Oral hypoglycemic agents for gestational diabetes mellitus?

Impact of treatment with metformin in comparison with insulin in gestational diabetes in libyan population a randomized controlled study

Background:

The aim of this study was the comparison of the glycemic control and maternal outcomes in women affected with gestational diabetes mellitus (GDM) managed with metformin versus insulin.

Materials and Methods:

The participants included in this study were 140 women diagnosed with GDM. They were randomized into two groups, women included in the first group were treated with metformin and the women of the second group were managed with insulin.

Results:

The glycemic control was similar in both the treatment arms and the only noteworthy difference was found in the mean fasting blood glucose, which was significantly higher in the women receiving insulin as compared to the women receiving metformin. There were no substantial differences in the maternal outcome with the use of metformin compared to insulin in women with GDM.

Conclusion:

The incidence of operative delivery was higher in metformin-treated group, whereas the hospital admission rate was considerably elevated in insulin-treated group.

Omega-3 Fatty Acids Effects on Inflammatory Biomarkers and Lipid Profiles among Diabetic and Cardiovascular Disease Patients: A Systematic Review and Meta-Analysis

The purpose of this systematic review and meta-analysis was to investigate omega-3 fatty acids’ influence on 12 inflammatory biomarkers—LDL, HDL, total cholesterol, TG, HbA1c, Apo AI, Apo AII, Apo B, CRP, TNF-α, glucose, and fasting blood glucose among diabetic and cardiovascular disease (CVD) patients. We searched articles in six database engines, and 16 of the 696 articles reviewed met the inclusion criteria. Among these, lipid and inflammatory biomarkers investigated commonly included total cholesterol (11 studies), LDL, and TG (10 studies each). Overall, omega-3 was associated with a significant reduction in Apo AII among diabetic patients, as compared to different controls (−8.0 mg/dL 95% CI: −12.71, −3.29, p = 0.0009), triglycerides (−44.88 mg/dL 95% CI: −82.6, −7.16, p < 0.0001), HDL (−2.27 mg/dL 95% CI: −3.72, −0.83, p = 0.002), and increased fasting blood glucose (16.14 mg/dL 95% CI: 6.25, 26.04, p = 0.001). Omega-3 also was associated with increased LDL among CVD patients (2.10 mg/dL 95% CI: 1.00, 3.20, p = 0.0002). We conclude that omega-3 fatty acids may be associated with lower inflammatory biomarkers among diabetic and cardiovascular patients. Clinicians should be aware of these potential benefits; however, it is essential to recommend that patients consult with clinicians before any omega-3 intake.

SUGAR-DIP trial: oral medication strategy versus insulin for diabetes in pregnancy, study protocol for a multicentre, open-label, non-inferiority, randomised controlled trial

INTRODUCTION

In women with gestational diabetes mellitus (GDM) requiring pharmacotherapy, insulin was the established first-line treatment. More recently, oral glucose lowering drugs (OGLDs) have gained popularity as a patient-friendly, less expensive and safe alternative. Monotherapy with metformin or glibenclamide (glyburide) is incorporated in several international guidelines. In women who do not reach sufficient glucose control with OGLD monotherapy, usually insulin is added, either with or without continuation of OGLDs. No reliable data from clinical trials, however, are available on the effectiveness of a treatment strategy using all three agents, metformin, glibenclamide and insulin, in a stepwise approach, compared with insulin-only therapy for improving pregnancy outcomes. In this trial, we aim to assess the clinical effectiveness, cost-effectiveness and patient experience of a stepwise combined OGLD treatment protocol, compared with conventional insulin-based therapy for GDM.

METHODS

The SUGAR-DIP trial is an open-label, multicentre randomised controlled non-inferiority trial. Participants are women with GDM who do not reach target glycaemic control with modification of diet, between 16 and 34 weeks of gestation. Participants will be randomised to either treatment with OGLDs, starting with metformin and supplemented as needed with glibenclamide, or randomised to treatment with insulin. In women who do not reach target glycaemic control with combined metformin and glibenclamide, glibenclamide will be substituted with insulin, while continuing metformin. The primary outcome will be the incidence of large-for-gestational-age infants (birth weight >90th percentile). Secondary outcome measures are maternal diabetes-related endpoints, obstetric complications, neonatal complications and cost-effectiveness analysis. Outcomes will be analysed according to the intention-to-treat principle.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the Utrecht University Medical Centre. Approval by the boards of management for all participating hospitals will be obtained. Trial results will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NTR6134; Pre-results.

