LYCEUM NORTHWESTERN UNIVERSITY

DR. FRANCISCO Q. DUQUE MEDICAL FOUNDATION

COLLEGE OF MEDICINE

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS IN OBSTETRICS II

“Meta-Analysis on the Comparison of Metformin and Insulin in

the Management of Gestational Diabetes Mellitus”

Victorino C. Garcia, Jr.1, Bello, Jerilou2, Caluag, Adrienne 3, Chukaew, Sauvaleeporn4,

Fernando, Merielle5, Hersi, Khalif6, Kalangeg, Kristie7, Mangahas, Michael Francis8,
Mohammed, Mohammed9, Panlasigui, Rikkimae10, Rahut, Ranee11

1
Lead Researcher, Associate Professor, College of Medicine, LyceumNorthwestern University
2
Assistant Researchers, College of Medicine, Lyceum Northwestern University

1
 ABSTRACT

Title: META-ANALYSIS ON THE COMPARISON OF METFORMIN AND INSULIN IN

THE MANAGEMENT OF GESTATIONAL DIABETES MELLITUS

AUTHOR: Dr. Victorino C. Garcia, et. al.

SCHOOL: Lyceum Northwestern University

RESEARCH ADVISER: Dr. Victorino C. Garcia Jr.

KEYWORDS: Gestational diabetes mellitus, Metformin, Insulin

Metformin and insulin management of gestational diabetes mellitus

Study on metformin for gestational diabetes mellitus

Study on insulin for gestational diabetes mellitus

Metformin and insulin management of gestational diabetes mellitus

Meta-analysis metformin and insulin in the management of gestational diabetes mellitus

Randomized controlled trials of treatment with metformin vs. insulin with gestational diabetes
mellitus

Gestational Diabetes Mellitus is a major health risk both for the mother and the fetus. In the

United States, 5 to 6 percent of pregnancies—almost 250,000 women—are affected annually by

various forms of gestational diabetes. The most important correlate perinatal correlate is

excessive fetal growth, which may result in both maternal and fetal birth trauma. The likelihood

of fetal death with appropriately treated gestational diabetes mellitus is not different from that in

the general population. The research work focused on determining the safety and effectiveness of

Metformin in gestational diabetes. It further aimed to give answers to the following questions:

1. Is Metformin safe and effective against gestational diabetes mellitus?

2
 2. Is there a significant difference between the effectiveness of Metformin and Insulin in

gestational diabetes mellitus?

3. Which of the two drugs is safer for gestational diabetes mellitus?

The results showed that Metformin gave a higher safety and effectiveness as compared to insulin

in terms of the weight of the baby, risk of NICU admission rate, pre-eclampsia and frequency of

neonatal hypoglycaemia.

METHODS

Forest plot table 1: Test for Herogeneity: Chi-square = 85.2347; df = 7 p-value = 0.00065, forest

plot relative risk of insulin vs metformin by macrosmia show that patients who took metformin

showed better outcomes in terms of the babies’ weight. Forest plot table 2: Test for Herogeneity:

Chi-square = 64.5612; df = 6 p-value = 0.0002, relative risk of Insulin vs Metformin by

Neonatal Intensive Care unit admissions showed that patients from metformin group showed

better outcomes. Forest plot table 3: Test for Herogeneity: Chi-square = 191.8012; df = 6 p

value = 0.0031, relative risk of Insulin vs Metformin by neonatal hypoglycemia showed that

patients taking insulin are the ones that are higher in risk for having neonatal hypoglycemia.

Forest plot 4: Test for Herogeneity: Chi-square = 112.31 df = 6 p-value = >0.0001, relative risk

of insulin vs Metformin by preeclampsia, showed that patients who took insulin has higher risk

in developing pre- eclampsia.

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Based from the results of the four forest plots, in which all of them showed p- values <0.5 means

that values of relative risk for Meta- analysis is significant and therefore conclude that

Metformin is safe and effective against gestational diabetes mellitus; there is a significant

difference between the effectiveness of Metformin and Insulin in gestational diabetes mellitus in

terms of neonatal hypoglycemia and pre-eclampsia, and Metformin is safer for gestational

diabetes mellitus as determined by the _________

CHAPTER I

INTRODUCTION

RATIONALE AND BACKGORUND OF THE STUDY

Glucose intolerance developing during pregnancy is classified as Gestational Diabetes.

