may cause gestational hypertension, increase the probability of infection, abnormal embryonic development, and increase the abortion rate. Oral hypoglycemic drugs may be another effective means of blood glucose control in addition to insulin injection. We included controlled clinical studies for meta-analysis to understand the effect of oral hypoglycemic drugs in gestational diabetes. Methods The databases were searched with the keywords “Glycemic control” & “gestational diabetes”: Embase (January, 2000–August, 2021), Pubmed (January, 2000–August, 2021), Web of Science (January, 2000–August, 2021), Ovid (January, 2000–August, 2021), and ClinicalTrials.org to obtain the randomized controlled trial (RCT) literatures related to the treatment of gestational diabetes with oral hypoglycemic drugs, after screening, the R language toolkit was used for the analysis. Results A total of 10 articles with a total of 1,938 patients were included, 7 studies used metformin as an hypoglycemic agent. Meta-analysis showed that oral metformin had no significant difference in fasting blood glucose levels after the intervention compared with insulin injection [MD = −0.35, 95%CI(−0.70,1.40), Z = 0.66, P = 0.51], with no significant difference in postprandial blood glucose levels after intervention [MD = −2.20, 95%CI(−5.94,1.55), Z = −1.15, P = 0.25], and no statistical difference in glycosylated hemoglobin [MD = 0.10, 95%CI(−0.17,−0.04), Z = −0.94, P = 0.31]. Metformin was more conducive to reducing maternal weight during pregnancy than insulin [MD = −1.55, 95%CI(−2.77,−0.34), Z = −2.5, P = 0.0123], metformin reduced the abortion rate compared with insulin [RR = 0.81, 95%CI(0.63,1.05), Z = −2.61, P = 0.015], and reduced cesarean section rate [RR = 0.66, 95%CI(0.49,0.90), Z = −3.95, P = 0.0001]. Discussion The application of oral hypoglycemic drug metformin in blood glucose control of gestational diabetes can play a hypoglycemic effect equivalent to insulin and can control the weight of pregnant women, reduce the rate of abortion and cesarean section, and improve pregnancy outcomes.
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Affiliation(s)
- Tingting Wang
- Department of Obstetric, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wei Zhang
- Department of Obstetric, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Hannah W, Bhavadharini B, Beks H, Deepa M, Anjana RM, Uma R, Martin E, McNamara K, Versace V, Saravanan P, Mohan V. Global burden of early pregnancy gestational diabetes mellitus (eGDM): A systematic review. Acta Diabetol 2022; 59:403-427. [PMID: 34743219 DOI: 10.1007/s00592-021-01800-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 09/07/2021] [Indexed: 01/02/2023]
Abstract
AIMS Gestational diabetes mellitus (GDM) diagnosed during the first trimester of pregnancy is called 'early pregnancy Gestational Diabetes Mellitus' (eGDM). The burden of eGDM has only been studied sporadically. This review aims to understand the global burden of eGDM in terms of prevalence, risk factors, pregnancy outcomes, treatment and postpartum dysglycemia. METHODS: A review of epidemiologic studies reporting on early GDM screening as per Joanna Briggs Institute (JBI) methodology for prevalence reviews was conducted. A customized search strategy was used to search electronic databases namely, PubMed, CINAHL, EMBASE, Cochrane Library, Scopus, MEDLINE, Ovid, ScienceDirect, and Google Scholar. Three independent reviewers reviewed studies using Covidence software. Observational studies irrespective of study design and regardless of diagnostic criteria were included. Quality of evidence was appraised, and findings were synthesized. RESULTS Of 58 included studies, 41 reported a prevalence of eGDM, ranging from 0.7 to 36.8%. Body mass index (BMI), previous history of GDM, family history of diabetes and multiparity were reported as eGDM risk factors. Adverse pregnancy outcomes associated with eGDM were macrosomia, caesarean delivery, induction of labour, hypertension, preterm delivery, and shoulder dystocia. The incidence of postpartum dysglycemia and the need for insulin was higher in women with eGDM. The risk of bias was moderate. Heterogeneity of studies is a limitation. Meta-analysis was not performed. CONCLUSIONS There is heterogeneity in the prevalence of eGDM and intrapartum and postpartum ill effects for the mother and the offspring. There is a need to develop a universal screening protocol for eGDM.
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Affiliation(s)
- Wesley Hannah
- Madras Diabetes Research Foundation - ICMR Center for Advanced Research on Diabetes and Dr. Mohan's Diabetes Specialities Centre, No 4, Conran Smith Road, Gopalapuram, Chennai, 600 086, India
- Deakin University, Geelong, Australia
| | | | | | - Mohan Deepa
- Madras Diabetes Research Foundation - ICMR Center for Advanced Research on Diabetes and Dr. Mohan's Diabetes Specialities Centre, No 4, Conran Smith Road, Gopalapuram, Chennai, 600 086, India
| | - Ranjit Mohan Anjana
- Madras Diabetes Research Foundation - ICMR Center for Advanced Research on Diabetes and Dr. Mohan's Diabetes Specialities Centre, No 4, Conran Smith Road, Gopalapuram, Chennai, 600 086, India
| | - Ram Uma
- Seethapathy Clinic & Hospital, Chennai, India
| | | | | | | | - Ponnusamy Saravanan
- Populations, Evidence and Technologies, Warwick Medical School, Gibbet Hill, Division of Health Sciences, University of Warwick, Coventry, UK
- Department of Diabetes, Endocrinology and Metabolism, George Eliot Hospital NHS Trust, Nunetaon, UK
| | - Viswanathan Mohan
- Madras Diabetes Research Foundation - ICMR Center for Advanced Research on Diabetes and Dr. Mohan's Diabetes Specialities Centre, No 4, Conran Smith Road, Gopalapuram, Chennai, 600 086, India.
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Liu S, Sun Y, Luo N. Doppler Ultrasound Imaging Combined with Fetal Heart Detection in Predicting Fetal Distress in Pregnancy-Induced Hypertension under the Guidance of Artificial Intelligence Algorithm. JOURNAL OF HEALTHCARE ENGINEERING 2021; 2021:4405189. [PMID: 34659686 PMCID: PMC8519722 DOI: 10.1155/2021/4405189] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022]
Abstract
This study was to improve the feasibility and economic benefits of intelligent medical system Doppler ultrasound (DUS) imaging technology combined with fetal heart detection to predict the fetal distress in pregnancy-induced hypertension (PIH), so as to reduce the risk of deterioration of the patient's condition. The characteristics of DUS images were analyzed, and a diffusion filter reducing the specificity was adopted to improve the smooth speckle noise of DUS images. 120 pregnant women in hospital were the subjects of the study, all of whom received ultrasound cord blood flow testing and fetal heart monitoring. 88 PIH patients with fetal distress were diagnosed and included in the observation group, and 32 healthy pregnant women tested during the same period were identified as the control group. Clinical data were reviewed and analyzed. The diagnostic rates of fetal distress by simple fetal heart monitoring and DUS detection combined with fetal heart monitoring were compared. The results showed that 26.7% of fetal distress were diagnosed by fetal heart monitoring alone, and 73.3% of fetal distress were diagnosed by combined testing, so the diagnostic accuracy of the combined detection method was greatly higher than the single fetal heart detection (P < 0.05). The Pulsatility index (PI), resistance index (RI), and S/D values detected by the umbilical artery in the observation group were 1.48, 0.85, and 4.31, respectively. The PI, RI, and S/D values detected by the umbilical artery in the control group were 0.96, 0.64, and 3.59, respectively. The results of arterial detection were significantly higher than those of the control group, and the difference was of significant scientific significance (P < 0.05). In summary, the PI and RI values of the middle cerebral artery (MCA) detected by DUS diagnosis can effectively reflect the current status of the fetus in the uterus and reduce the mortality of the fetus. The images guided by DUS imaging technology can clearly show the current status of the fetus in the uterus, effectively improve the medical diagnostic efficiency, and have important reference value for the development of intelligent medical equipment.
