Glibenclamide and metfoRmin versus stAndard care in gEstational diabeteS (GRACES): a feasibility open label randomised trial

Novel Cytocompatible Chitosan Schiff Base Derivative as a Potent Antibacterial, Antidiabetic, and Anticancer Agent

This study intends to develop a novel bioactive chitosan Schiff base (CTS-SB) derivative via coupling of chitosan (CTS) with 4-((5, 5-dimethyl-3-oxocyclohex-1-en-1-yl) amino) benzene-sulfonamide. The alteration in the chemical structure of CTS-SB was verified using 1H NMR and FT-IR analysis, while the thermal and morphological properties were inspected by TGA and SEM characterization tools, respectively. Ion exchange capacity of the developed CTS-SB derivative recorded a maximal value of 12.1 meq/g compared to 10.1 meq/g for pristine CTS. In addition, antibacterial activity of CTS-SB derivative was greatly boosted against Escherichia coli (E coli) and Staphylococcus aureus (S. aureus) bacteria. Minimum inhibition concentration of CTS-SB derivative was perceived at 50 µg/mL, while the highest concentration (250 µg/mL) could inhibit the growth of S. aureus up to 91%. What’s more, enhanced antidiabetic activity by CTS-SB derivative, which displayed higher inhibitory values of α-amylase (57.9%) and α-glucosidase (63.9%), compared to those of pure CTS (49.8 and 53.4%), respectively Furthermore, cytotoxicity investigation on HepG-2 cell line revealed potential anticancer activity along with good safety margin against primary human skin fibroblasts (HSF cells) and decent cytocompatibility. Collectively, the gained results hypothesized that CTS-SB derivative could be effectively applied as a promising antibacterial, anticancer and antidiabetic agent for advanced biomedical applications.

A multi-centered trial investigating gestational treatment with ursodeoxycholic acid compared to metformin to reduce effects of diabetes mellitus (GUARD): a randomized controlled trial protocol

BACKGROUND

Each year in the UK, approximately 35,000 women develop gestational diabetes mellitus (GDM). The condition increases the risk of obstetric and neonatal complications for mother and child, including preeclampsia, preterm birth, and large for gestational age babies. Biochemical consequences include maternal hyperglycemia, neonatal hypoglycemia, and dyslipidemia. Metformin is the most commonly used firstline pharmacological treatment. However, there are concerns about its widespread use during pregnancy, due to its limited efficacy and potential safety concerns. Therefore, there is a need for additional therapies that improve both maternal-fetal glucose and lipid metabolism. Ursodeoxycholic acid (UDCA) is not currently used for treatment for GDM. However, it can improve glucose control in type 2 diabetes, and it improves fetal lipid profiles in gestational cholestasis. Consequentially, it is hypothesized that treatment with UDCA for women with GDM may improve both maternal metabolism and neonatal outcomes. The primary outcome of this trial is to assess the efficacy of UDCA compared with metformin to improve glucose levels in women with GDM.

METHODS

The trial is a two-armed, open-label, multi-center, randomized controlled trial. Women are eligible if they have been diagnosed with GDM by an oral glucose tolerance test between 24 + 0 and 30 + 6 weeks' gestation, and if they require pharmacological intervention. In total, 158 pregnant women will be recruited across seven NHS Trusts in England and Wales. Women who consent will be recruited and randomized to either metformin or UDCA, which will be taken daily until the birth of their baby. Maternal and neonatal blood samples will be taken to evaluate the impact of the treatments on maternal glucose control, and maternal and neonatal lipid metabolism. Maternal and fetal outcomes will be evaluated, and acceptability of UDCA compared with metformin will be assessed.

DISCUSSION

This trial has the potential to identify a potential new treatment for women with GDM. If successful, a future large multi-center trial will be designed to investigate where decisions can be personalized to identify which women will respond more effectively to UDCA than alternatives to improve maternal and baby outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04407650.

Efficacy of dietary supplements targeting gut microbiota in the prevention and treatment of gestational diabetes mellitus

Gestational diabetes mellitus (GDM) is a kind of metabolic disease occurring during gestation period, which often leads to adverse pregnancy outcomes and seriously harms the health of mothers and infants. The pathogenesis of GDM may be bound up with the abnormal gut microbiota composition in pregnant women. Previous studies have clarified that dietary supplements can regulate the gut microbiota to play a role. Therefore, using dietary supplements, such as probiotics, prebiotics, and synbiotics to target the gut microbiota to regulate the disordered gut microbiota would become a potential method that benefits for preventing and treating GDM. This paper reviews a series of clinical trials in recent years, expounds on the clinical effects of dietary supplements such as probiotics on GDM, and discusses the intervention effects of dietary supplements on GDM related risk factors, including overweight, obesity, and type 2 diabetes mellitus (T2DM). In addition, the relationship of GDM and gut microbiota is also discussed, and the possible mechanisms of dietary supplements are summarized. This review will help to promote the further development of dietary supplements targeting gut microbiota and provide more knowledge support for clinical application in the prevention and treatment of various diseases.