The worldwide prevalence of DM has risen dramatically over the past two decades, from an

estimated 30 million cases in 1985 to 382 million in 2013. The countries with the greatest

number of individuals with diabetes in 2013 are China (98.4 million), India (65.1 million),

United States (24.4 million), Brazil (11.9 million) and Russian Federation (10.9 million). Up to

80% of individuals with diabetes live in low income or medium income countries (Harrisons

Principle of Internal Medicine). In the United States, 5 to 6 percent of pregnancies—almost

250,000 women—are affected annually by various forms of gestational diabetes. Risk factors of

acquiring such disease are the following: Severe obesity, strong family history of Type 2

Diabetes and previous history of GDM, impaired glucose metabolism or glucosoria (Williams

Obstetrics). Different complications for both the mother and the fetus can arise such as large for

gestational age (LGA), macrosomia, shoulder dystocia, neonatal hypoglycaemia, and the need

for cesarean section which are all manageable and preventable. There have been numerous

4
researches that were done regarding the different management of diabetes mellitus, both

chemical and herbal.

Many pharmaceutical companies offer medications that are made up of herbal plants and

prepared chemically, however, there were no approved drugs that can offer absolute cure. Diet

modification is often used as first-line treatment, and if partly or wholly unsuccessful or where

women have substantially elevated glucose at diagnosis, pharmacological treatments (metformin,

glibenclamide (glyburide) and/or insulin) are offered. They can be prescribed with various

medication, but there should be a balance of therapeutic effect and safety to both the mother and

the fetus. Common drugs prescribed are Insulin and Metformin, several studies have been

conducted regarding the effect of the said drugs to the diabetic mother and it’s safety to the

developing fetus.

The researchers, as future clinicians whose purpose is to promote health and wellness for

both the mother and the fetus, therefore aimed at gathering and analyzing pertinent and reliable

data and then critically appraise the published evidences on the effectiveness and safety of the

Insulin and Metformin in gestational diabetes.

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 CONCEPTUAL FRAMEWORK

Journals published from the year 2016-2017 were

identified using the keywords Metformin, Insulin
and Gestational Diabetes Mellitus

Subjects were women diagnosed with Journals excluded based on titles and
Gestational Diabetes Mellitus requiring abstracts
drug treatment.

Randomized control trials that has results of efficacy of

Metformin and Insulin for gestational diabetes mellitus, Non-RCT studies were

studies done from August 2016 until December 2017 were excluded

included.

The title, abstract and full text screening was done by five
reviewers with disagreements resolved by the consensus of
the other members of the review team. 6
 Figure 1.1 Conceptual Framework of Meta-Analysis on the Comparison of

Metformin and Insulin in the Management of Gestational Diabetes Mellitus

PARADIGM OF THE STUDY

INPUT PROCESS OUTPUT

RCT’s of Efficacy of Used the following Metformin showed

Metformin vs Insulin search engines using more favorable
from the year 2015- the following MESH outcomes compared to
2017 with the terms Gestational Insulin in terms of the
following variables: Diabetes, Metformin, following
and Insulin:
Fetal outcomes: Fetal outcomes:
 PubMed
 Macrosomia  Macrosomia
 Cochrane
 NICU Admission  NICU Admission
 Elsevier
 Neonatal  Neonatal
Hypoglycemia The journals gathered Hypoglycemia
were statistically
Maternal Outcome: Maternal Outcome:
treated by a
 Pre- eclampsia Biostatistician  Pre- eclampsia

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 Figure 1.2 Paradigm of the Meta-Analysis on the Comparison of Metformin and Insulin in the

Management of Gestational Diabetes Mellitus

This study compared the results of the studies gathered regarding the effects of

Metformin and Insulin when used in the treatment of gestational diabetes, since both drugs are

capable to decrease glucose. The researchers have used the MESH terms Gestational diabetes,

Metformin and Insulin in PubMed, Cochrane and Elsevier search engines to gather journals that

were used for meta-analysis.

STATEMENT OF THE PROBLEM

The following sub-problems are to be answered:

1. Is Metformin safe and effective against gestational diabetes mellitus?

2. Is there a significant difference between the effectiveness of Metformin and Insulin in

gestational diabetes mellitus?

3. Which of the two drugs is safer for gestational diabetes mellitus?

HYPOTHESIS OF THE STUDY

1. Metformin is safe and effective against gestational diabetes.

2. There is no significant difference between the effectiveness of decreasing glucose level

of Metformin and Insulin in gestational diabetes mellitus.