The efficacy of metformin compared with insulin in regulating blood glucose levels during gestational diabetes mellitus: A randomized clinical trial

BACKGROUND

Insulin has been a conventional medication in the treatment of female patients suffering from gestational diabetes mellitus (GDM). However, the need for a large number of insulin injections in these patients causes them a lot of discomforts. Recently, an alternative medication, metformin, has received considerable attention in the treatment of GDM. The aim of this study was to compare the efficacy of metformin and insulin in regulating blood glucose levels and fetal outcomes in GDM.

METHODS

This randomized clinical trial included 286 pregnant women diagnosed with positive GDM at 24-28 weeks of pregnancy. The subjects were randomly divided into two groups of 143 patients, with one group receiving insulin and the other undergoing a treatment plan using metformin. Fasting plasma glucose (FPG), 2-hr plasma glucose (PG) and glycated hemoglobin (HbA1c) were recorded twice a month until delivery. Other variables, including birth delivery method, cause of cesarean section, gestational age at the delivery time, birth trauma, Apgar score, birth weight, admission at neonatal intensive care unit (NICU), and neonatal hypoglycemia were also registered.

RESULTS

Age of mother, body mass index, history of diabetes in the family, previous history of GDM, parity, FPG, 1- and 2-hr PG after meals, and 75-g glucose tolerance test before treatment were not statistically different between the two groups. FPG, PG, and HbA1c did not show significant differences between the two groups after completing the course of treatment. There was also no significant difference between two groups regarding the birth delivery method, the cause of cesarean section, birth trauma, Apgar score, birth weight, admission at NICU, and neonatal hypoglycemia.

CONCLUSION

As mean FPG and 2-hr PG were not significantly different between the two groups, it seems that metformin can be recommended as an effective substitute for insulin in the treatment of GDM. However, there are still some undesirable risk factors with both treatments that may threaten the mother and the newborn.

Comparative efficacy and safety of oral antidiabetic drugs and insulin in treating gestational diabetes mellitus: An updated PRISMA-compliant network meta-analysis

BACKGROUND

The safety and efficacy of different drugs in treatment of gestational diabetes mellitus (GDM) patients who could not maintain normal glucose level only through diet and exercise remains to be debated. We performed this network meta-analysis (NAM) to compare and rank different antidiabetic drugs in glucose level control and pregnancy outcomes in GDM patients.

METHODS

We searched PubMed, Cochrane Library, Web of Science, and Embase up to December 31, 2016. Randomized controlled trials (RCTs) related to different drugs in the treatment of GDM patients were enrolled. We extracted the relevant information and assessed the risk of bias with the Cochrane risk of bias tool. We did pair-wise meta-analyses using the fixed-effects model or random-effects model and then adopted random-effects NAM combining both direct and indirect evidence within a Bayesian framework, to calculate the odds ratio (OR) or standardized mean difference (SMD) and to draw a surface under the cumulative ranking curve of the neonatal and maternal outcomes of different treatments in GDM patients.

RESULTS

Thirty-two randomized controlled trials (RCTs) were included in this NAM, including 6 kinds of treatments (metformin, metformin plus insulin, insulin, glyburide, acarbose, and placebo). The results of the NAM showed that regarding the incidence of macrosomia and LGA, metformin had lower incidence than glyburide (OR, 0.5411 and 0.4177). In terms of the incidence of admission to the NICU, insulin had higher incidence compared with glyburide (OR, 1.844). As for the incidence of neonatal hypoglycemia, metformin had lower incidence than insulin and glyburide (OR, 0.6331 and 0.3898), and insulin was lower than glyburide (OR, 0.6236). For mean birth weight, metformin plus insulin was lower than insulin (SMD, -0.5806), glyburide (SMD, -0.7388), and placebo (SMD, -0.6649). Besides, metformin was observed to have lower birth weight than glyburide (SMD, 0.2591). As for weight gain, metformin and metformin plus insulin were lower than insulin (SMD, -0.9166, -1.53). Ranking results showed that glyburide might be the optimum treatment regarding average glucose control, and metformin is the fastest in glucose control for GDM patients; glyburide have the highest incidence of macrosomia, preeclampsia, hyperbilirubinemia, neonatal hypoglycemia, shortest gestational age at delivery, and lowest mean birth weight; metformin (plus insulin when required) have the lowest incidence of macrosomia, PIH, LGA, RDS, low gestational age at delivery, and low birth weight. Besides, insulin had the highest incidence of NICU admission, acarbose had the lowest risk of neonatal hypoglycemia.