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Affiliation(s)
- Su Liu
- Department of Obstetrics, The Third Affiliated Hospital of Qiqihar Medical College, Qiqihar 161000, Heilongjiang, China
| | - Yue Sun
- Department of Ultrasound, The Third Affiliated Hospital of Qiqihar Medical College, Qiqihar 161000, Heilongjiang, China
| | - Na Luo
- Department of Ultrasound, The Third Affiliated Hospital of Qiqihar Medical College, Qiqihar 161000, Heilongjiang, China
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Kgosidialwa O, Bogdanet D, Egan A, Newman C, O'Shea PM, Biesty L, McDonagh C, O'Shea C, Devane D, Dunne F. A systematic review on outcome reporting in randomised controlled trials assessing treatment interventions in pregnant women with pregestational diabetes. BJOG 2021; 128:1894-1904. [PMID: 34258852 DOI: 10.1111/1471-0528.16842] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Pregestational diabetes mellitus (PGDM) is associated with adverse pregnancy outcomes. Studies assessing interventions to improve maternal and infant outcomes have increased exponentially over recent years. Several outcomes in this field of maternal diabetes are rare, making it difficult to synthesise evidence. OBJECTIVES To collect outcomes reported in studies assessing treatment interventions in pregnant women with PGDM. SEARCH STRATEGY CENTRAL, Web of Science, Medline, CINAHL, Embase and ClinicalTrials.gov from their inception until 27 January 2020. SELECTION CRITERIA Any randomised controlled trial assessing treatment interventions in pregnant women with PGDM reported in English. DATA COLLECTION AND ANALYSIS Two independent reviewers assessed the suitability of articles and retrieved the data. Outcomes extracted from the literature were broadly categorised into maternal, fetal/infant or other outcomes by the study advisory group. MAIN RESULTS Sixty-seven of the 1475 studies identified fulfilled the inclusion criteria. The median number of outcomes reported per study was 15 (range 1-46). The majority of studies were from North America and Europe. Insulin and metformin were the most commonly investigated pharmacological interventions. Glucose monitoring was the most assessed technological intervention. In all, 131 unique outcomes were extracted: maternal (n = 69), fetal/infant (n = 61) and other (n = 1). CONCLUSIONS Outcome reporting in treatment interventions trials of pregnant women with PGDM is varied, making it difficult to synthesise evidence, especially for rare outcomes. Systems are needed to standardise outcome reporting in future clinical trials and so facilitate evidence synthesis in this area of maternal diabetes. REGISTRATION The systematic review was registered prospectively with the International Prospective Register of Systematic Reviews (PROSPERO) database (Registration number CRD42020173549). TWEETABLE ABSTRACT Outcome reporting is heterogeneous in intervention trials of pregnant women with diabetes existing before pregnancy.
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Affiliation(s)
- O Kgosidialwa
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - D Bogdanet
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - A Egan
- Department of Endocrinology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - C Newman
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - P M O'Shea
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - L Biesty
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.,Ireland HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - C McDonagh
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - C O'Shea
- School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - D Devane
- School of Nursing and Midwifery, National University of Ireland Galway, Galway, Ireland.,Ireland HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - F Dunne
- School of Medicine, National University of Ireland Galway, Galway, Ireland
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Kgosidialwa O, Bogdanet D, Egan AM, O'Shea PM, Newman C, Griffin TP, McDonagh C, O'Shea C, Carmody L, Cooray SD, Anastasiou E, Wender-Ozegowska E, Clarson C, Spadola A, Alvarado F, Noctor E, Dempsey E, Napoli A, Crowther C, Galjaard S, Loeken MR, Maresh M, Gillespie P, de Valk H, Agostini A, Biesty L, Devane D, Dunne F. A core outcome set for the treatment of pregnant women with pregestational diabetes: an international consensus study. BJOG 2021; 128:1855-1868. [PMID: 34218508 PMCID: PMC9311326 DOI: 10.1111/1471-0528.16825] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2021] [Indexed: 12/21/2022]
Abstract
Objective To develop a core outcome set (COS) for randomised controlled trials (RCTs) evaluating the effectiveness of interventions for the treatment of pregnant women with pregestational diabetes mellitus (PGDM). Design A consensus developmental study. Setting International. Population Two hundred and five stakeholders completed the first round. Methods The study consisted of three components. (1) A systematic review of the literature to produce a list of outcomes reported in RCTs assessing the effectiveness of interventions for the treatment of pregnant women with PGDM. (2) A three-round, online eDelphi survey to prioritise these outcomes by international stakeholders (including healthcare professionals, researchers and women with PGDM). (3) A consensus meeting where stakeholders from each group decided on the final COS. Main outcome measures All outcomes were extracted from the literature. Results We extracted 131 unique outcomes from 67 records meeting the full inclusion criteria. Of the 205 stakeholders who completed the first round, 174/205 (85%) and 165/174 (95%) completed rounds 2 and 3, respectively. Participants at the subsequent consensus meeting chose 19 outcomes for inclusion into the COS: trimester-specific haemoglobin A1c, maternal weight gain during pregnancy, severe maternal hypoglycaemia, diabetic ketoacidosis, miscarriage, pregnancy-induced hypertension, pre-eclampsia, maternal death, birthweight, large for gestational age, small for gestational age, gestational age at birth, preterm birth, mode of birth, shoulder dystocia, neonatal hypoglycaemia, congenital malformations, stillbirth and neonatal death. Conclusions This COS will enable better comparison between RCTs to produce robust evidence synthesis, improve trial reporting and optimise research efficiency in studies assessing treatment of pregnant women with PGDM. 165 key stakeholders have developed #Treatment #CoreOutcomes in pregnant women with #diabetes existing before pregnancy.
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Affiliation(s)
- O Kgosidialwa
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - D Bogdanet
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - A M Egan
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - P M O'Shea
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C Newman
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - T P Griffin
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C McDonagh
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - C O'Shea
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - L Carmody
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - S D Cooray
- Diabetes and Endocrinology Units, Monash Health, Clayton, Vic., Australia.,Monash Centre for Health Research and Implementation, Monash University, Clayton, Vic., Australia
| | - E Anastasiou
- Department Diabetes & Pregnancy Outpatients, Mitera Hospital, Athens, Greece
| | - E Wender-Ozegowska
- Department of Reproduction, Poznan University of Medical Sciences, Poznan, Poland
| | - C Clarson
- Department of Paediatrics, University of Western Ontario, London, ON, Canada.,Lawson Health Research Institute, London, ON, Canada
| | - A Spadola
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA
| | - F Alvarado
- Mother Infant Research Institute, Tufts Medical Center, Boston, MA, USA
| | - E Noctor
- Division of Endocrinology, University Hospital Limerick, Limerick, Ireland
| | - E Dempsey
- INFANT Centre and Department of Paediatrics & Child Health, University College Cork, Cork, Ireland
| | - A Napoli
- Department of Clinical and Molecular Medicine, Sant'Andrea University Hospital, Sapienza, University of Rome, Rome, Italy
| | - C Crowther
- Liggins Institute, The University of Auckland, Auckland, New Zealand
| | - S Galjaard
- Department of Obstetrics and Gynaecology, Division of Obstetrics and Prenatal Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - M R Loeken
- Section of Islet Cell and Regenerative Biology, Joslin Diabetes Center, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Mja Maresh
- Department of Obstetrics, St Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | - P Gillespie
- Health Economics and Policy Analysis Centre (HEPAC), National University of Ireland, Galway, Ireland
| | - H de Valk
- Department of Internal Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - A Agostini
- A.S.LViterbo Distretto A, Consultorio Montefiascone, Rome, Italy
| | - L Biesty
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland
| | - D Devane
- School of Nursing & Midwifery, National University of Ireland Galway, Galway, Ireland.,HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland
| | - F Dunne
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
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10
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Hurrell A, White SL, Webster LM. Prescribing for pregnancy: managing diabetes. Drug Ther Bull 2021; 59:88-92. [PMID: 34035135 DOI: 10.1136/dtb.2019.000005] [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] [Indexed: 06/12/2023]
Abstract
Topics for DTB review articles are selected by DTB's editorial board to provide concise overviews of medicines and other treatments to help patients get the best care. Articles include a summary of key points and a brief overview for patients. Articles may also have a series of multiple choice CME questions.
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Affiliation(s)
- Alice Hurrell
- Women and Children's Health, King's College London, London, UK
| | - Sara L White
- Women and Children's Health, King's College London, London, UK
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11
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Chaves C, Cunha F, Martinho M, Garrido S, Silva-Vieira M, Estevinho C, Melo A, Figueiredo O, Morgado A, Almeida MC, Almeida M. Metformin combined with insulin in women with gestational diabetes mellitus: a propensity score-matched study. Acta Diabetol 2021; 58:615-621. [PMID: 33459895 DOI: 10.1007/s00592-020-01665-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 12/24/2020] [Indexed: 01/22/2023]
Abstract
AIM Metformin use in gestational diabetes (GDM) is a common practice. Although its use in combination with insulin might be advantageous, it was never formally tested. We studied whether combined treatment was associated with better obstetric or neonatal outcomes compared to insulin alone. METHODS This is a retrospective study, using the Portuguese National Registry of GDM (2012-2017), of women treated with insulin ± metformin. Primary endpoints were obstetric and neonatal complications. Secondary endpoints were gestational weight gain (GWG) and insulin dose. A propensity score-matched analysis was performed to balance the distribution of age, BMI, insulin treatment duration, HbA1c, first trimester diagnosis of GDM and previous GDM or macrosomia. Women treated with metformin plus insulin and insulin only were then compared. RESULTS A total of 4034 women were treated with insulin or insulin plus metformin (10.2%). After propensity score matching, we studied two groups of 386 patients. Obstetric and neonatal complications were similar. Women treated with metformin plus insulin had 201 (52.1%) obstetric complications versus 184 (47.7%) in insulin-only group, p = 0.22; and 112 (29.0%) neonatal complications versus 96 (24.9%), p = 0.19. Patients treated with metformin plus insulin had similar GWG, excessive weight gain and insulin dose compared to the insulin-only group. CONCLUSIONS Women with GDM treated with insulin plus metformin had similar obstetric and neonatal complications, weight gained and insulin dose compared to those only treated with insulin.