3. Metformin in safer than Insulin for gestational diabetes mellitus.

SCOPE AND DELIMITATION OF THE STUDY

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 The main focus of the study was to come-up with an updated meta-analysis on

comparison between metformin and insulin for the management of gestational diabetes mellitus

utilizing a randomized control trial study. Studies were included if they met the following

criteria: subjects were women are diagnosed with Gestational Diabetes Mellitus requiring drug

treatment, randomized control trials that has results of efficacy of Metformin and Insulin for

gestational diabetes mellitus, studies done from August 2016 until December 2017. Trials had to

report on effects on adverse effects outcomes such Pre- eclampsia, Premature birth, Cesarean

section and Weight gain during pregnancy. Journals that were uplifted were from the Elsevier,

MEDLINE and PubMed. Whereas the following studies are excluded if these criteria are met:

reviews, letters and comments and studies that results to the effectiveness of metformin and

insulin with other diseases.

Study Selection

Inclusion and exclusion criteria

The studies were included if they met the following criteria:

1. Subjects were women diagnosed with Gestational Diabetes Mellitus requiring drug

treatment.

2. Randomized control trials that has results of efficacy of Metformin and Insulin for

gestational diabetes mellitus, studies done from August 2016 until December 2017.

The randomized control trials had to report on the adverse effects outcomes, such as, Pre-

eclampsia, Premature birth, Cesarean section, and Weight gain during pregnancy. Whereas the

following studies are excluded if these criteria are met: Reviews, letters and comments and

studies that results to the effectiveness of metformin and insulin with other diseases.

9
OBJECTIVES OF THE STUDY

General Objective

To promote health in pregnant women with gestational diabetes.

Specific Objectives

1. To be able to gather pertinent and reliable data on the effectiveness of Metformin in

gestational diabetes.

2. To be able to compare the effectiveness of Metformin in various researches made on

gestational diabetes.

3. To be able to know if Metformin is more effective than Insulin for gestational diabetes.

4. To critically appraise the published evidences on the safety and effectiveness of

Metformin in gestational diabetes.

DEFINITION OF TERMS

 GESTATIONAL DIABETES - defined as carbohydrate intolerance of variable severity

with onset or first recognition during pregnancy (illiams Obstetrics 24th edition)

 GESTATIONAL DIABETES MELLITUS (GDM) - diabetes is induced by pregnancy—

ostensibly because of exaggerated physiological changes in glucose metabolism

(Williams Obstetrics 24th edition, pp. 1136).

 HYPERGLYCEMIA – defined as excess of sugar in the blood (https://www.merriam-

webster.com/dictionary/hyperglycemia).

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 INSULIN – It is the mainstay for treatment of virtually all type 1 and type 2 diabetes

patients (Goodman & Gilman's The Pharmacological Basis of Therapeutics 12th Edition,

pp. 1248).

 MACROSOMIA - is defined by birthweights that exceed 90th percentiles for a given

gestational week or newborn weight exceeding 4000 grams (8 lb 13 oz) (Williams

Obstetrics 24th edition, pp. 884-885).

 META-ANALYSIS - quantitative, formal, epidemiological study design used to

systematically assess previous research studies to derive conclusions about that body of

research (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3049418/)

 METFORMIN – It is currently the most commonly used oral agent to treat type 2

diabetes and is generally accepted the first-line treatment for this condition (Goodman &

Gilman's The Pharmacological Basis of Therapeutics 12th Edition, pp. 1260).

 PREECLAMPSIA - Preeclampsia is defined as the presence of (1) a systolic blood

pressure (SBP) greater than or equal to 140 mm Hg or a diastolic blood pressure (DBP)

greater than or equal to 90 mm Hg or higher, on two occasions at least 4 hours apart in a

previously normotensive patient, OR (2) an SBP greater than or equal to 160 mm Hg or a

DBP greater than or equal to 110 mm Hg or higher (Medscape).It is a pregnancy-specific

syndrome that can affect virtually every organ system (Williams Obstetrics 24th edition,

pp. 729).

 RANDOMIZED CONTROLLED TRIALS (RCT) - quantitative, comparative, controlled

experiments in which investigators study two or more interventions in a series of

individuals who receive them in random order. The RCT is one of the simplest and most

11
 powerful tools in clinical research

(https://www.medicinenet.com/script/main/art.asp?articlekey=39532).

CHAPTER II

REVIEW OF RELATED LITERATURE

Gestational diabetes mellitus (GDM) is the most common medical complication of

pregnancy. It is associated with maternal and neonatal adverse outcomes. Maintaining adequate

blood glucose level in GDM reduces morbidity for both the mother and baby. The initial

treatment for GDM consists of diet and exercise. If these measures fail to achieve glycemic

goals, insulin should be initiated. For several decades, insulin has been the most reliable

treatment strategy and the gold standard for GDM. Metformin on the other hand is an effective

insulin sensitizing agent and it appears that it may perhaps open a new door in managing GDM

(Singh et al,2016).