CONCLUSION

Our study concluded that metformin is fastest in glucose control, with a more favorable pregnancy outcomes-would be a better option, but its rate of glucose control is the lowest.However, glyburide is the optimumtreatment regarding the rate of glucose control, but withmore adverse outcomes. This NAMbased on 32 RCTs will strongly help to guide further development of management for GDM patients, clinicians should carefully balance the risk-benefit profile of different treatments according to various situations.

Could Metformin Manage Gestational Diabetes Mellitus instead of Insulin?

Gestational diabetes mellitus (GDM) complicates a significant number of pregnancies. Blood glucose control improves perinatal outcomes. Medical nutrition therapy is the foundation in management. Aim of This Study. To evaluate efficacy of metformin in comparison to insulin for managing GDM. Methods. In prospective randomized comparative study, 150 antenatal women whose pregnancies had been complicated by GDM and did not respond to diet alone were recruited from antenatal clinics at Obstetrics Department in Zagazig University Hospitals from November 2012 to December 2014. They were divided randomly into two groups, 75 patients in each, and were subjected to either insulin or metformin medication. Outcomes were comparing the effects of both medications on maternal glycemic control, antenatal complications, and neonatal outcome. Results. No significant difference in controlling high blood sugar in GDM with the use of metformin or insulin (P = 0.95, 0.15). Maternal complications in both groups had no significant difference and fetal outcomes were as well similar except the fact that the hypoglycemia occurred more in insulin group with P value 0.01. Conclusion. Glycaemic control in GDM can be achieved by using metformin orally without increasing risk of maternal hypoglycemia with satisfying neonatal outcome.

Comparison of Glibenclamide and Insulin on Neonatal Outcomes in Pregnant Women with Gestational Diabetes

BACKGROUND

Untreated or poorly controlled gestational diabetes can cause serious complications for mother and newborn. Glibenclamide is rarely used in treating mothers with this disease. This study aimed at comparing the effect of glibenclamide and insulin on neonatal outcomes in women with gestational diabetes mellitus.

METHODS

In this randomized controlled clinical trial, 249 pregnant women aged 18-45 years within the 11(th)-33(rd) weeks of gestation with gestational diabetes, single fetus pregnancy, and in need of hyperglycemia treatment were entered and grouped randomly as either glibenclamide or insulin. In the insulin group (n = 129), insulin was administered with an initial dose of 0.2 IU/kg subcutaneously twice per day, whereas in the glibenclamide group (n = 120), 1.25 mg oral glibenclamide was administered once daily and increased if needed.

RESULTS

The results showed no significant difference in means age, gestational age, and body mass index between women in the two groups. In addition, there were no significant differences in the frequency of neonatal hypoglycemia, anomaly, hyperbilirubinemia, admission in Neonatal Intensive Care Unit (NICU), and neonatal respiratory distress between two groups. Macrosomia was lower in the glibenclamide group than the insulin group (3.3% vs. 13.2%, respectively, P = 0.005). Regression logistics model results showed that the type of treatment (odds ratio [OR]: 4.62; confidence interval [CI]: 1.45-14.02; P = 0.01) and gestational age at delivery (OR: 1.41; CI: 1.04-1.74; P = 0.01) were as predictor factors of macrosomia.

CONCLUSIONS

The results of this study revealed that glibenclamide is able to reduce the risk of fetal macrosomia without increasing neonatal anomalies, jaundice, hypocalcemia, infant respiratory distress, and NICU admission.

Adherence to the DASH and Mediterranean diets is associated with decreased risk for gestational diabetes mellitus

OBJECTIVES

Few studies have examined the association between adherence to the Dietary Approaches to Stop Hypertension (DASH) or Mediterranean (MED) diets and prevalence of gestational diabetes mellitus (GDM). The aim of the present study was to evaluate the association between the two diets and GDM.