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Affiliation(s)
- Catarina Chaves
- Serviço de Endocrinologia do Centro Hospitalar do Tâmega e Sousa, Avenida do Hospital Padre Américo 210, 4564-007, Guilhufe, Penafiel, Portugal.
| | - Filipe Cunha
- Serviço de Endocrinologia do Centro Hospitalar do Tâmega e Sousa, Avenida do Hospital Padre Américo 210, 4564-007, Guilhufe, Penafiel, Portugal
| | - Mariana Martinho
- Serviço de Endocrinologia do Centro Hospitalar do Tâmega e Sousa, Avenida do Hospital Padre Américo 210, 4564-007, Guilhufe, Penafiel, Portugal
| | - Susana Garrido
- Serviço de Endocrinologia do Centro Hospitalar do Tâmega e Sousa, Avenida do Hospital Padre Américo 210, 4564-007, Guilhufe, Penafiel, Portugal
| | - Margarida Silva-Vieira
- Serviço de Endocrinologia do Centro Hospitalar do Tâmega e Sousa, Avenida do Hospital Padre Américo 210, 4564-007, Guilhufe, Penafiel, Portugal
| | - Catarina Estevinho
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar do Tâmega e Sousa, Penafiel, Portugal
| | - Anabela Melo
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar do Tâmega e Sousa, Penafiel, Portugal
| | - Odete Figueiredo
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar do Tâmega e Sousa, Penafiel, Portugal
| | - Ana Morgado
- Serviço de Ginecologia e Obstetrícia do Centro Hospitalar do Tâmega e Sousa, Penafiel, Portugal
| | - Maria Céu Almeida
- Serviço de Obstetrícia, Maternidade Bissaya Barreto, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Margarida Almeida
- Serviço de Endocrinologia do Centro Hospitalar do Tâmega e Sousa, Avenida do Hospital Padre Américo 210, 4564-007, Guilhufe, Penafiel, Portugal
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12
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Nadeau HCG, Maxted ME, Madhavan D, Pierce SL, Feghali M, Scifres C. Insulin Dosing, Glycemic Control, and Perinatal Outcomes in Pregnancies Complicated by Type-2 Diabetes. Am J Perinatol 2021; 38:535-543. [PMID: 33065743 DOI: 10.1055/s-0040-1718579] [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] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study aimed to evaluate the prevalence of severe insulin resistance (insulin requirements ≥2 units/kg) at delivery and the relationship between severe insulin resistance, glycemic control, and adverse perinatal outcomes in pregnant women with type-2 diabetes mellitus. STUDY DESIGN This is a retrospective cohort study of women with type-2 diabetes mellitus who delivered between January 2015 and December 2017 at a tertiary academic medical center. Maternal demographic information, self-monitored blood sugars, and insulin doses were abstracted from the medical record. Multivariable logistic regression was used to identify maternal baseline characteristics associated with severe insulin resistance at delivery. RESULTS Overall 72/160 (45%) of women had severe insulin resistance. Women in the severe insulin resistance group demonstrated evidence of suboptimal glycemic control as evidenced by higher mean hemoglobin A1c (HbA1c) values (7.2 [ ± 1.1] vs. 6.6 [ ± 1.3%], p = 0.003), higher mean fasting (104.0 [ ± 17.4] vs. 95.2 [ ± 11.7 mg/dL], p < 0.001) and postprandial glucose values (132.4 [ ± 17.2] vs. 121.9 [ ± 16.9 mg/dL]), p < 0.001), and a higher percentage of total glucose values that were elevated above targets (37.7 [95% confidence interval (CI): 26.8-50] vs. 25.6 [95% CI: 13.3-41.3%], p < 0.001). Maternal HbA1c ≥6.5% and insulin use prior to pregnancy were associated with a higher prevalence of severe insulin resistance, while Hispanic ethnicity and non-White race were associated with a lower prevalence of severe insulin resistance. The rates of adverse perinatal outcomes including large for gestational age (LGA) birth weight, cesarean delivery, and hypertensive disorders of pregnancy did not differ between groups. CONCLUSION Severe insulin resistance is common among pregnant women with type-2 diabetes, and it is associated with suboptimal glycemic control. Future studies are necessary to develop strategies to identify women with severe insulin resistance early in pregnancy and facilitate adequate insulin dosing. KEY POINTS · Severe insulin resistance is common.. · BMI does not predict severe insulin resistance.. · Suboptimal glycemic control is common..
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Affiliation(s)
- Hugh C G Nadeau
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Marta E Maxted
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Devika Madhavan
- Department of Medicine, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Stephanie L Pierce
- Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
| | - Maisa Feghali
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Magee-Women's Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Christina Scifres
- Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, Indiana
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13
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Shpakov AO. Improvement Effect of Metformin on Female and Male Reproduction in Endocrine Pathologies and Its Mechanisms. Pharmaceuticals (Basel) 2021; 14:ph14010042. [PMID: 33429918 PMCID: PMC7826885 DOI: 10.3390/ph14010042] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/02/2021] [Accepted: 01/06/2021] [Indexed: 02/07/2023] Open
Abstract
Metformin (MF), a first-line drug to treat type 2 diabetes mellitus (T2DM), alone and in combination with other drugs, restores the ovarian function in women with polycystic ovary syndrome (PCOS) and improves fetal development, pregnancy outcomes and offspring health in gestational diabetes mellitus (GDM) and T2DM. MF treatment is demonstrated to improve the efficiency of in vitro fertilization and is considered a supplementary drug in assisted reproductive technologies. MF administration shows positive effect on steroidogenesis and spermatogenesis in men with metabolic disorders, thus MF treatment indicates prospective use for improvement of male reproductive functions and fertility. MF lacks teratogenic effects and has positive health effect in newborns. The review is focused on use of MF therapy for restoration of female and male reproductive functions and improvement of pregnancy outcomes in metabolic and endocrine disorders. The mechanisms of MF action are discussed, including normalization of metabolic and hormonal status in PCOS, GDM, T2DM and metabolic syndrome and restoration of functional activity and hormonal regulation of the gonadal axis.
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Affiliation(s)
- Alexander O Shpakov
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry of Russian Academy of Sciences, 194223 Saint Petersburg, Russia
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14
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A Pragmatic Approach to the Treatment of Women With Type 2 Diabetes in Pregnancy. Clin Obstet Gynecol 2020; 64:159-173. [PMID: 33481417 DOI: 10.1097/grf.0000000000000592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Type 2 diabetes mellitus (DM) is a growing problem among reproductive-aged women. Contemporary trends in obesity and delayed child-bearing are expected to result in an increasing number of pregnancies affected by type 2 DM. Women with known type 2 DM can greatly benefit from preconception care as improved periconception glycemic control and weight loss can decrease the neonatal and maternal risks associated with type 2 DM and pregnancy. Antenatal mainstays of management include frequent blood glucose monitoring, insulin therapy, optimization of coexisting medical conditions, and fetal surveillance. Careful attention to postpartum glucose control, infant feeding choices, and contraceptive counseling are important aspects of immediate postpartum care.
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15
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Dempsey A, Mumby C, Bernatavicius G, Roberts SA, Myers JE. Metformin treatment vs a diabetes model of prenatal care in women with mild fasting hyperglycemia diagnosed in pregnancy: a feasibility study. J Matern Fetal Neonatal Med 2020; 35:4469-4477. [PMID: 33243030 DOI: 10.1080/14767058.2020.1852209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Guidelines disagree on the diagnostic thresholds for gestational diabetes (GDM); treatment of women with mild fasting hyperglycemia may not be cost-effective and increase unnecessary intervention. MATERIALS AND METHODS Single-center, open-label randomized controlled feasibility trial (ISRCTN86503951). "Metformin" treatment (2 g/day) without home blood glucose monitoring (HBGM) compared to NICE "standard" diabetes prenatal care in women with fasting 5.1-5.4 mmol/L, 2H <8.5 mmol/L) at oral glucose tolerance test (OGTT). RESULTS Process outcome: From the 173 women approached, 40/147 (27%) met the eligibility criteria and agreed to participate (non-completion n = 3). All women received dietary advice. Overall, compliance was good; with the majority of women in the treatment arm reporting missing metformin tablets less than 1-3 times/week. In the treatment arm (n = 18), median compliance (returned packets) was 65% [0-98%]; four women were unable to tolerate the full recommended dose of metformin. All women reported being satisfied with their treatment; with 9 out of 18 women (metformin arm) reporting they would choose the same treatment in a future pregnancy however 8 women reported they would want closer prenatal monitoring. Clinical outcome: Baseline characteristics and pregnancy outcomes were not different between participants and non-participants (n = 133). In women randomized to the standard care arm who performed HBGM, 15/19 were prescribed metformin based on values above target despite diet and lifestyle modifications; two women required additional insulin (10%). Data on glycemic control were available for 16/19 women; a reduction in fasting and post-prandial glucose was achieved in 15/16 from recruitment to 36 weeks. There was no change in A1C in women in the treatment arm vs the standard care arm. There was no difference in the rates of LGA between participants (n = 40) and non-participants (n = 133), although there was a reduction in the median birthweight centiles in the participants, the majority of whom received metformin treatment, compared with the non-participants (35 [IQR 12-54] vs 52 [25-78]; p = .045). DISCUSSION Treatment with metformin in conjunction with routine care was acceptable to women with mild fasting hyperglycemia who participated in the trial, although overall recruitment to the study was low. Most women with mild fasting hyperglycemia (5.1-5.4 mmol/L) would meet the threshold for pharmacological treatment if identified as GDM based on current NICE guideline target blood glucose levels. However, given the low consent rate, it is unlikely that a future RCT comparing metformin treatment (in conjunction with routine prenatal care and without HBGM monitoring) to a diabetes prenatal clinic model of care would have the generalisability to inform the future management of this group.