According to Saleh et. al. (2016), health education for dose adjustment of insulin is

essential to provide confident safe self-administration of insulin. Currently, considerable costs of

12
health education on the safe use of insulin in addition to the cost of the drug itself are chased.

Observably, oral therapy if safe and effective could be more satisfactory and desired.

Presently, Metformin is becoming more widely used in Australia among pregnancy specialists

and endocrinologists. There have been few observable risks identified with metformin over

insulin, slightly lower gestational age at delivery (pooled mean difference −0.16 weeks (−0.30 to

−0.02)), and more preterm birth (pooled risk ratio 1.50 (1.04 to 2.16)) and studies are emerging

which show benefits to mothers and the neonate (Gray, S. et. al. 2017).

Metformin is a biguanide compound, which exerts its clinical effect by both reducing

hepatic glucose output and by increasing insulin sensitivity. This results in a decreased glucose

level without an associated high risk of either hypoglycemia or weight gain. These characteristics

have established metformin as an ideal first-line treatment for people with type 2 diabetes

mellitus and, hypothetically, a particularly attractive drug for use in pregnancy. Confidence

regarding the use of metformin in pregnancy has been reinforced by the results of several

observational studies and randomized trials over the past decade (Feig, D. & Moses, R. 2011).

Moreover, the success rate of a drug in achieving targeted glucose levels also depends on

disease severity as reflected by plasma glucose values. The rate of success for achieving

glycaemic control in metformin-treated patients ranged from 54 to 79 per cent (Tripathi, R., et al.

2017).

Meanwhile a study on the mean blood glucose level at overnight fasting and postprandial

and HbAlc level at delivery were similar in both groups throughout GDM treatment. The number

of patients who reached the goal of an approximately equal fasting and postprandial glycaemia

did not differ significantly between the two groups. Consequently, Metformin was found to be

effective in the management of gestational diabetes mellitus. (Feig, D. et al. 2011).

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 In general, Metformin is effective as insulin for the management of GDM. Metformin can

be used securely during pregnancy as it is not linked with congenital malformations or increased

maternal or neonatal complications. In addition, Metformin decreases the rate of neonatal

hypoglycemia. Current studies show that metformin is safe and effective in treatment of

gestational diabetes mellitus. Acceptability of metformin is better than insulin as it is

noninjectable and with lower risk of hypoglycaemia. ((Feig, D. et al. 2011)

Similarly in the study “Treatment of Gestational Diabetes Mellitus: Insulin or

Metformin?” by Somani, P. (2016), metformin has established as an ideal first-line treatment for

type 2 diabetes mellitus, and hypothetically a particularly attractive drug for use in pregnancy. A

total of 32 on metformin (Intervention group) and 33 on insulin (Active control group) subjects

completed study. Of the 32 women assigned to metformin, 96.87% continued to receive

metformin until delivery and 25% of the metformin group received supplemental insulin. There

was no significant difference in mean birth weight between the groups. There were no significant

differences in neonatal and maternal complications between groups. However, treatment

satisfaction (70.97%) was significantly better in the metformin group, whereas, better control of

postprandial plasma glucose was achieved in insulin group.

Another study conducted by Singh favors metformin which can be used as a safe and

effective oral hypoglycaemic agent in GDM, especially in low-resource settings where cost,

storage and compliance are logistic issues.

Therefore, using oral hypoglycemic agents in controlling blood sugar almost parallels

with the effect of insulin. Hypothetically, metformin is an alternative to insulin in the treatment

of hyperglycemia during pregnancy. It reduces hyperglycemia by suppressing hepatic glucose

output so it reduces hepatic gluconeogenesis and it is intensifying insulin sensitivity therefore

14
enhancing peripheral glucose uptake. Glycaemic control in GDM can be achieved by using

metformin orally without increasing risk of maternal hypoglycemia with satisfying neonatal

outcome.

CHAPTER III

RESEARCH METHODOLOGY

METHODS

Patient Involvement

The results of different randomized controlled trials from the year 2016- 2017 about the effects

of metformin in pregnancy were included in this study. Pregnant women who has, had and those

are at risk of having gestational diabetes mellitus were selected and they will be the contributory

factor for the appraisal and review of the effects of metformin in pregnancy for this study.