METHODS

In a case-control hospital-based study, pregnant women with (n = 200) and without (n = 260) GMD were recruited. An average of three 24-h dietary records were used to assess participants' dietary intakes. DASH scores were calculated based on the Fung method and MED scores were calculated using the Trichopoulou method. GDM was defined as fasting glucose >95 mg/dL or 1-h postprandial glucose >140 mg/dL for the first time in the pregnancy. The risk for GDM was assessed across tertiles of DASH and MED scores.

RESULTS

DASH and MED diets were negatively related to fasting blood glucose, hemoglobin A1c, and serum triacylglycerol concentrations. High-density lipoprotein cholesterol was significantly higher for those in the top tertile of the DASH diet but not the MED diet in comparison with the lowest tertile. Total serum cholesterol level was lower in the third tertile of the MED diet but not in the DASH diet. Participants in the highest tertile of the MED diet had 80% lower risk for GDM compared with those in the lowest tertile (Ptrend = 0.006). Greater adherence to the DASH eating plan was associated with 71% reduced risk for GDM (Ptrend = 0.006) after adjustment for potential confounders.

CONCLUSION

Adherence to either the DASH or Mediterranean diet is associated with decreased risk for GDM.

Effects of selenium supplementation on glucose homeostasis, inflammation, and oxidative stress in gestational diabetes: Randomized, double-blind, placebo-controlled trial

OBJECTIVE

To our knowledge, no reports are available indicating the effects of selenium supplementation on metabolic parameters, inflammatory factors, and oxidative stress in gestational diabetes mellitus (GDM). The aim of this study was to assess the effects of selenium supplementation on metabolic status in pregnant women with GDM who were not on oral hypoglycemic agents.

METHODS

This randomized, double-blind, placebo-controlled clinical trial was performed with 70 women with GDM. Patients were randomly assigned to receive either 200 μg selenium supplements as tablet (n = 35) or placebo (n = 35) for 6 wk from weeks 24 to 28 of gestation. Fasting plasma samples were taken at study baseline and after 6 wk of intervention to quantify related variables.

RESULTS

Selenium supplementation, compared with placebo, resulted in a significant reduction in fasting plasma glucose (-10.5 ± 11.9 versus +4.5 ± 12.9 mg/dL; P < 0.001), serum insulin levels (-1.98 ± 11.25 versus +5.26 ± 9.33 μIU/mL; P = 0.005), homeostasis model of assessment (HOMA)-insulin resistance (-0.84 ± 2.76 versus +1.47 ± 2.46; P < 0.001) and a significant increase in quantitative insulin sensitivity check index (+0.008 ± 0.03 versus -0.01 ± 0.01; P = 0.009). Additionally, a significant decrease in serum high-sensitivity C-reactive protein (hs-CRP) levels (-791.8 ± 2271.8 versus +500.5 ± 2563.3 ng/mL; P = 0.02) was seen after the administration of selenium supplements compared with placebo. Additionally, we observed a significant elevation in plasma glutathione (+52.14 ± 58.31 versus -39.93 ± 153.52 μmol/L; P = 0.002) and a significant reduction in plasma malondialdehyde levels (-0.01 ± 0.36 versus +0.67 ± 1.90 μmol/L; P = 0.04) after consumption of selenium supplements compared with placebo. We did not find any significant effect of taking selenium supplements on HOMA β-cell function, lipid profiles, plasma nitric oxide, or total antioxidant capacity concentrations.

CONCLUSION

Selenium supplementation in pregnant women with GDM demonstrated beneficial effects on glucose metabolism, hs-CRP levels, and biomarkers of oxidative stress.

Metformin versus insulin treatment in gestational diabetes in pregnancy in a developing country: a randomized control trial

AIM

To compare treatment with metformin alone, metformin plus insulin and insulin alone in women with gestational diabetes (GDM).

METHOD

A total of 150 gestational diabetic patients who fulfilled the eligibility criteria were included in this prospective randomized control open labeled study. A risk factor based screening was done followed by a GCT and then local GTT criteria from antenatal clinics. They were initially divided into two groups with odd numbers assigned to metformin treatment and even numbers to insulin treatment. Metformin and/or insulin treatment was given and target blood sugar levels aimed at FBS ≤ 100 mg/dl and postprandial levels ≤ 126 mg/dl. Supplemental insulin was added to metformin treatment group to maintain the glycemic targets if required. Patients were followed until delivery and maternal fetal outcomes and pharmacotherapeutic characteristics were recorded on a performa.