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Affiliation(s)
- Alice Dempsey
- Maternal and Fetal Health Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK
| | - Clare Mumby
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Stephen A Roberts
- Centre for Biostatistics, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Jenny E Myers
- Maternal and Fetal Health Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,Manchester University NHS Foundation Trust, Manchester, UK
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16
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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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17
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Bailey CJ. Metformin in women with type 2 diabetes in pregnancy. Lancet Diabetes Endocrinol 2020; 8:802-803. [PMID: 32946813 DOI: 10.1016/s2213-8587(20)30308-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 08/04/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Clifford J Bailey
- School of Life and Health Sciences, Aston University, Birmingham B4 7ET, UK.
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18
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Feig DS, Donovan LE, Zinman B, Sanchez JJ, Asztalos E, Ryan EA, Fantus IG, Hutton E, Armson AB, Lipscombe LL, Simmons D, Barrett JFR, Karanicolas PJ, Tobin S, McIntyre HD, Tian SY, Tomlinson G, Murphy KE. Metformin in women with type 2 diabetes in pregnancy (MiTy): a multicentre, international, randomised, placebo-controlled trial. Lancet Diabetes Endocrinol 2020; 8:834-844. [PMID: 32946820 DOI: 10.1016/s2213-8587(20)30310-7] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/06/2020] [Accepted: 07/08/2020] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although metformin is increasingly being used in women with type 2 diabetes during pregnancy, little data exist on the benefits and harms of metformin use on pregnancy outcomes in these women. We aimed to investigate the effects of the addition of metformin to a standard regimen of insulin on neonatal morbidity and mortality in pregnant women with type 2 diabetes. METHODS In this prospective, multicentre, international, randomised, parallel, double-masked, placebo-controlled trial, women with type 2 diabetes during pregnancy were randomly assigned from 25 centres in Canada and four in Australia to receive either metformin 1000 mg twice daily or placebo, added to insulin. Randomisation was done via a web-based computerised randomisation service and stratified by centre and pre-pregnancy BMI (<30 kg/m2 or ≥30 kg/m2) in a ratio of 1:1 using random block sizes of 4 and 6. Women were eligible if they had type 2 diabetes, were on insulin, had a singleton viable pregnancy, and were between 6 and 22 weeks plus 6 days' gestation. Participants were asked to check their fasting blood glucose level before the first meal of the day, before the last meal of the day, and 2 h after each meal. Insulin doses were adjusted aiming for identical glucose targets (fasting glucose <5·3 mmol/L [95 mg/dL], 2-h postprandial glucose <6·7 mmol/L [120 mg/dL]). Study visits were done monthly and patients were seen every 1-4 weeks as was needed for standard clinical care. At study visits blood pressure and bodyweight were measured; patients were asked about tolerance to their pills, any hospitalisations, insulin doses, and severe hypoglycaemia events; and glucometer readings were downloaded to the central coordinating centre. Participants, caregivers, and outcome assessors were masked to the intervention. The primary outcome was a composite of fetal and neonatal outcomes, for which we calculated the relative risk and 95% CI between groups, stratifying by site and BMI using a log-binomial regression model with an intention-to-treat analysis. Secondary outcomes included several relevant maternal and neonatal outcomes. The trial was registered with ClinicalTrials.gov, NCT01353391. FINDINGS Between May 25, 2011, and Oct 11, 2018, we randomly assigned 502 women, 253 (50%) to metformin and 249 (50%) to placebo. Complete data were available for 233 (92%) participants in the metformin group and 240 (96%) in the placebo group for the primary outcome. We found no significant difference in the primary composite neonatal outcome between the two groups (40% vs 40%; p=0·86; relative risk [RR] 1·02 [0·83 to 1·26]). Compared with women in the placebo group, metformin-treated women achieved better glycaemic control (HbA1c at 34 weeks' gestation 41·0 mmol/mol [SD 8·5] vs 43·2 mmol/mol [-10]; 5·90% vs 6·10%; p=0·015; mean glucose 6·05 [0·93] vs 6·27 [0·90]; difference -0·2 [-0·4 to 0·0]), required less insulin (1·1 units per kg per day vs 1·5 units per kg per day; difference -0·4 [95% CI -0·5 to -0·2]; p<0·0001), gained less weight (7·2 kg vs 9·0 kg; difference -1·8 [-2·7 to -0·9]; p<0·0001) and had fewer caesarean births (125 [53%] of 234 in the metformin group vs 148 [63%] of 236 in the placebo group; relative risk [RR] 0·85 [95% CI 0·73 to 0·99]; p=0·031). We found no significant difference between the groups in hypertensive disorders (55 [23%] in the metformin group vs 56 [23%] in the placebo group; p=0·93; RR 0·99 [0·72 to 1·35]). Compared with those in the placebo group, metformin-exposed infants weighed less (mean birthweight 3156 g [SD 742] vs 3375 g [742]; difference -218 [-353 to -82]; p=0·002), fewer were above the 97th centile for birthweight (20 [9%] in the metformin group vs 34 [15%] in the placebo group; RR 0·58 [0·34 to 0·97]; p=0·041), fewer weighed 4000 g or more at birth (28 [12%] in the metformin group vs 44 [19%] in the placebo group; RR 0·65 [0·43 to 0·99]; p=0·046), and metformin-exposed infants had reduced adiposity measures (mean sum of skinfolds 16·0 mm [SD 5·0] vs 17·4 [6·2] mm; difference -1·41 [-2·6 to -0·2]; p=0·024; mean neonatal fat mass 13·2 [SD 6·2] vs 14·6 [5·0]; p=0·017). 30 (13%) infants in the metformin group and 15 (7%) in the placebo group were small for gestational age (RR 1·96 [1·10 to 3·64]; p=0·026). We found no significant difference in the cord c-peptide between groups (673 pmol/L [435] in the metformin group vs 758 pmol/L [595] in the placebo group; p=0·10; ratio of means 0·88 [0·72 to 1·02]). The most common adverse event reported was gastrointestinal (38 events in the metformin group and 38 events in the placebo group). INTERPRETATION We found several maternal glycaemic and neonatal adiposity benefits in the metformin group. Along with reduced maternal weight gain and insulin dosage and improved glycaemic control, the lower adiposity and infant size measurements resulted in fewer large infants but a higher proportion of small-for-gestational-age infants. Understanding the implications of these effects on infants will be important to properly advise patients who are contemplating the use of metformin during pregnancy. FUNDING Canadian Institutes of Health Research, Lunenfeld-Tanenbaum Research Institute, University of Toronto.
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Affiliation(s)
- Denice S Feig
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada; Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada.
| | - Lois E Donovan
- Cumming School of Medicine, Department of Medicine, Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Calgary, AB, Canada
| | - Bernard Zinman
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada; Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada
| | | | | | | | - I George Fantus
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada; Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada
| | | | | | - Lorraine L Lipscombe
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Women's College Hospital, Toronto, ON, Canada
| | | | - Jon F R Barrett
- Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Paul J Karanicolas
- Sunnybrook Research Institute, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - H David McIntyre
- Mater Research, University of Queensland, South Brisbane, QLD, Australia
| | | | - George Tomlinson
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health, Network, Toronto, ON, Canada
| | - Kellie E Murphy
- Department of Medicine, University of Toronto, Toronto, ON, Canada; Lunenfeld-Tanenbaum Research Institute, Toronto, ON, Canada; Sinai Health System, Mount Sinai Hospital, Toronto, ON, Canada; Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON, Canada
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Novel approaches to combat preeclampsia: from new drugs to innovative delivery. Placenta 2020; 102:10-16. [PMID: 32980138 DOI: 10.1016/j.placenta.2020.08.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/30/2020] [Accepted: 08/31/2020] [Indexed: 12/22/2022]
Abstract
Preeclampsia is a complex disease affecting 2-8% of pregnancies worldwide. It poses significant risk of maternal and perinatal morbidity and mortality. Despite the rising research interest to discover new therapeutic approaches to prevent and treat preeclampsia, options remain limited. Identifying the important pathological stages in the progression of this disease allows us to evaluate effective candidate therapeutics. Three important stages in the pathophysiology are: 1) placental hypoxia and oxidative stress, 2) excess release of anti-angiogenic and pro-inflammatory factors, and 3) widespread systemic endothelial dysfunction and vasoconstriction. Repurposing drugs already safe for use in pregnancy is an attractive option for discovery of novel therapeutics. There are many drugs currently being assessed to treat preeclampsia, including proton pump inhibitors (PPIs), metformin, statins, sulfasalazine, sofalcone, resveratrol, melatonin, and sildenafil citrate. These drugs show positive effects in preclinical studies, targeting placental and endothelial dysfunction. However, using novel therapeutics can raise safety concerns for the developing fetus. Therefore, innovative targeted delivery systems are being developed to safely administer these therapeutics directly to the placenta and/or endothelium. These include nanoparticle delivery systems, developed and used by the oncology field, now being adapted for obstetrics. This technology is currently being assessed in animal models and shows promise for treating preeclampsia. Combining effective therapeutics with targeted drug delivery could be the future of preeclampsia treatment.