Search Methods

15
We started with using keyword based searching (Metformin, Insulin and Gestational Diabetes

Mellitus) in multiple databases and identified types of study. The search strategy of choosing

randomized controlled trials (RCT) of treatment with Metformin vs. Insulin of women with

GDM. We also considered the date it was published and limited it to studies between August

2016 and 2017. The bibliographical databases searched were Elsevier, MEDLINE and PubMed

among others. The studies were not bounded by the country it was published in. The searches

were started August 2017 and were organized using the same search strategies to qualify studies

that fit the parameters given. We also included other form of references like journals,

supplementary files, and readings. To balance the sensitivity and precision, we asked the experts

what inclusion criteria should be considered aside from the parameters given, as well as

screening the reference list and citations from the articles found.

Data extraction and risk of bias assessment

The title, abstract and full text screening was done by five reviewers with disagreements resolved

by the consensus of the other members of the review team. The risk of bias of the clinical trials

that were included was assessed by the Cochrane risk of bias tool which considers sequence

generation, allocation concealment, blinding of participants and medical staff to treatment

allocation, blinding of the assessors, loss to follow-up, selective reporting of outcomes and other

sources of bias. Each criterion was classified as either low or high risk of bias or unclear. Two

reviewers assessed all the criteria.

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 CHAPTER IV

RESULTS AND DISCUSSION

Forest Plot of Relative Risk of Insulin vs Metformin by Macrosomia

Events/
Sample Relative
Study Size Risk

Sikder et. al 137/550 23.12

Fadl et. al 10/69 14.49275
Terti et al 6/216 2.777778
Elnour et.al 27/180 15
Moosavi et.al 7/160 4.375
Ijas et. al 20/97 18.5567
Macklin et.al 4/30 13.33333
Hassan et. al 22/150 14.66667

17
Metaanalysis 231/1452 18.312

Test for Herogeneity: Chi-square = 85.2347 df = 7 p-value = 0.00065

Test for overal effect: z=0.3261 p-value = 0.0002

Figure 4.1 Forest plot of relative risk of Insulin vs Metformin by macrosomia

Considering 8 previous studies, our systematic review estimated that the relative risk of

having macrosomia babies for those patients who received insulin is approximately 18.312. This

means that the risk of having macrosomia babies are higher to those patients who received

insulin as compared to those patients in Metformin treatment. Hence, patients who took

Metformin showed better outcomes in terms of the weight of the babies.

Note that since the p-value is less than 0.05, the values of relative risk for metaanalysis is

significant. Same for the succeeding data.

Forest Plot of Relative Risk of Insulin vs Metformin by NICU Admission

Total
Events/ Relative
Study Sample Size Risk

Sikder et.al 149/550 27.09091

Tertti et. al 73/216 33.7963
Moosavi et.al 11/160 18.3333
Saberi et. al 47/200 23.5
Ijas et. al 20/97 20.61856
Hassan et. al 33/150 22
Karim et. al 16/118 13.55932

18
Meta-
analysis 349/1491 22.69971

Test for Herogeneity: Chi-square = 64.5612 df = 6 p-value = 0.0002

Test for overal effect: z=0.3167 p-value = 0.0011

Figure 4.2 Forest plot of relative risk of Insulin vs Metformin by NICU admission

Considering 7 previous studies, the NICU admission rate for metformin group are found

to be as compared to insulin group and hence, this meta-analysis showed that the relative risk of

NICU admission for insulin group is approximately 22.69971 which means that the risk of

babies from insulin group to be admitted in NICU are higher than those babies from the

metformin group. In terms of NICU admission rate, patients from metformin group showed

better outcomes.

Forest Plot of Relative Risk of Insulin vs Metformin by Neonatal Hypoglycemia

Events/Sample Relative
Study Size Risk
Sikder et.al 154/550 28
Tertti et. al 18/69 26.086
Spaulonci et. al 13/94 13.829
Moosavi et. al 5/160 3.125
Saberi et. al 25/100 25
Ijas et. al 11/97 11.34021
Hassan et. al 30/150 20
Meta-analysis 256/1220 19.562

19
 Test for Herogeneity: Chi-square = 191.8012 df = 6 p-value = 0.0031

Test for overal effect: z=0.3242 p-value = 0.0013

Figure 4.3 Forest plot of relative risk of Insulin vs Metformin by neonatal hypoglycemia

Considering 7 previous studies, women using metformin presented lower frequency of

neonatal hypoglycemia and that incidence of neonatal hypoglycemia are significantly higher for

those patients in the insulin group. The systematic review estimated that the relative risk of

having neonatal hypoglycemia for babies from insulin group is approximately 19.562 . This

means that the risk of having neonatal hypoglycemia for babies from insulin group are

significantly higher as compared to those babies from Metformin group.