RESULTS

Less maternal weight gain was found in the metformin treated groups (9.8 ± 1.5 kg [metformin alone] vs. 9.8 ± 1.4 kg [metformin plus insulin] vs. 12.5 ± 1.1 kg [insulin alone] P < 0.000). Preeclampsia was significantly less in metformin treated groups. There were no perinatal deaths in the study. Mean birth weight was significantly less in metformin treated groups (3.4 ± 0.4 kg vs. 3.3 ± 0.5 kg vs. 3.7 ± 0.5 kg P < 0.01). Less neonatal morbidity was observed in metformin groups. 42.7% of patients required supplemental insulin (mean dose of 13.6 ± 2 units) in the metformin group. Mean gestational age at which insulin was added was 31.8 ± 5.9 weeks.

CONCLUSION

Metformin is an effective and cheap treatment option for women with gestational diabetes with or without supplemental insulin.

Effects of calcium-vitamin D co-supplementation on glycaemic control, inflammation and oxidative stress in gestational diabetes: a randomised placebo-controlled trial

AIMS/HYPOTHESIS

This study was designed to assess the effects of calcium and vitamin D supplementation on the metabolic status of pregnant women with gestational diabetes mellitus (GDM).

METHODS

This randomised placebo-controlled trial was performed at maternity clinics affiliated to Kashan University of Medical Sciences, Kashan, Iran. Participants were 56 women with GDM at 24-28 weeks' gestation (18 to 40 years of age). Subjects were randomly assigned to receive calcium plus vitamin D supplements or placebo. All study participants were blinded to group assignment. Individuals in the calcium-vitamin D group (n = 28) received 1,000 mg calcium per day and a 50,000 U vitamin D3 pearl twice during the study (at study baseline and on day 21 of the intervention), and those in the placebo group (n = 28) received two placebos at the mentioned times. Fasting blood samples were taken at study baseline and after 6 weeks of intervention.

RESULTS

The study was completed by 51 participants (calcium-vitamin D n = 25, placebo n = 26). However, as the analysis was based on an intention-to-treat approach, all 56 women with GDM (28 in each group) were included in the final analysis. After the administration of calcium plus vitamin D supplements, we observed a significant reduction in fasting plasma glucose (-0.89 ± 0.69 vs +0.26 ± 0.92 mmol/l, p < 0.001), serum insulin levels (-13.55 ± 35.25 vs +9.17 ± 38.50 pmol/l, p = 0.02) and HOMA-IR (-0.91 ± 1.18 vs +0.63 ± 2.01, p = 0.001) and a significant increase in QUICKI (+0.02 ± 0.03 vs -0.002 ± 0.02, p = 0.003) compared with placebo. In addition, a significant reduction in serum LDL-cholesterol (-0.23 ± 0.79 vs +0.26 ± 0.74 mmol/l, p = 0.02) and total cholesterol: HDL-cholesterol ratio (-0.49 ± 1.09 vs +0.18 ± 0.37, p = 0.003) and a significant elevation in HDL-cholesterol levels (+0.15 ± 0.25 vs -0.02 ± 0.24 mmol/l, p = 0.01) was seen after intervention in the calcium-vitamin D group compared with placebo. In addition, calcium plus vitamin D supplementation resulted in a significant increase in GSH (+51.14 ± 131.64 vs -47.27 ± 203.63 μmol/l, p = 0.03) and prevented a rise in MDA levels (+0.06 ± 0.66 vs +0.93 ± 2.00 μmol/l, p = 0.03) compared with placebo.

CONCLUSIONS/INTERPRETATION

Calcium plus vitamin D supplementation in women with GDM had beneficial effects on their metabolic profile.

TRIAL REGISTRATION

www.irct.ir IRCT201311205623N11.

FUNDING

The study was supported by a grant (no. 92110) from Kashan University of Medical Sciences.