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20
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Blair RA, Rosenberg EA, Palermo NE. The Use of Non-insulin Agents in Gestational Diabetes: Clinical Considerations in Tailoring Therapy. Curr Diab Rep 2019; 19:158. [PMID: 31811400 PMCID: PMC7213051 DOI: 10.1007/s11892-019-1243-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW To assess evidence to date for use of non-insulin agents in treatment of gestational diabetes mellitus. RECENT FINDINGS There has been increasing interest in the use of non-insulin agents, primarily metformin and glyburide (which both cross the placenta). Metformin has been associated with less maternal weight gain; however, recent studies have shown a trend toward increased weight in offspring exposed to metformin in utero. Glyburide has been associated with increased neonatal hypoglycemia. Glycemic control during pregnancy is essential to optimize both maternal and fetal outcomes. There are a myriad of factors to consider when designing treatment programs including patient preference, phenotype, and glucose patterns. While insulin is typically recommended as first-line, some women refuse or cannot afford insulin and in those cases, non-insulin agents may be used. Further studies are needed to assess treatment in pregnancy, perinatal outcomes, and particularly long-term metabolic profiles in mothers and offspring.
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Affiliation(s)
- Rachel A Blair
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Emily A Rosenberg
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA
| | - Nadine E Palermo
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Harvard Medical School, 221 Longwood Avenue, Boston, MA, 02115, USA.
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21
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Alqudah A, McMullan P, Todd A, O’Doherty C, McVey A, McConnell M, O’Donoghue J, Gallagher J, Watson CJ, McClements L. Service evaluation of diabetes management during pregnancy in a regional maternity hospital: potential scope for increased self-management and remote patient monitoring through mHealth solutions. BMC Health Serv Res 2019; 19:662. [PMID: 31514743 PMCID: PMC6743173 DOI: 10.1186/s12913-019-4471-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 08/27/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pre-gestational and gestational diabetes mellitus are common complications in pregnancy affecting one in six pregnancies. The maternity services are under significant strain managing the increasing number of complex pregnancies. This has an impact on patients' experience of antenatal care. Therefore, there is a clear need to address pregnancy care. One possible solution is to use home-based digital technology to reduce clinic visits and improve clinical monitoring. METHODS The aim of this study was to evaluate the antenatal services provided to pregnant women with diabetes who were monitored at the joint metabolic and obstetric clinic at the Southern Health and Social Care Trust in Northern Ireland. RESULTS The questionnaires were completed by sixty-three women, most of whom had gestational diabetes mellitus. Most of the participants were between 25 and 35 years of age (69.8%), had one or more children (65.1%) and spent over 2 h attending the clinics (63.9%); 78% of women indicated that their travel time to and from the clinic appointment was over 15 min. Over 70% of women used smartphones for health-related purposes. However, only 8.8% used smartphones to manage their health or diabetes. Less than 25% of the women surveyed expressed concerns about using digital technology from home to monitor various aspects of their health in pregnancy. CONCLUSIONS Overall, pregnant women who had or developed diabetes in pregnancy experience frequent hospital visits and long waiting times in the maternity clinics. Most of these pregnant women are willing to self-manage their condition from home and to be monitored remotely by the healthcare staff.
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Affiliation(s)
- Abdelrahim Alqudah
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, United Kingdom
- School of Pharmacy, The Hashemite University, Zarqa, Jordan
| | - Paul McMullan
- Craigavon Area Hospital, Southern Health and Social Care Trust, Craigavon, United Kingdom
| | - Anna Todd
- Craigavon Area Hospital, Southern Health and Social Care Trust, Craigavon, United Kingdom
| | - Conor O’Doherty
- Craigavon Area Hospital, Southern Health and Social Care Trust, Craigavon, United Kingdom
| | - Anne McVey
- Craigavon Area Hospital, Southern Health and Social Care Trust, Craigavon, United Kingdom
| | - Mae McConnell
- Craigavon Area Hospital, Southern Health and Social Care Trust, Craigavon, United Kingdom
| | | | - Joe Gallagher
- gHealth Research group, School of Medicine, University College Dublin, Dublin 4, Ireland
| | - Chris J. Watson
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, United Kingdom
| | - Lana McClements
- The Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, United Kingdom
- School of Life Sciences, Faculty of Science, University of Technology Sydney, Sydney, Australia
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22
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Abstract
Hyperglycemia is common during pregnancy, involving multisystem adaptations. Pregnancy-induced metabolic changes increase insulin resistance. Pregnancy-induced insulin resistance adds to preexisting insulin resistance. Preexisting pancreatic β-cell defect compromises the ability to enhance insulin secretion, leading to hyperglycemia. Women with type 2 DM have similar rates of major congenital malformations, stillbirth, and neonatal mortality, but an even higher risk of perinatal mortality. In utero type 2 DM exposure confers greater risk and reduces time to development of type 2 DM in offspring. Preconception care to improve metabolic control in women with type 2 diabetes is critical.
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Affiliation(s)
- Anil Kapur
- World Diabetes Foundation, 30 A, Krogshoejvej, Bagsverd 2880, Denmark; FIGO Pregnancy and NCD Committee, Jabotinski Street, Petah Tiqwa 49100, Israel.
| | - Harold David McIntyre
- FIGO Pregnancy and NCD Committee, Jabotinski Street, Petah Tiqwa 49100, Israel; UQ Mater Clinical Unit, Faculty of Medicine, Mater Health Services, University of Queensland, Raymond Terrace, South Brisbane, Brisbane, Qld 4101, Australia
| | - Moshe Hod
- FIGO Pregnancy and NCD Committee, Jabotinski Street, Petah Tiqwa 49100, Israel; Department of Obstetrics and Gynecology, Clalit Health Services, Mor Women's Health Center, Rabin Medical Center, Tel Aviv University, 18 Aba Ahimeir St., Tel Aviv 6949204, Israel
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23
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Abstract
IMPORTANCE The presence of preexisting type 1 or type 2 diabetes in pregnancy increases the risk of adverse maternal and neonatal outcomes, such as preeclampsia, cesarean delivery, preterm delivery, macrosomia, and congenital defects. Approximately 0.9% of the 4 million births in the United States annually are complicated by preexisting diabetes. OBSERVATIONS Women with diabetes have increased risk for adverse maternal and neonatal outcomes, and similar risks are present with type 1 and type 2 diabetes. Both forms of diabetes require similar intensity of diabetes care. Preconception planning is very important to avoid unintended pregnancies and to minimize risk of congenital defects. Hemoglobin A1c goals are less than 6.5% at conception and less than 6.0% during pregnancy. It is also critical to screen for and manage comorbid illnesses, such as retinopathy and nephropathy. Medications known to be unsafe in pregnancy, such as angiotensin-converting enzyme inhibitors and statins, should be discontinued. Women with obesity should be screened for obstructive sleep apnea, which is often undiagnosed and can result in poor outcomes. Blood pressure goals must be considered carefully because lower treatment thresholds may be required for women with nephropathy. During pregnancy, continuous glucose monitoring can improve glycemic control and neonatal outcomes in women with type 1 diabetes. Insulin is first-line therapy for all women with preexisting diabetes; injections and insulin pump therapy are both effective approaches. Rates of severe hypoglycemia are increased during pregnancy; therefore, glucagon should be available to the patient and close contacts should be trained in its use. Low-dose aspirin is recommended soon after 12 weeks' gestation to minimize the risk of preeclampsia. The importance of discussing long-acting reversible contraception before and after pregnancy, to allow for appropriate preconception planning, cannot be overstated. CONCLUSIONS AND RELEVANCE Preexisting diabetes in pregnancy is complex and is associated with significant maternal and neonatal risk. Optimization of glycemic control, medication regimens, and careful attention to comorbid conditions can help mitigate these risks and ensure quality diabetes care before, during, and after pregnancy.
