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Use of Metformin in Gestational Diabetes

Metformin is associated with improved treatment satisfaction and a favorable impact on quality of life (QoL) compared with insulin alone or in combination….

The rise in obesity and the increasing age of mothers have contributed to an increasing incidence of GDM. Depending on the diagnostic criteria used, GDM complicates up to 10% of pregnancies. Treatment conventionally consists of lifestyle measures (diet and physical activity) initially. If target glucose values are not achieved, insulin has traditionally been instituted. Because of the need for constant injections, the risks of hypoglycemia and the potential for weight gain, insulin therapy might be expected to have a negative impact on the QoL for GDM mothers. By contrast, metformin is gaining increasing acceptance as a safe alternative to insulin in the management of GDM. It is associated with improved insulin sensitivity and less maternal weight gain and there is evidence of reduced maternal risk of pre-eclampsia and need for operative delivery. In this study, Latif et al, compare treatment satisfaction and QoL in GDM women receiving metformin alone, insulin alone or a combination of both treatments.

One hundred and ninety seven women whose pregnancies had been complicated by GDM were recruited over a 12-month period (2011–2012). Of those, 128 were eligible to be analyzed and 68 patients were treated with metformin alone, 32 with insulin and 28 with the combination of metformin and insulin.Patients had started on insulin as NovoRapid with meals and Insulatard at night if metformin was relatively contra-indicated (renal impairment, history of GI symptoms, inadequate fetal growth on scan) or if this was patient preference. Otherwise, patients were offered metformin initially at a daily dose of 500 mg with meals, slowly increased to a maximum dose of 3 g a day, depending on glucose levels and tolerance. If maternal glucose levels still exceeded target levels, then combination therapy using both insulin and metformin was commenced. The Patients’ perspectives were assessed using the Audit of Diabetes-Dependent Quality of Life (ADDQoL) and Diabetes Treatment Satisfaction Questionnaire (DTSQ). Measured items included key aspects of social functioning such as working life, family life, relationships, and self-confidence.

Women with GDM taking either metformin or insulin demonstrated a higher quality of life (QoL) amongst each of the 19 life domains tested than women on the combination. Metformin treatment was associated with the least negative impact on QoL (−1.6) as compared with insulin and insulin + metformin groups (−1.7, -1.9) respectively. The Total Treatment Satisfaction (TTS) was highest in metformin treated patients (5.2) compared with insulin (4.7) or the combination (4.6). With regard to hypoglycemia, patients taking metformin had the lowest score and unsurprisingly, those on insulin alone had the highest score for perceived hypoglycemia. Metformin was also reported to be a more convenient option for women with GDM in comparison to insulin, or metformin + insulin reflecting its oral administration.

Based on these results, the authors concluded that this study adds to previous evidence that when tolerated metformin is associated with improved treatment satisfaction and a favorable impact on QoL compared with insulin alone or in combination.

Practice Pearls:

  • GDM complicates up to 10% of pregnancies.
  • Metformin treatment was associated with the least negative impact on QoL.
  • Metformin was also reported to be a more convenient option for women with GDM in comparison to insulin, or metformin + insulin.

British Journal of Diabetes and Vascular Disease, August 2013