Effects of omega-3 fatty acid supplementation on insulin metabolism and lipid profiles in gestational diabetes: Randomized, double-blind, placebo-controlled trial

BACKGROUND & AIMS

We are aware of no study that examined the effects of omega-3 fatty acid supplementation on insulin metabolism and lipid profiles in gestational diabetes (GDM). This study was designed to assess the effects of omega-3 fatty acid supplementation on insulin concentrations and lipid profiles among pregnant women with GDM.

METHODS

This randomized, double-blind, placebo-controlled clinical trial was performed among 56 women with GDM. Subjects were randomly assigned to receive either 1000 mg omega-3 fatty acid supplements containing 180 mg eicosapentaenoic acid and 120 mg docosahexanoic acid (n = 28) or placebo (n = 28) for 6 weeks. Fasting blood samples were taken at study baseline and after 6 weeks of intervention to quantify biochemical variables.

RESULTS

Although omega-3 fatty acid supplementation did not led to a significant change in serum insulin levels and HOMA-IR in omega-3 fatty acid group, we found a significant difference in changes in serum insulin levels (change from baseline: -1.5 ± 7.5 vs. +3.5 ± 8.5 μIU/mL, P = 0.02) and HOMA-IR (-0.4 ± 2.1 vs. +1.1 ± 2.4, P = 0.02) comparing the two groups. Furthermore, a significant reduction in serum high sensitivity C-reactive protein (hs-CRP) levels was seen after omega-3 fatty acid supplementation compared with placebo (-236.3 ± 1541.9 vs. 898.6 ± 2292.7 ng/mL, P = 0.03). Omega-3 fatty acid supplementation did not influence fasting plasma glucose, homeostatic model assessment-Beta cell function (HOMA-B), quantitative insulin sensitivity check index (QUICKI) and lipid profiles.

CONCLUSIONS

Omega-3 fatty acid supplementation in GDM women had beneficial effects on insulin resistance, however, it did not affect plasma glucose, HOMA-B, QUICKI and lipid profiles. Clinical registration number: www.irct.ir as IRCT201312265623N16.

Translation and validation of an Iranian version of the Diabetes Quality of Life measure

Aims/Introduction:  The objective of this study was to translate and validate an Iranian version of the Diabetes Quality of Life (DQOL) questionnaire in an Iranian population of males and females with a diagnosis of type 2 diabetes.

Materials and Methods:  A total of 503 patients with type 2 diabetes were recruited from nine diabetes clinics across several Iranian cities. A standard backward and forward translation procedure was used to convert the English version of the DQOL into the Iranian language (Persian). Internal consistency, convergent validity, known group comparison, confirmatory factor analysis (CFA) and factorial invariance were applied for the assessment of psychometric properties of the translated version.

Results:  The translated version of the DQOL showed adequate internal consistency reliabilities for all subscales (Cronbach’s α >0.70). CFA confirmed the underlying domain structure to be the same as for the original English version, therefore supporting the factorial validity of the translated questionnaire. In addition, questionnaire responsiveness showed good sensitivity to interventions.

Conclusions:  In conclusion, the translated Iranian version of DQOL has shown high internal reliability and good construct validity, and can potentially be applied as an assessment tool for health‐related quality of life in patients with diabetes. (J Diabetes Invest, doi: 10.1111/j.2040‐1124.2012.00217.x, 2012)

The use of glyburide in the management of gestational diabetes mellitus: a meta-analysis

PURPOSE

Glyburide has been used for managing gestational diabetes mellitus (GDM) in a number of countries. It is rather inexpensive. However, its efficacy and safety remain controversial. With this meta-analysis, we evaluated glyburide in comparison with insulin.

MATERIAL/METHODS

With a systematic literature search strategy, a total of 93 randomized controlled trials (RCTs) with insulin and glyburide comparison were identified. Based on the revised Consolidated Standards of Reporting Trials (CONSORT) checklist, five of them met the inclusion criteria and were included in this meta-analysis.

RESULTS

Six hundred and seventy four subjects were included in these five RCTs. When compared with insulin, glyburide had an increased relative risk (RR) for neonatal hypoglycemia (RR: 1.98; 95% confidence interval [CI]: 1.17, 3.36). Estimation of standard mean differences (SMD) showed that both fetal birth weight and incidence of macrosomia were higher in subjects receiving glyburide than in those receiving insulin (SMD: 0.21; 95% CI: 0.06, 0.36; RR: 2.22; 95% CI: 1.07, 4.61 respectively). There were no significant differences in maternal glucose control, glycated hemoglobin, the rate of Cesarean section, large-for-gestational age, neonatal hypocalcemia, length of stay for neonatal ICU admissions, preterm birth, or congenital anomalies.