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Affiliation(s)
| | - Rachel Blair
- Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Anne L. Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, California, United States
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24
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Barbour LA, Feig DS. Metformin for Gestational Diabetes Mellitus: Progeny, Perspective, and a Personalized Approach. Diabetes Care 2019; 42:396-399. [PMID: 30787061 DOI: 10.2337/dci18-0055] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Linda A Barbour
- Division of Endocrinology, Metabolism and Diabetes, Department of Medicine, and Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado, Anschutz Medical Campus, Aurora, CO
| | - Denice S Feig
- Department of Medicine, Division of Endocrinology and Metabolism, University of Toronto, Lunenfeld-Tanenbaum Research Institute, Toronto, Ontario, Canada
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25
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Cesta CE, Cohen JM, Pazzagli L, Bateman BT, Bröms G, Einarsdóttir K, Furu K, Havard A, Heino A, Hernandez-Diaz S, Huybrechts KF, Karlstad Ø, Kieler H, Li J, Leinonen MK, Gulseth HL, Tran D, Yu Y, Zoega H, Odsbu I. Antidiabetic medication use during pregnancy: an international utilization study. BMJ Open Diabetes Res Care 2019; 7:e000759. [PMID: 31798900 PMCID: PMC6861111 DOI: 10.1136/bmjdrc-2019-000759] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 08/30/2019] [Accepted: 09/08/2019] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE Diabetes in pregnancy and consequently the need for treatment with antidiabetic medication (ADM) has become increasingly prevalent. The prevalence and patterns of use of ADM in pregnancy from 2006 onward in seven different countries was assessed. RESEARCH DESIGN AND METHODS Data sources included individually linked data from the nationwide health registers in Denmark (2006-2016), Finland (2006-2016), Iceland (2006-2012), Norway (2006-2015), Sweden (2006-2015), state-wide administrative and claims data for New South Wales, Australia (2006-2012) and two US insurance databases: Medicaid Analytic eXtract (MAX; 2006-2012, public) and IBM MarketScan (2012-2015, private). The prevalence of ADM use was calculated as the proportion of pregnancies with at least one filled prescription of an ADM in the 90 days before pregnancy or within the three trimesters of pregnancy. RESULTS Prevalence of any ADM use in 5 279 231 pregnancies was 3% (n=147 999) and varied from under 2% (Denmark, Norway, and Sweden) to above 5% (Australia and US). Insulin was the most used ADM, and metformin was the most used oral hypoglycemic agent with increasing use over time in all countries. In 11.4%-62.5% of pregnancies with prepregnancy use, ADM (primarily metformin) was discontinued. When ADM treatment was initiated in late pregnancy for treatment of gestational diabetes mellitus, insulin was most often dispensed, except in the US, where glibenclamide was most often used. CONCLUSIONS Prevalence and patterns of use of ADM classes varied between countries and over time. While insulin remained the most common ADM used in pregnancy, metformin use increased significantly over the study period.
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Affiliation(s)
- Carolyn E Cesta
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jacqueline M Cohen
- Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway
| | - Laura Pazzagli
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Brian T Bateman
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Department of Anesthesiology, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Gabriella Bröms
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Internal Medicine, Danderyds Sjukhus AB, Stockholm, Sweden
| | - Kristjana Einarsdóttir
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Kari Furu
- Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway
- Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
| | - Alys Havard
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Anna Heino
- Information Services Department, National Institute for Health and Welfare, Helsinki, Finland
| | - Sonia Hernandez-Diaz
- Department of Epidemiology, Harvard University T H Chan School of Public Health, Boston, Massachusetts, USA
| | - Krista F Huybrechts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Øystein Karlstad
- Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway
| | - Helle Kieler
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department for Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Jiong Li
- Department of Clinical Epidemiology, Aarhus Universitet, Aarhus, Denmark
| | - Maarit K Leinonen
- Information Services Department, National Institute for Health and Welfare, Helsinki, Finland
| | - Hanne L Gulseth
- Department of Chronic Diseases and Ageing, Norwegian Institute of Public Health, Oslo, Norway
| | - Duong Tran
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Yongfu Yu
- Department of Clinical Epidemiology, Aarhus Universitet, Aarhus, Denmark
| | - Helga Zoega
- Centre of Public Health Sciences, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
- Centre for Big Data Research in Health, UNSW Sydney, Sydney, New South Wales, Australia
| | - Ingvild Odsbu
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Fat mass estimation in neonates: anthropometric models compared with air displacement plethysmography. Br J Nutr 2018; 121:285-290. [PMID: 30444206 DOI: 10.1017/s0007114518003355] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Newborn adiposity, a nutritional measure of the maternal-fetal intra-uterine environment, is representative of future metabolic health. An anthropometric model using weight, length and flank skinfold to estimate neonatal fat mass has been used in numerous epidemiological studies. Air displacement plethysmography (ADP), a non-invasive technology to measure body composition, is impractical for large epidemiological studies. The study objective was to determine the consistency of the original anthropometric fat mass estimation equation with ADP. Full-term neonates were studied at 12-72 h of life with weight, length, head circumference, flank skinfold thickness and ADP measurements. Statistical analyses evaluated three models to predict neonatal fat mass. Lin's concordance correlation coefficient, mean prediction error and root mean squared error between the predicted and observed ADP fat mass values were used to evaluate the models, where ADP was considered the gold standard. A multi-ethnic cohort of 468 neonates were studied. Models (M) for predicting fat mass were developed using 349 neonates from site 1, then independently evaluated in 119 neonates from site 2. M0 was the original anthropometric model, M1 used the same variables as M0 but with updated parameters and M2 additionally included head circumference. In the independent validation cohort, Lin's concordance correlation estimates demonstrated reasonable accuracy (model 0: 0·843, 1: 0·732, 2: 0·747). Mean prediction error and root mean squared error in the independent validation was much smaller for M0 compared with M1 and M2. The original anthropometric model to estimate neonatal fat mass is reasonable for predicting ADP, thus we advocate its continued use in epidemiological studies.
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27
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Hosseiny ZS, Nikpour P, Bakhtiary A, Mostafavi FS, Matinfar M, Jahani M, Aboutorabi R. Evaluation of Osteopontin Gene Expression in Endometrium of Diabetic Rat Models Treated with Metformin and Pioglitazone. INTERNATIONAL JOURNAL OF FERTILITY & STERILITY 2018; 12:293-297. [PMID: 30291688 PMCID: PMC6186281 DOI: 10.22074/ijfs.2019.5471] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 05/19/2018] [Indexed: 12/21/2022]
Abstract
Background Osteopontin (Opn) is one of the co-factors involved in cell adhesion and invasion during the implantation process. Several reports have shown Opn expression changes in diabetic condition in several tissues. In addition, an increased incidence of spontaneous abortion is reported in diabetic women. We, therefore, designed a study to evaluate the effects of diabetes on Opn expression at implantation time after treatment with metformin and pioglitazone. Materials and Methods In this interventional and experimental study, 28 rats were randomly divided into four groups, namely control, diabetic, pioglitazone-treated diabetic rats and metformin-treated diabetic rats. Streptozotocin (STZ) and nicotinamide (NA) were used to induce type 2 diabetes (T2D). During the implantation window, the endometrium was removed and the expression of Opn was analysed by reverse transcription quantitative polymerase chain reaction (RT-qPCR). Results Opn expression was significantly higher (30.70 fold-changes) in the diabetic group in comparison with the control group (P=0.04). Furthermore, the expression of Opn was significantly lower in the diabetic group treated with pioglitazone when compared with the diabetic group (P=0.04). Conclusion According to the high Opn expression and the possibility of increased adhesion of endometrial epithelial cells, the invasion of blastocyst may be affected and thus reduced. As pioglitazone significantly reversed the upregulation of Opn in diabetic rats, it may be considered as a therapeutic compound for treating T2D.
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Affiliation(s)
- Zeinab Sadat Hosseiny
- Department of Anatomical Sciences, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Parvaneh Nikpour
- Department of Genetics and Molecular Biology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Abas Bakhtiary
- Department of Anatomical Sciences, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Fatemah Sadat Mostafavi
- Department of Anatomical Sciences, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mohammad Matinfar
- Department of Internal Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mehrnaz Jahani
- Department of Genetics and Molecular Biology, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Roshanak Aboutorabi
- Department of Anatomical Sciences, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Electronic Address:
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28
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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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Keely E, Berger H, Feig DS. New Diabetes Canada Clinical Practice Guidelines for Diabetes and Pregnancy - What's Changed? JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2018; 40:1484-1489. [PMID: 30274918 DOI: 10.1016/j.jogc.2018.06.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2018] [Revised: 06/23/2018] [Indexed: 01/11/2023]
Affiliation(s)
- Erin Keely
- Department of Medicine, University of Ottawa, Ottawa, ON; The Ottawa Hospital, Ottawa, ON.
| | - Howard Berger
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, ON; Maternal Fetal Medicine, St. Michael's Hospital, Toronto, ON
| | - Denice S Feig
- Department of Medicine, University of Toronto, Toronto, On, Canada; Mount Sinai Hospital, Toronto, ON
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Diav-Citrin O, Steinmetz-Shoob S, Shechtman S, Ornoy A. In-utero exposure to metformin for type 2 diabetes or polycystic ovary syndrome: A prospective comparative observational study. Reprod Toxicol 2018; 80:85-91. [DOI: 10.1016/j.reprotox.2018.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 05/14/2018] [Accepted: 05/26/2018] [Indexed: 12/16/2022]
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Hyer S, Balani J, Shehata H. Metformin in Pregnancy: Mechanisms and Clinical Applications. Int J Mol Sci 2018; 19:E1954. [PMID: 29973490 PMCID: PMC6073429 DOI: 10.3390/ijms19071954] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 06/12/2018] [Accepted: 06/29/2018] [Indexed: 01/27/2023] Open
Abstract
Metformin use in pregnancy is increasing worldwide as randomised controlled trial (RCT) evidence is emerging demonstrating its safety and efficacy. The Metformin in Gestational Diabetes (MiG) RCT changed practice in many countries demonstrating that metformin had similar pregnancy outcomes to insulin therapy with less maternal weight gain and a high degree of patient acceptability. A multicentre RCT is currently assessing the addition of metformin to insulin in pregnant women with type 2 diabetes. RCT evidence is also available for the use of metformin in pregnancy for women with Polycystic Ovarian Syndrome and for nondiabetic women with obesity. No evidence of an increase in congenital malformations or miscarriages has been observed even when metformin is started before pregnancy and continued to term. Body composition and metabolic outcomes at two, seven, and nine years have now been reported for the offspring of mothers treated in the MiG study. In this review, we will briefly discuss the action of metformin and then consider the evidence from the key clinical trials.