Assessment of the level and distribution of health system responsiveness in Oyo State, Nigeria

Background

Health systems need to be evaluated to ascertain if they are meeting their objectives. There is an increased interest in health system responsiveness (HSR) as a means to appraise health systems. This becomes vital as we put people at the centre of integrated health systems and put a premium on their rights and perspectives. Thus, this study assessed the levels, distribution and factors associated with HSR in Oyo State.

Methods

The study was a cross-sectional study with 717 adults, who had used an out-patient health facility in the preceding 12 months, interviewed using a semi-structured, interviewer-administered questionnaire. HSR was measured on a multi-domain and multi-item (7 domains and 20 items) 5-point Likert scale that was developed by the WHO to measure HSR globally. Summary scores were computed for level, distribution and the most important domains of HSR. Determinants of poor HSR were determined using binomial logistic regression. The level of statistical significance was set at 5%.

Results

The overall level of HSR was 47%. The highest-rated domains were confidentiality (72%), dignity (64%) and choice (60%), while the least rated were prompt attention (43%) and communication (52%). The overall distribution of HSR was 0.228 (range of 0 to 1) with the domains of prompt attention (0.595) and choice (0.506) being the most unequally distributed. The most important domains were communication, prompt attention and dignity. The least important domains were choice and confidentiality. The factors associated with poor HSR (overall) were no formal education, (OR = 2.81; 95% CI: 1.35–5.86), primary education as the highest level of education (OR = 2.19; 95% CI: 1.28–3.75), poor socioeconomic class (OR = 1.86; 95% CI: 1.23–2.80), using a government-owned facility (OR = 1.56; 95% CI: 1.11–2.19) and not using the usual health facility (OR = 1.69; 95% CI: 1.13–2.53).

Conclusions

The overall level of HSR in Oyo State was low with the domains of prompt attention, communication and autonomy being the least rated domains. Therefore, concerted efforts should be targeted at improving HSR as this will improve wellbeing, health system utilization, and the overall health system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08276-9.

Metformin versus glyburide in treatment and control of gestational diabetes mellitus: a systematic review with meta-analysis

Objective

Methods

Results

Conclusion

Comparison of Insulin, Metformin, and Glyburide on Perinatal Complications of Gestational Diabetes Mellitus: A Systematic Review and Meta-Analysis

AIM

This systematic and meta-analysis was conducted to evaluate the efficacy and safety of insulin, metformin, and glyburide on perinatal complications for gestational diabetes mellitus (GDM).

METHODS

Medline (PubMed), EMBASE, The Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials [CENTRAL], and Cochrane Methodology Register), Web of Science (Science and Social Science Citation Index), and ClinicalTrials (Clinicaltrials.gov) were searched, as well as manual searching. We included randomized controlled trials comparing efficacy and safety of metformin versus glyburide, metformin versus insulin, and glyburide versus insulin in patients with GDM.

RESULTS

We included 32 articles including 5,964 patients published from inception to July 2020. Compared with insulin, metformin was more effective at lower incidence of macrosomia (RR: 0.66, 95% CI: 0.50-0.88, p = 0.005), lower incidence of neonatal intensive care unit admission (RR: 0.78, 95% CI: 0.67-0.91, p = 0.002), less neonatal hypoglycemia (RR: 0.67, 95% CI: 0.56-0.80, p < 0.0001), decreased birth weight (BW) (SMD: -0.37, 95% CI: -0.62 to -0.12, p = 0.004), lower incidence of large for gestational age (RR: 0.76, 95% CI: 0.50-0.90, p = 0.002), shorter gestation age at delivery (MD: -0.22, 95% CI: -0.34 to -0.10, p = 0.0002), lower maternal weight gain (MD: -1.41, 95% CI: -2.28 to -0.55, p = 0.001), less incidence of caesarean section delivery (RR: 0.86, 95% CI: 0.78-0.95, p = 0.0004), lower maternal postprandial blood glucose (SMD: -0.41, 95% CI: -0.72 to -0.11, p = 0.008), and lower incidence of pregnancy-induced hypertension (RR: 0.47, 95% CI: 0.27-0.83, p = 0.01). However, glyburide, compared with insulin, was associated with higher BW (MD: 54.95, 95% CI: 3.87-106.03, p = 0.03) and increased the incidence of neonatal hypoglycemia (RR: 1.52, 95% CI: 1.12-2.07, p = 0.007). Meanwhile, compared to glyburide, metformin was associated with higher maternal fasting blood glucose (SMD: 0.20, 95% CI: 0.05-0.36, p = 0.01) and lower incidence of induction of labor (RR: 0.76, 95% CI: 0.59-0.97, p = 0.03).