CONCLUSIONS

Our study suggested that in women with GDM, glyburide is as effective as insulin, but the risks of neonatal hypoglycemia, high fetal birth weight, and macrosomia were higher.

The role of adding metformin in insulin-resistant diabetic pregnant women: a randomized controlled trial

PURPOSE

The aim of the present study is to assess the impact of adding oral metformin to insulin therapy in pregnant women with insulin-resistant diabetes mellitus.

METHODS

The current non-inferiority randomized controlled trial was conducted at Ain Shams University Maternity Hospital. The study included pregnant women with gestational or pre-existing diabetes mellitus at gestations between 20 and 34 weeks, who showed insulin resistance (defined as poor glycemic control at a daily dose of ≥1.12 units/kg). Recruited women were randomized into one of two groups: group I, including women who received oral metformin without increasing the insulin dose; and group II, including women who had their insulin dose increased. The primary outcome was maternal glycemic control. Secondary outcomes included maternal bouts of hypoglycemia, need for another hospital admission for uncontrolled diabetes during pregnancy, gestational age at delivery, mode of delivery, birth weight, birth trauma, congenital anomalies, 1- and 5-min Apgar score, neonatal hypoglycemia, need for neonatal intensive care unit (NICU) admission and adverse neonatal outcomes.

RESULTS

A total number of 154 women with diabetes mellitus with pregnancy were approached; of them 90 women were eligible and were randomly allocated and included in the final analysis. The recruited 90 women were randomized into one of two groups: group I (metformin group) (n = 46), including women who received oral metformin in addition to the same initial insulin dose; and group II (control group) (n = 44), including women who had their insulin dose increased according to the standard protocol. The mean age of included women was 29.84 ± 5.37 years (range 20-42 years). The mean gestational age at recruitment was 28.7 ± 3.71 weeks (range 21-34 weeks). Among the 46 women of group I, 17 (36.9 %) women reached proper glycemic control at a daily metformin dose of 1,500 mg, 18 (39.2 %) at a daily dose of 2,000 mg, while 11 (23.9 %) received metformin at a daily dose of 2,000 mg without reaching proper glycemic control and needed raising the dose of insulin dose.

CONCLUSION

Adding metformin to insulin therapy in women with insulin-resistant diabetes mellitus with pregnancy seems to be effective in proper glycemic control in a considerable proportion of women, along with benefits of reduced hospital stay, reduced frequency of maternal hypoglycemia as well as reduced frequency of neonatal hypoglycemia, NICU admission and neonatal respiratory distress syndrome.

Efficacy and safety of metformin during pregnancy in women with gestational diabetes mellitus or polycystic ovary syndrome: a systematic review

BACKGROUND

Metformin is an effective oral anti-hyperglycemic agent that is widely used to manage diabetes mellitus type 2 in the general population and more recently, in pregnancy. However, as metformin crosses the placenta, its use during pregnancy raises concerns regarding potential adverse effects on the mother and fetus.

OBJECTIVE

(i) To provide background for the use of metformin during pregnancy through a narrative review and (ii) to critically appraise the published evidence on the efficacy and safety of using metformin during pregnancy through a systematic review.

RESULTS

Metformin appears to be effective and safe for the treatment of gestational diabetes mellitus (GDM), particularly for overweight or obese women. However, patients with multiple risk factors for insulin resistance may not meet their treatment goals with metformin alone and may require supplementary insulin. Evidence suggests that there are potential advantages for the use of metformin over insulin in GDM with respect to maternal weight gain and neonatal outcomes. Furthermore, patients are more accepting of metformin than insulin. The use of metformin throughout pregnancy in women with polycystic ovary syndrome reduces the rates of early pregnancy loss and preterm labor and protects against fetal growth restriction. There have been no demonstrable teratogenic effects, intra-uterine deaths or developmental delays with the use of metformin.