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Affiliation(s)
- Steve Hyer
- Department of Endocrinology, Epsom and St. Helier University Hospitals NHS Trust, Wrythe Lane, Carshalton SM5 1AA, Surrey, UK.
| | - Jyoti Balani
- Department of Endocrinology, Epsom and St. Helier University Hospitals NHS Trust, Wrythe Lane, Carshalton SM5 1AA, Surrey, UK.
| | - Hassan Shehata
- Department of Maternal Medicine, Epsom and St. Helier University Hospitals NHS Trust, Wrythe Lane, Carshalton SM5 1AA, Surrey, UK.
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Priya G, Kalra S. Metformin in the management of diabetes during pregnancy and lactation. Drugs Context 2018; 7:212523. [PMID: 29942340 PMCID: PMC6012930 DOI: 10.7573/dic.212523] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2017] [Revised: 05/21/2018] [Accepted: 05/22/2018] [Indexed: 02/07/2023] Open
Abstract
This review explores the current place of metformin in the management of gestational diabetes (GDM) and type 2 diabetes during pregnancy and lactation. The rationale and basic pharmacology of metformin usage in pregnancy is discussed along with the evidence from observational and randomized controlled trials in women with GDM or overt diabetes. There seems to be adequate evidence of efficacy and short-term safety of metformin in relation to maternal and neonatal outcomes in GDM, with possible benefits related to lower maternal weight gain and lower risk of neonatal hypoglycemia and macrosomia. Additionally, metformin offers the advantages of oral administration, convenience, less cost and greater acceptability. Metformin may, therefore, be considered in milder forms of GDM where glycemic goals are not attained by lifestyle modification. However, failure rate is likely to be higher in those with an earlier diagnosis of GDM, higher blood glucose, higher body mass index (BMI) or previous history of GDM, and insulin remains the cornerstone of pharmacological treatment in such cases. The use of metformin in type 2 diabetes has been assessed in observational and small randomized trials. Metformin monotherapy in women with overt diabetes is highly unlikely to achieve glycemic targets. Hence, the use should be restricted as adjunct to insulin and may be considered in women with high insulin dose requirements or rapid weight gain. There is clearly a need for more clinical trials to assess the effect of combined insulin plus metformin therapy in pregnancy with type 2 diabetes. Additionally, there is a paucity of data on long-term effects in offspring exposed to metformin in utero. It is imperative to further explore its impact on offspring as metformin has significant transplacental transfer and has the potential to impact the programming of the epigenome. Therefore, caution must be exercised when prescribing metformin in pregnant women. More research is clearly needed before metformin can be considered as standard of care in the management of diabetes during pregnancy.
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Affiliation(s)
- Gagan Priya
- Department of Endocrinology, Fortis Hospital, Mohali, India
| | - Sanjay Kalra
- Department of Endocrinology, Bharti Hospital, Karnal, India
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Sacks DA, Feig DS. Caring for pregnant women whose diabetes antedates pregnancy: is there room for improvement? Diabetologia 2018; 61:1022-1026. [PMID: 29411042 DOI: 10.1007/s00125-018-4565-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 01/04/2018] [Indexed: 10/18/2022]
Affiliation(s)
- David A Sacks
- Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles Avenue, Pasadena, CA, 91101, USA.
- Department of Obstetrics and Gynecology, University of Southern California Keck School of Medicine, Los Angeles, CA, USA.
| | - Denice S Feig
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
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Polasek TM, Doogue MP, Thynne TRJ. Metformin treatment of type 2 diabetes mellitus in pregnancy: update on safety and efficacy. Ther Adv Drug Saf 2018; 9:287-295. [PMID: 29854390 DOI: 10.1177/2042098618769831] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 03/19/2018] [Indexed: 12/27/2022] Open
Abstract
With the increasing prevalence of type 2 diabetes mellitus (T2DM) in women of childbearing age, prescribing antidiabetic medications in first-trimester pregnancy is becoming more common. Metformin treatment during this time is usually avoided in countries with well-resourced healthcare. This is based on historical concerns about safety to the foetus and the widespread availability of insulin. However, there is now increasing interest in the potential benefits of metformin in pregnant women with T2DM. In this commentary, the main evidence supporting metformin safety in pregnancy is summarized, with an emphasis on the first trimester. Based on a structured literature search, the recent randomized controlled trials comparing metformin and insulin are reviewed. We then show that prescribing advice for metformin in pregnancy is inconsistent and product information/package inserts (PI) are universally out of date. This causes confusion and pushes some women and their clinicians to change from metformin to insulin. The potential advantages of metformin in pregnant women with T2DM are then discussed, including oral dosing and improved acceptability, lower resource utilization and cost, decreased insulin requirements, less maternal weight gain and less risk of maternal and neonatal hypoglycaemia. The conclusion is that metformin is a cheap and efficacious antidiabetic medication for many pregnant women with T2DM, with reasonable evidence for safety. Drug information resources should be updated so that metformin can be considered more broadly in women with T2DM who present for antenatal care.
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Affiliation(s)
- Thomas M Polasek
- Department of Clinical Pharmacology, Flinders University School of Medicine and Flinders Medical Centre, Bedford Park, South Australia 5042, Australia d3 Medicine, A Certara Company, Parkville, Victoria, 3052, Australia
| | - Matthew P Doogue
- Department of Medicine, University of Otago, Dunedin, New Zealand Christchurch Hospital, Canterbury District Health Board, Christchurch, New Zealand
| | - Tilenka R J Thynne
- Department of Clinical Pharmacology, Flinders University School of Medicine and Flinders Medical Centre, Bedford Park, South Australia, Australia
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Qvigstad E. The diversity of gestational diabetes: a therapeutic challenge. Eur J Endocrinol 2018; 178:C1-C5. [PMID: 29339526 DOI: 10.1530/eje-18-0012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Accepted: 01/15/2018] [Indexed: 01/17/2023]
Abstract
Metformin as the first drug of choice for glucose lowering in gestational diabetes (GDM) is still controversial, despite recent publications reporting similar outcomes in comparison to insulin, both for offspring and mothers. The use of metformin during pregnancy is increasing and several recent guidelines recommend metformin use in GDM pregnancies. Background, current metformin use and unresolved concerns are discussed in the context of the article from Gante and coworkers.