Forest Plot of Relative Risk of Insulin vs Metformin by Pre-eclampsia

Events/Sample Relative
Study Size Risk
Fadl et. al 8/72 11.11
Tertti et. al 38/217 6.92
Elnour et. al 33/165 19.39
Pavao et. al 22/94 23.40
Moosavi et. al 28/160 18.33
Macklin et.al 5/20 25
Saleh et. al 25/137 18.2418
Meta-analysis 113/745 19.67

Test for Herogeneity: Chi-square = 112.31 df = 6 p-value = >0.0001

20
Test for overal effect: z=0.3812 p-value = 0.0016

Figure 4.4 Forest plot of relative risk of Insulin vs Metformin by pre-eclampsia

Overall, pre-eclampsia was significantly less in metformin treated groups and hence, the

incidence of suffering from pre-eclampsia are most common to insulin group. The relative risk of

suffering from pre-eclampsia for insulin group is estimated to be 19.67 indicating that the risk of

having suffering from pre-eclampsia for insulin group are significantly higher as compared to

those metformin treated patients.

CHAPTER V

SUMMARY, CONCLUSION AND RECOMMENDATION

The main focus of this chapter is to present the summary of all the procedures performed

in the meta-analysis, the results obtained, the conclusions and the recommendations for the

future researchers.

SUMMARY

The research work focused on determining the safety and effectiveness of Metformin in

gestational diabetes. It further aimed to give answers to the following questions:

4. Is Metformin safe and effective against gestational diabetes mellitus?

21
 5. Is there a significant difference between the effectiveness of Metformin and Insulin in

gestational diabetes mellitus?

6. Which of the two drugs is safer for gestational diabetes mellitus?

Fourteen (14) studies on Metformin were retrieved from the meta-analysis, Treatments for

gestational diabetes: a systematic review and meta-analysis. The group gathered 2 new studies

which served as updates of the study on hand.

The results showed that Metformin gave a higher safety and effectiveness as compared to insulin

in terms of the weight of the baby, risk of NICU admission rate, pre-eclampsia and frequency of

neonatal hypoglycaemia.

CONCLUSION

1. Metformin is safe and effective against gestational diabetes mellitus.

2. There is a significant difference between the effectiveness of Metformin and Insulin in

gestational diabetes mellitus in terms of neonatal hypoglycemia and pre-eclampsia.

3. Metformin is safer for gestational diabetes mellitus.

In this study it shows that using Metformin is more safe and effective compared to using Insulin

in managing Gestational Diabetes Mellitus.

RECOMMENDATION

To further enhance and improve the study, the researchers recommend that the following

measures be done:

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1. To obtain more randomized controlled trials (RCTs) to supply new evidence in giving a

definite answer to the treatment regimen of gestational diabetes.

2. To consider additional neonatal parameters such as large for gestational age (LGA) and

APGAR score, as well as maternal parameters such as HbA1c and FBS levels before,

during and after treatment.

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pp. 4423 – 4429. DOI: 10.14260/jemds/2016/1011.

 Spaulonci CP, Bernardes LS, Trindade TC, et al. Randomized trial of metformin vs

insulin in the management of gestational diabetes. Am J Obstet Gynecol 2013;209:34.e1-

7.

 Tertti K, Ekblad U, Koskinen P, Vahlberg T, Ronemma T. Metformin vs insulin in

gestational diabetes. A randomized study characterizing metformin patients needing

additional insulin. Blackwell Publishing Ltd. Diabetes, Obsity and Metabolism

2013;15:246-251

26
APPENDICES

Randomized controlled study in pregnancy on treatment of

marked hyperglycemia that is short of overt diabetes

n=72

27
Metformin vs. insulin in gestational diabetes. A randomized
study characterizing metformin patients needing additional
Insulin

28
Pharmaceutical care of patients with gestational diabetes
Mellitus

29
 Randomized trial of metformin vs insulin in the management of gestational diabetes

Pregnancy outcome
The 2 groups did not differ in terms of the frequency of preeclampsia (10/46 [21.7%] in
group 1 and 7/46 [15.2%] in Of those, preeclampsia was superimposed to chronic
hypertension in 5 patients that had chronic hypertension in group 1 (5/14, 35.7%) and in
3 patients (3/12, 25%) in group 2 (P ¼.683).