CONCLUSIONS

The publications reviewed in this paper support the efficacy and safety of metformin during pregnancy with respect to immediate pregnancy outcomes. Because there are no guidelines for the continuous use of metformin in pregnancy, the duration of treatment is based on clinical judgment and experience on a case-by-case basis.

Metformin vs insulin in the management of gestational diabetes: a meta-analysis

BACKGROUND

Nowadays, there have been increasing studies comparing metformin with insulin. But the use of metformin in pregnant women is still controversial, therefore, we aim to examine the efficiency and safety of metformin by conducting a meta-analysis of randomized controlled trials (RCTs) comparing the effects of metformin with insulin on glycemic control, maternal and neonatal outcomes in gestational diabetes mellitus (GDM).

METHODS

We used the key words "gestational diabetes" in combination with "metformin" and searched the databases including Pubmed, the Cochrane Library, Web of knowledge, and Clinical Trial Registries. A random-effects model was used to compute the summary risk estimates.

RESULTS

Meta-analysis of 5 RCTs involving 1270 participants detected that average weight gains after enrollment were much lower in the metformin group (n = 1006, P = 0.003, SMD = -0.47, 95%CI [-0.77 to -0.16]); average gestational ages at delivery were significantly lower in the metformin group (n = 1270, P = 0.02, SMD = -0.14, 95%CI [-0.25 to -0.03]); incidence of preterm birth was significantly more in metformin group (n = 1110, P = 0.01, OR = 1.74, 95%CI [1.13 to 2.68]); the incidence of pregnancy induced hypertension was significantly less in the metformin group (n = 1110, P = 0.02, OR = 0.52, 95%CI [0.30 to 0.90]). The fasting blood sugar levels of OGTT were significantly lower in the metformin only group than in the supplemental insulin group (n = 478, P = 0.0006, SMD = -0.83, 95%CI [-1.31 to -0.36]).

CONCLUSIONS

Metformin is comparable with insulin in glycemic control and neonatal outcomes. It might be more suitable for women with mild GDM. This meta-analysis also provides some significant benefits and risks of the use of metformin in GDM and help to inform further development of management guidelines.

Use of oral hypoglycemic and insulin agents in pregnant patients

Although insulin remains the standard medication for the treatment of all types of patients with diabetes during pregnancy, oral hypoglycemics may be considered as alternative medications in the treatment of some types of diabetes in pregnancy.

Effect of calcium-vitamin D supplementation on metabolic profiles in pregnant women at risk for pre-eclampsia: a randomized placebo-controlled trial

Increased metabolic profiles during pregnancy are associated with an increased risk of maternal and neonatal morbidity and remain a significant medical challenge. To our knowledge, no reports are available indicating the effects of calcium-vitamin D supplementation on metabolic profiles among pregnant women at risk for pre-eclampsia. This study was designed to determine the effects of consumption calcium-vitamin D supplements on metabolic profiles among Iranian pregnant women at risk for pre-eclampsia. This randomized single-blind controlled clinical trial was performed among 49 pregnant women at risk for pre-eclampsia, primigravida, aged 18-35 year old who were carrying singleton pregnancy at their third trimester. Subjects were randomly assigned to consume the placebo (n = 25) or calcium-vitamin D supplements (n = 24) for 9 weeks. Calcium-vitamin D supplements were containing 500 mg carbonate calcium plus 200 IU vitamin D3. Fasting blood samples were taken at baseline and after 9 week intervention to measures of Fasting Plasma Glucose (FPG) and serum lipid profiles. Consumption of calcium-vitamin D supplements resulted in decreased FPG and serum triglycerides levels as compared to the placebo (-9.1 vs. 0.5 mg dL(-1); p = 0.03, -11.7 vs. 49.9 mg dL(-1); p = 0.001, respectively). No significant differences were found comparing calcium-vitamin D supplements and the placebo in terms of their effect on serum total-, HDL-, LDL-cholesterol levels. Within-group differences in the placebo group revealed a significant increase in serum triglycerides levels (+49.9 mg dL(-1), p < 0.0001). In conclusion, consumption of calcium-vitamin D supplements for 9 weeks during pregnancy among pregnant women at risk for pre-eclampsia resulted in decreased FPG and serum triglycerides levels as compared to the placebo group, but could not affect serum total-, HDL-, LDL-cholesterol levels.