CONCLUSIONS

This review suggests that metformin can decrease the incidence of perinatal complications, and it should be considered as a generally safe alternative to insulin.

Short- and long-term outcomes of gestational diabetes and its treatment on fetal development

Globally the prevalence of gestational diabetes mellitus (GDM) is rising mainly due to the increase in maternal obesity. A number of different methods to screen for and diagnose GDM have been described although consensus on the preferred methods does not yet exist. GDM has significant short- and long-term health risks for the mother, developing fetus and the children born to mothers with GDM. Short-term risks for the fetus include macrosomia (excessive birthweight), shoulder dystocia, birth trauma, and hypoglycaemia in the immediate postpartum period. Long-term risks for offspring born to mothers with GDM include increased rates of childhood and adulthood obesity and an increased cardiometabolic risk. A number of pharmacological treatments for GDM have been identified, these include insulin and oral glucose-lowering drugs metformin and glibenclamide. Whilst these oral glucose-lowering drugs show similar short-term childhood outcomes to insulin there is increasing evidence that these drugs may have adverse long-term outcomes on children and adults exposed to the drugs in utero. Future research on treatments for GDM should include long-term follow- up of children exposed to glucose lowering medication in utero to determine the long-term cardiometabolic risk in the offspring born to mothers with GDM.

Comparative impact of pharmacological treatments for gestational diabetes on neonatal anthropometry independent of maternal glycaemic control: A systematic review and meta-analysis

BACKGROUND

Fetal growth in gestational diabetes mellitus (GDM) is directly linked to maternal glycaemic control; however, this relationship may be altered by oral anti-hyperglycaemic agents. Unlike insulin, such drugs cross the placenta and may thus have independent effects on fetal or placental tissues. We investigated the association between GDM treatment and fetal, neonatal, and childhood growth.

METHODS AND FINDINGS

PubMed, Ovid Embase, Medline, Web of Science, ClinicalTrials.gov, and Cochrane databases were systematically searched (inception to 12 February 2020). Outcomes of GDM-affected pregnancies randomised to treatment with metformin, glyburide, or insulin were included. Studies including preexisting diabetes or nondiabetic women were excluded. Two reviewers independently assessed eligibility and risk of bias, with conflicts resolved by a third reviewer. Maternal outcome measures were glycaemic control, weight gain, and treatment failure. Offspring anthropometric parameters included fetal, neonatal, and childhood weight and body composition data. Thirty-three studies (n = 4,944), from geographical locations including Europe, North Africa, the Middle East, Asia, Australia/New Zealand, and the United States/Latin America, met eligibility criteria. Twenty-two studies (n = 2,801) randomised women to metformin versus insulin, 8 studies (n = 1,722) to glyburide versus insulin, and 3 studies (n = 421) to metformin versus glyburide. Eleven studies (n = 2,204) reported maternal outcomes. No differences in fasting blood glucose (FBS), random blood glucose (RBS), or glycated haemoglobin (HbA1c) were reported. No studies reported fetal growth parameters. Thirty-three studies (n = 4,733) reported birth weight. Glyburide-exposed neonates were heavier at birth (58.20 g, 95% confidence interval [CI] 10.10-106.31, p = 0.02) with increased risk of macrosomia (odds ratio [OR] 1.38, 95% CI 1.01-1.89, p = 0.04) versus neonates of insulin-treated mothers. Metformin-exposed neonates were born lighter (-73.92 g, 95% CI -114.79 to -33.06 g, p < 0.001) with reduced risk of macrosomia (OR 0.60, 95% CI 0.45-0.79, p < 0.001) than insulin-exposed neonates. Metformin-exposed neonates were born lighter (-191.73 g, 95% CI -288.01 to -94.74, p < 0.001) with a nonsignificant reduction in macrosomia risk (OR 0.32, 95% CI 0.08-1.19, I2 = 0%, p = 0.09) versus glyburide-exposed neonates. Glyburide-exposed neonates had a nonsignificant increase in total fat mass (103.2 g, 95% CI -3.91 to 210.31, p = 0.06) and increased abdominal (0.90 cm, 95% CI 0.03-1.77, p = 0.04) and chest circumferences (0.80 cm, 95% CI 0.07-1.53, p = 0.03) versus insulin-exposed neonates. Metformin-exposed neonates had decreased ponderal index (-0.13 kg/m3, 95% CI -0.26 to -0.00, p = 0.04) and reduced head (-0.21, 95% CI -0.39 to -0.03, p = 0.03) and chest circumferences (-0.34 cm, 95% CI -0.62 to -0.05, p = 0.02) versus the insulin-treated group. Metformin-exposed neonates had decreased ponderal index (-0.09 kg/m3, 95% CI -0.17 to -0.01, p = 0.03) versus glyburide-exposed neonates. Study limitations include heterogeneity in dosing, heterogeneity in GDM diagnostic criteria, and few studies reporting longitudinal growth outcomes.