30
Metformin-compared-with-insulin-in-the-management-of-gestational-diabetes-mellitus-
A-randomized-clinical-trial

31
Comparison-of-Newborn-Outcomes-in-Women-with-Gestational-Diabetes-Mellitus-
Treated-with-Metformin-or-Insulin-A-Randomised-Blinded-Trial

32
Metformin-should-be-considered-in-the-treatment-of-gestational-diabetes-a-prospective-
randomised-study

Metformin-prevents-macrosomia-and-neonatal

33
Metformin-versus-insulin-treatment-in-gestational-diabetes-in-pregnancy-in-a-
developing-country.-A-randomized-control-trial

34
 Clinical Study
Could Metformin Manage Gestational Diabetes
Mellitus instead of Insulin?
Hend S. Saleh,

35
36
CURRICULUM
VITAE

37
PERSONAL DATA:

Name: BELLO, JERILOU Z.

Address: Calasiao, Pangasinan

Sex: Male

Nationality: Filipino

Birth date: April 7, 1989

Age: 28 years old

Status: Single

Religion: Roman Catholic

Contact Number: 09121122107

Email: luizulueta7@gmail.com

Educational Background:

Post – Graduation: 3rd year student, Doctor of Medicine

Lyceum Northwestern University Dr. Francisco Q. Duque Medical
Foundation

Tertiary: Bachelor of Science in Nursing

University of Pangasinan
Dagupan City

Secondary: Calasiao Comprehensive National High School

Dagupan City

Primary: Harvent School

Dagupan City

38
PERSONAL DATA:

Name: ADRIENNE D. CALUAG

Address: 888 Ayusip Rd. Bonuan, Boquig,
Dagupan City Pangasinan
Sex: Female
Nationality: Filipino
Birth date: August 13, 1993
Age: 24years old
Status: Single
Religion: Roman Catholic
Contact No.: 09165183879
Email: adrienne.caluag@yahoo.com

EDUCATIONAL BACKGROUND:
Post – Graduation: 3rd year student, Doctor of Medicine
Lyceum Northwestern University Dr. Francisco Q. Duque Medical
Foundation
2015- Present

Tertiary: Bachelor of Science in Pharmacy

Saint Louis University, Baguio City
SY: 2010-2014

Secondary: Dominican School

Dagupan City, Pangasinan
SY: 2006-2010

Primary: Creative Montessori Center

Dagupan City, Pangasinan
SY: 2001-2006

39
PERSONAL DATA:

Name: Chukaew,Saovaleeporn
Sex: Female
Nationality: Thai
Birth date: May 11, 1985
Age: 33 years old
Status: Single
Religion: Buddhist
Contact Numb er: 09213264613
Email: bo_062-3@hotmail.com

EDUCATIONAL BACKGROUND:

Post – Graduation: 3rd year student, Doctor of Medicine

Lyceum Northwestern University Dr. Francisco Q. Duque Medical
Foundation
2015- Present

Tertiary:
Secondary:
Primary:

40
PERSONAL DATA
Name: Merielle C. Fernando
Address: Pangapisan North Lingayen, Pangasinan
Sex: Female
Nationality: Filipino
Birthdate: August 13, 1992
Age: 25 years old
Status: Single
Religion: Roman Catholic
Contact Number: 09366163110
Email: merielle.fernando@gmail.com

EDUCATIONAL BACKGROUND:
Post – Graduation: 3rd year student, Doctor of Medicine
Lyceum Northwestern University Dr. Francisco Q. Duque Medical
Foundation
2015 – Present

Tertiary: Bachelor in Pharmacy

Saint Louis University, Baguio City
SY: 2009-2013

Secondary: Pangasinan National High School.

Lingayen, Pangasinan
SY: 2005-2009

Primary: Lingayen Educational Center.

Lingayen, Pangasinan
SY: 1999-2005

41
PERSONAL DATA
Name: Hersi Khalif Abdirahman
Address: Tapuac, Dagupan City, Pangasinan
Sex: Male
Nationality: Somali
Birthdate: December 26, 1992
Age: 25 years old
Status: Single
Religion: Muslim
Contact Number: 09260170969
Email: khalifazeeg@gmail.com

EDUCATIONAL BACKGOROUND:
Post – Graduation: 3rd year student, Doctor of Medicine
Lyceum Northwestern University Dr. Francisco Q. Duque Medical
Foundation
2015 – Present

Tertiary: Bachelor of Science in Biology

Lyceum Northwestern University, Dagupan city
SY: 2014-2015

Secondary: Wadi Sofia International Cambridge School.

Kota bharu, kalantan, malaysia
SY: 2010-2013

Primary: New indain school.

