Metformin for the treatment of gestational diabetes: An updated meta-analysis

• In an update meta-analysis, treatment with metformin was associated with better clinical outcomes particularly on neonatal hypoglycemia, NICU admission compared with insulin in GDM, while glycemic control and other outcomes were comparable.
• Using a Bayesian analysis, the efficacy of metformin was consistently higher than insulin with a probability of over 98% on neonatal hypoglycemia and NICU admission.

ObjectiveTo assess the efficacy of metformin and insulin in the treatment of pregnant women with gestational diabetes mellitus (GDM).MethodsA meta-analysis was conducted by including randomized controlled trials comparing metformin and insulin in GDM. An electronic search was conducted to identify relevant studies. Data were synthesized by a random effects meta-analysis model. A Bayesian analysis was also performed to account for uncertainties in the treatment efficacy.ResultsEight clinical trials involving 1712 individuals were included in the final analysis. The pooled estimates of metformin–insulin differences were very small and statistically non-significant in fasting plasma glucose, postprandial plasma glucose and HbA1c, measured at 36–37 weeks of gestation. Notably, 14–46% of those receiving metformin required additional insulin. Compared with the insulin group, metformin treatment was associated with a lower incidence of neonatal hypoglycemia (relative risk, RR 0.74; 95% CI 0.58–0.93; P = 0.01) and of neonatal intensive care admission (RR 0.76; 95% CI 0.59–0.97; P = 0.03). Bayesian analysis revealed that the efficacy of metformin was consistently higher than insulin with a probability of over 98% on these two neonatal complications. Other outcomes were not significantly different between the two treatment groups.ConclusionIn women with gestational diabetes, metformin use and insulin therapy have comparable glycemic control profile, but metformin use was associated with lower risk of neonatal hypoglycemia.