CONCLUSIONS

Maternal randomisation to glyburide resulted in heavier neonates with a propensity to increased adiposity versus insulin- or metformin-exposed groups. Metformin-exposed neonates were lighter with reduced lean mass versus insulin- or glyburide-exposed groups, independent of maternal glycaemic control. Oral anti-hyperglycaemics cross the placenta, so effects on fetal anthropometry could result from direct actions on the fetus and/or placenta. We highlight a need for further studies examining the effects of intrauterine exposure to antidiabetic agents on longitudinal growth, and the importance of monitoring fetal growth and maternal glycaemic control when treating GDM. This review protocol was registered with PROSPERO (CRD42019134664/CRD42018117503).

Comparative Efficacy and Safety of Metformin, Glyburide, and Insulin in Treating Gestational Diabetes Mellitus: A Meta-Analysis

To compare the efficacy and safety of metformin, glyburide, and insulin in treating gestational diabetes mellitus (GDM), a meta-analysis of randomized controlled trials (RCTs) was conducted. PubMed, Embase, CINAHL, Web of Science, and Cochrane Library to November 13, 2018, were searched for RCT adjusted estimates of the efficacy and safety of metformin, glyburide, and insulin treatments in GDM patients. There were 41 studies involving 7703 GDM patients which were included in this meta-analysis; 12 primary outcomes and 24 secondary outcomes were detected and analyzed. Compared with metformin, insulin had a significant increase in the risk of preeclampsia (RR, 0.57; 95% CI, 0.45 to 0.72; P < 0.001), NICU admission (RR, 0.75; 95% CI, 0.64 to 0.87; P < 0.001), neonatal hypoglycemia (RR, 0.57; 95% CI, 0.49 to 0.66; P < 0.001), and macrosomia (RR, 0.68; 95% CI, 0.55 to 0.86; P < 0.05). To the outcomes of birth weight and gestational age at delivery, insulin had a significant increase when compared with metformin (MD, 114.48; 95% CI, 37.32 to 191.64; P < 0.01; MD, 0.23; 95% CI, 0.12 to 0.34; P < 0.001; respectively). Of the two groups between glyburide and metformin, metformin had lower gestational weight gain compared with glyburide (MD, 1.67; 95% CI, 0.26 to 3.07; P < 0.05). Glyburide had a higher risk of neonatal hypoglycemia compared with insulin (RR, 1.76; 95% CI, 1.32 to 2.36; P < 0.001). This meta-analysis found that metformin could be a safe and effective treatment for GDM. However, clinicians should pay attention on the long-term offspring outcomes of the relative data with GDM patients treated with metformin. Compared with insulin, glyburide had a higher increase of neonatal hypoglycemia. The use of glyburide in pregnancy for GDM women appears to be unclear.

Pharmacotherapy for hyperglycemia in pregnancy - Do oral agents have a place?

Diabetes is a frequent condition in pregnancy and achieving adequate glycemic control is of paramount importance. Insulin treatment is the gold standard, oral agents are more attractive, but their safety and efficiency should be a prerequisite for their use. We have more information regarding treatment of women with gestational diabetes mellitus where glyburide can induce a picture of fetal hyperinsulinism (higher birthweight and more neonatal hypoglycemia) whereas metformin requires supplemental insulin in a larger proportion of women but achieves satisfactory perinatal outcomes with the exception of preterm birth. Information in patients with Type 2 Diabetes Mellitus is much more limited but also favors metformin. Combinations provide additional possibilities. However, as to long-term outcomes, we have no information on the impact of exposure to glyburide and it is still unclear if in utero exposure to metformin will have any effect on the offspring and the direction of this effect. Women prefer oral agents, indicating the need of additional studies.

Gestational Diabetes Mellitus: Mechanisms, Treatment, and Complications

Gestational diabetes mellitus (GDM) is the most common metabolic disturbance during pregnancy. The prevalence is rising and correlates with the increase in maternal obesity over recent decades. The etiology of GDM is complex, with genetic and environmental factors implicated in mechanistic and epidemiological studies. GDM begets important short- and long-term health risks for the mother, developing fetus, and offspring. This includes the high likelihood of subsequent maternal type 2 diabetes (T2DM), and possible adverse cardiometabolic phenotypes in the offspring. The most clinically and cost-effective methods of screening for GDM remain uncertain. Whilst treatments with lifestyle and pharmacological interventions have demonstrated short-term benefits, the long-term impact for the offspring of intrauterine exposure to antidiabetic medication remains unclear.