Ras al khiamah, united arab Emirates
SY: 2000-2005

42
PERSONAL DATA:

Name: KRISTIE C. KALANGEG

Address: #151 Talubin, Bontoc, Mountain Province
Sex: Female
Nationality: Filipino
Birth date: December 15, 1986
Age: 31 years old
Status: Married
Religion: Roman Catholic
Contact no: 09453582702
Email add: kasscyrock@gmail.com

EDUCATIONAL BACKGROUND:
Post – Graduation: 3rd year student, Doctor of Medicine
Lyceum Northwestern University Dr. Francisco Q. Duque Medical
Foundation
2015 – Present

Tertiary: Bachelor of Science in Nursing

University of Baguio, Baguio City, 2006-2008

Bachelor of Science in Medical Technology

Saint Louis University. Baguio City, 2003-2006

Secondary: Saint Vincent’s School

Bontoc, Mountain Province
1999-2003

Primary: Saint Vincent’s School

Bontoc, Mountain Province
1993-1999

43
PERSONAL DATA:
Name: Michael Francis M. Mangahas
Address: Poblacion East, Sta. Ignacia, Tarlac
Sex: Male
Nationality: Filipino
Birthdate: March 24, 1994
Age: 23 years old
Status: Single
Religion: Roman Catholic
Contact Number: 09279730716
Email: mfmmangahas.sbcm@gmail.com

EDUCATIONAL BACKGROUND:
Post – Graduation: 3rd year student, Doctor of Medicine
Lyceum Northwestern University Dr. Francisco Q. Duque Medical
Foundation
2015 – Present

San Beda College

College of Medicine, San Miguel, Manila, 2014-2015

Tertiary: Bachelor of Science in Medical Technology

Far Eastern University, Nicanor Reyes Sr. St. Sampaloc, Manila
SY: 2010-2014

Secondary: Tarlac Montessori School

La Puerta del Sol Hi-Land Subd. San Sebastian, Tarlac, SY: 2006-2010

Primary: Tarlac Montessori School

La Puerta del Sol Hi-Land Subd. San Sebastian, Tarlac, SY: 2000-2006

44
PERSONAL DATA:
Name: Mohamed mohamed hussein
Address: Amado street, Dagupan city, Pangasinan
Sex: Male
Nationality: Somali
Birthdate: April/07/1990
Age: 27 years old
Status: Single
Religion: Islam
Contact Number: 09273245277
Email: baashi571@gmail.com

EDUCATIONAL BACKGROUND:
Post – Graduation: 3rd year student, Doctor of Medicine
Lyceum Northwestern University Dr. Francisco Q. Duque Medical
Foundation
2013 – Present

Tertiary: Bachelor of science in nursing

Mogadishu University
Mogadishu city-somalia
SY: 2009-2013

Secondary: Hamar High School.

Mogadisho-somalia
SY: 2005-2009

Primary: Waberi elementary school

Garowe-somalia
SY: 1998-2005

45
PERSONAL DATA:
Name: RIKKIEMAE MARIA Z. PANLASIGUI
Address: 18 Bacar, Magsingal, Ilocos Sur
Sex: Female
Nationality: Filipino
Birth date: May 16, 1994
Age: 23 years old
Status: Single
Religion: Roman Catholic
Contact no: 09277742990
Email: rikkiemaemaria@gmail.com

EDUCATIONAL BACKGROUND:
Post – Graduation: 3rd year student, Doctor of Medicine
Lyceum Northwestern University Dr. Francisco Q. Duque Medical
Foundation
2015 – Present

Tertiary: Bachelor of Science in Nursing

St. Louis University
Baguio City
S.Y. 2010- 2014

Secondary: St. Paul College of Ilocos Sur (University System)

Bantay, Ilocos Sur
S.Y. 2006- 2010

Primary: St. Paul College of Ilocos Sur (University System)

Bantay, Ilocos Sur
S.Y. 2000-2006

46
PERSONAL DATA:
Name: RAHUT, RANEE
Address: Amado, Dagupan City, Pangasinan
Sex: Female
Nationality: Thai
Birth date: December 19, 1990
Age: 27 years old
Status: Single
Religion: Buddhist
Contact Number: 09273073537
Email: ranee14@hotmail.com

EDUCATIONAL BACKGROUND:
Post – Graduation: 3rd year student, Doctor of Medicine
Lyceum Northwestern University Dr. Francisco Q. Duque Medical
Foundation
2014 – Present

Tertiary: Bachelor of Science in Biology

Mahidol University International College
2011-2014

Seconday: Harrow International School

TSIS
2000-2010

Primary: Wittaya Sathid School Phuket

1995-2000

47