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Affiliation(s)
- Elisabeth Qvigstad
- Department of Endocrinology, Morbid Obesity and Preventive Medicine, Oslo University Hospital, Oslo, Norway
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Tieu J, Coat S, Hague W, Middleton P, Shepherd E. Oral anti-diabetic agents for women with established diabetes/impaired glucose tolerance or previous gestational diabetes planning pregnancy, or pregnant women with pre-existing diabetes. Cochrane Database Syst Rev 2017; 10:CD007724. [PMID: 29045765 PMCID: PMC6485334 DOI: 10.1002/14651858.cd007724.pub3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND While most guidance recommends the use of insulin in women whose pregnancies are affected by pre-existing diabetes, oral anti-diabetic agents may be more acceptable to women. The effects of these oral anti-diabetic agents on maternal and infant health outcomes need to be established in pregnant women with pre-existing diabetes or impaired glucose tolerance, as well as in women with previous gestational diabetes mellitus preconceptionally or during a subsequent pregnancy. This review is an update of a review that was first published in 2010. OBJECTIVES To investigate the effects of oral anti-diabetic agents in women with established diabetes, impaired glucose tolerance or previous gestational diabetes who are planning a pregnancy, or pregnant women with pre-existing diabetes, on maternal and infant health. The use of oral anti-diabetic agents for the management of gestational diabetes in a current pregnancy is evaluated in a separate Cochrane Review. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2016) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) and quasi-RCTs assessing the effects of oral anti-diabetic agents in women with established diabetes, impaired glucose tolerance or previous gestational diabetes who were planning a pregnancy, or pregnant women with pre-existing diabetes. Cluster-RCTs were eligible for inclusion, but none were identified. DATA COLLECTION AND ANALYSIS Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of the included RCTs. Review authors checked the data for accuracy, and assessed the quality of the evidence using the GRADE approach. MAIN RESULTS We identified six RCTs (707 women), eligible for inclusion in this updated review, however, three RCTs had mixed populations (that is, they included pregnant women with gestational diabetes) and did not report data separately for the relevant subset of women for this review. Therefore we have only included outcome data from three RCTs; data were available for 241 women and their infants. The three RCTs all compared an oral anti-diabetic agent (metformin) with insulin. The women in the RCTs that contributed data had type 2 diabetes diagnosed before or during their pregnancy. Overall, the RCTs were judged to be at varying risk of bias. We assessed the quality of the evidence for selected important outcomes using GRADE; the evidence was low- or very low-quality, due to downgrading because of design limitations (risk of bias) and imprecise effect estimates (for many outcomes only one or two RCTs contributed data).For our primary outcomes there was no clear difference between metformin and insulin groups for pre-eclampsia (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.33 to 1.20; RCTs = 2; participants = 227; very low-quality evidence) although in one RCT women receiving metformin were less likely to have pregnancy-induced hypertension (RR 0.58, 95% CI 0.37 to 0.91; RCTs = 1; participants = 206; low-quality evidence). Women receiving metformin were less likely to have a caesarean section compared with those receiving insulin (RR 0.73, 95% CI 0.61 to 0.88; RCTs = 3; participants = 241; low-quality evidence). In one RCT there was no clear difference between groups for large-for-gestational-age infants (RR 1.12, 95% CI 0.73 to 1.72; RCTs = 1; participants = 206; very low-quality evidence). There were no perinatal deaths in two RCTs (very low-quality evidence). Neonatal mortality or morbidity composite outcome and childhood/adulthood neurosensory disability were not reported.For other secondary outcomes we assessed using GRADE, there were no clear differences between metformin and insulin groups for induction of labour (RR 1.42, 95% CI 0.62 to 3.28; RCTs = 2; participants = 35; very low-quality evidence), though infant hypoglycaemia was reduced in the metformin group (RR 0.34, 95% CI 0.18 to 0.62; RCTs = 3; infants = 241; very low-quality evidence). Perineal trauma, maternal postnatal depression and postnatal weight retention, and childhood/adulthood adiposity and diabetes were not reported. AUTHORS' CONCLUSIONS There are insufficient RCT data to evaluate the use of oral anti-diabetic agents in women with established diabetes, impaired glucose tolerance or previous gestational diabetes who are planning a pregnancy, or in pregnant women with pre-existing diabetes. Low to very low-quality evidence suggests possible reductions in pregnancy-induced hypertension, caesarean section birth and neonatal hypoglycaemia with metformin compared with insulin for women with type 2 diabetes diagnosed before or during their pregnancy, and no clear differences in pre-eclampsia, induction of labour and babies that are large-for-gestational age. Further high-quality RCTs that compare any combination of oral anti-diabetic agent, insulin and dietary and lifestyle advice for these women are needed. Future RCTs could be powered to evaluate effects on short- and long-term clinical outcomes; such RCTs could attempt to collect and report on the standard outcomes suggested in this review. We have identified three ongoing studies and four are awaiting classification. We will consider these when this review is updated.
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Affiliation(s)
- Joanna Tieu
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital, 1st floor, Queen Victoria Building72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Suzette Coat
- The University of Adelaide, Women's and Children's HospitalDiscipline of Obstetrics and GynaecologyAdelaideAustralia
| | - William Hague
- The University of Adelaide, Women's and Children's HospitalDiscipline of Obstetrics and GynaecologyAdelaideAustralia
| | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
| | - Emily Shepherd
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyWomen's and Children's Hospital, 1st floor, Queen Victoria Building72 King William RoadAdelaideSouth AustraliaAustralia5006
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Romero R, Erez O, Hüttemann M, Maymon E, Panaitescu B, Conde-Agudelo A, Pacora P, Yoon BH, Grossman LI. Metformin, the aspirin of the 21st century: its role in gestational diabetes mellitus, prevention of preeclampsia and cancer, and the promotion of longevity. Am J Obstet Gynecol 2017; 217:282-302. [PMID: 28619690 DOI: 10.1016/j.ajog.2017.06.003] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 05/30/2017] [Accepted: 06/05/2017] [Indexed: 12/16/2022]
Abstract
Metformin is everywhere. Originally introduced in clinical practice as an antidiabetic agent, its role as a therapeutic agent is expanding to include treatment of prediabetes mellitus, gestational diabetes mellitus, and polycystic ovarian disease; more recently, experimental studies and observations in randomized clinical trials suggest that metformin could have a place in the treatment or prevention of preeclampsia. This article provides a brief overview of the history of metformin in the treatment of diabetes mellitus and reviews the results of metaanalyses of metformin in gestational diabetes mellitus as well as the treatment of obese, non-diabetic, pregnant women to prevent macrosomia. We highlight the results of a randomized clinical trial in which metformin administration in early pregnancy did not reduce the frequency of large-for-gestational-age infants (the primary endpoint) but did decrease the frequency of preeclampsia (a secondary endpoint). The mechanisms by which metformin may prevent preeclampsia include a reduction in the production of antiangiogenic factors (soluble vascular endothelial growth factor receptor-1 and soluble endoglin) and the improvement of endothelial dysfunction, probably through an effect on the mitochondria. Another potential mechanism whereby metformin may play a role in the prevention of preeclampsia is its ability to modify cellular homeostasis and energy disposition, mediated by rapamycin, a mechanistic target. Metformin has a molecular weight of 129 Daltons and therefore readily crosses the placenta. There is considerable evidence to suggest that this agent is safe during pregnancy. New literature on the role of metformin as a chemotherapeutic adjuvant in the prevention of cancer and in prolonging life and protecting against aging is reviewed briefly. Herein, we discuss the mechanisms of action and potential benefits of metformin.
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Abstract
Metformin has been prescribed in pregnancy for over 40 years; for much of this time, use has been limited both in numbers and geographically, and the evidence base has been confined to observational studies. In early years, perceived safety concerns and lack of availability of the drug in many countries acted as a barrier to use. More recently, RCTs have begun to examine the role of metformin in pregnancy in much-needed detail. However, this evidence base has been interpreted differently in different countries, leading to very wide variation in its current application in pregnancy. In this short review, we will discuss the history of metformin in pregnancy and highlight some of the key clinical trials. We will then consider some of the remaining controversies associated with metformin use in pregnancy, most important of these being the potential for long-term 'programming' effects on the fetus as a result of metformin being able to cross the placenta. We will also consider clinical situations where metformin might be avoided. Finally, we will discuss some future directions for this drug as it reaches its sixtieth anniversary.
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Affiliation(s)
- Robert S Lindsay
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation (BHF) Glasgow Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
| | - Mary R Loeken
- Section on Islet Cell and Regenerative Biology, Joslin Diabetes Center, Boston, MA, USA
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Gray SG, McGuire TM, Cohen N, Little PJ. The emerging role of metformin in gestational diabetes mellitus. Diabetes Obes Metab 2017; 19:765-772. [PMID: 28127850 DOI: 10.1111/dom.12893] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Revised: 01/11/2017] [Accepted: 01/23/2017] [Indexed: 12/19/2022]
Abstract
Metformin use during pregnancy is controversial and there is disparity in the acceptance of metformin treatment in women with gestational diabetes mellitus (GDM) in Australia. Despite short term maternal and neonatal safety measures, the placental transfer of metformin during GDM treatment and the absence of long-term safety data in offspring has regulators and prescribers cautious about its use. To determine the current role in GDM management, this literature review describes the physiological changes that occur in GDM and other forms of diabetes in pregnancy (DIP) and international changes in guidelines for GDM diagnosis. Management options are considered, with a focus on the evolving evidence for metformin, its mechanism of action, the maternal, foetal and neonatal outcomes associated with its use and benefit vs risk when compared with the current gold standard, insulin. Investigation reveals a favourable balance of evidence to support the safety and long-term benefits, to mother and child, of using metformin as an alternate to insulin for treatment of GDM. Recent findings of the gastrointestinal-directed action of metformin are at least as important as the hepatic effect and the availability of a novel delayed-release metformin dose form to exploit this new information provides a product and therapeutic strategy ideally suited to the use of metformin in GDM.
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Affiliation(s)
- Susan G Gray
- School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - Treasure M McGuire
- School of Pharmacy, The University of Queensland, Brisbane, Australia
- Mater Pharmacy Services, Mater Health Services, Brisbane, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Australia
| | - Neale Cohen
- Diabetes Clinics, BakerIDI Heart and Diabetes Institute, Prahran, Australia
| | - Peter J Little
- School of Pharmacy, The University of Queensland, Brisbane, Australia
- Department of Pharmacy, Xinhua College of Sun Yat-sen University, Guangzhou, China
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