Download PDF
Am J Perinatol
DOI: 10.1055/s-0043-1777334
Original Article

Patient Priorities, Decisional Comfort, and Satisfaction with Metformin versus Insulin for the Treatment of Gestational Diabetes Mellitus

Kartik K. Venkatesh 
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
,
Jiqiang Wu
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
,
Anne Trinh
2   Center for Health Outcomes and Policy Evaluation Studies, The Ohio State University, Columbus, Ohio
,
Sharon Cross
3   Department of Patient Experience, The Ohio State University Wexner Medical Center, Columbus, Ohio
,
Donna Rice
4   DiabetesSisters, Raleigh, North Carolina
,
Camille E. Powe
5   Departments of Medicine and Obstetrics, Gynecology, and Reproductive Biology, Diabetes Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
,
Stephanie Brindle
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
,
Sophia Andreatta
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
,
Anna Bartholomew
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
,
Cora MacPherson
6   Department of Epidemiology and Biostatistics, George Washington University, Washington, District of Columbia
,
Maged M. Costantine 
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
,
George Saade
7   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical College, Norfolk, Virginia
,
Ann Scheck McAlearney
8   CATALYST—The Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, The Ohio State University, Columbus, Ohio
9   Department of Family and Community Medicine, College of Medicine, The Ohio State University, Columbus, Ohio
,
William A. Grobman
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
,
Mark B. Landon
1   Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, Ohio
› Author Affiliations Funding K.K.V. was supported by the Care Innovation and Community Improvement Program at The Ohio State University. K.K.V. and M.B.L. were funded by PCORI grant #BPS-2022C3-30335.
› Further Information
    Permissions and Reprints

Abstract

Objective We compared patient priorities, decisional comfort, and satisfaction with treating gestational diabetes mellitus (GDM) with metformin versus insulin among pregnant individuals with GDM requiring pharmacotherapy.

Study Design We conducted a cross-sectional study of patients' perspectives about GDM pharmacotherapy in an integrated prenatal and diabetes care program from October 19, 2022, to August 24, 2023. The exposure was metformin versus insulin as the initial medication decision. Outcomes included standardized measures of patient priorities, decisional comfort, and satisfaction about their medication decision.

Results Among 144 assessed individuals, 60.4% were prescribed metformin and 39.6% were prescribed insulin. Minoritized individuals were more likely to receive metformin compared with non-Hispanic White individuals (34.9 vs. 17.5%; p = 0.03). Individuals who were willing to participate in a GDM pharmacotherapy clinical trial were more likely to receive insulin than those who were unwilling (30.4 vs. 19.5%; p = 0.02). Individuals receiving metformin were more likely to report prioritizing avoiding injections (62.4 vs. 19.3%; adjusted odds ratio [aOR]: 2.83; 95% confidence interval [CI]: 1.10–7.31), wanting to take a medication no more than twice daily (56.0 vs. 30.4%; aOR: 3.67; 95% CI: 1.56–8.67), and believing that both medications can equally prevent adverse pregnancy outcomes (70.9 vs. 52.6%; aOR: 2.67; 95% CI: 1.19–6.03). Conversely, they were less likely to report prioritizing a medication that crosses the placenta (39.1 vs. 82.5%; aOR: 0.09; 95% CI: 0.03–0.25) and needing supplemental insulin to achieve glycemic control (21.2 vs. 47.4%; aOR: 0.36; 95% CI: 0.15–0.90). Individuals reported similarly high (mean score > 80%) levels of decisional comfort, personal satisfaction with medication decision-making, and satisfaction about their conversation with their provider about their medication decision with metformin and insulin (p ≥ 0.05 for all).

Conclusion Individuals with GDM requiring pharmacotherapy reported high levels of decision comfort and satisfaction with both metformin and insulin, although they expressed different priorities in medication decision-making. These results can inform future patient-centered GDM treatment strategies.

Key Points:

  • Pregnant individuals with GDM requiring pharmacotherapy expressed a high level of decisional comfort and satisfaction with medication decision making.

  • Individuals placed different priorities on deciding to take metformin versus insulin.

  • These results can inform interventions aimed at delivering person-centered diabetes care in pregnancy that integrates patient autonomy and knowledge about treatment options.

Keywords

gestational diabetes - patient-reported outcomes - metformin - insulin - pregnancy - diabetes - pharmacotherapy

Supplementary Material



Publication History

Received: 11 September 2023

Accepted: 06 November 2023

Article published online:
04 December 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 Shah NS, Wang MC, Freaney PM. et al. Trends in gestational diabetes at first live birth by race and ethnicity in the US, 2011-2019. JAMA 2021; 326 (07) 660-669
    CrossrefPubMedGoogle Scholar
  • 2 Venkatesh KK, Harrington K, Cameron NA. et al. Trends in gestational diabetes mellitus among nulliparous pregnant individuals with singleton live births in the United States between 2011 to 2019: an age-period-cohort analysis. Am J Obstet Gynecol MFM 2023; 5 (01) 100785
    CrossrefPubMedGoogle Scholar
  • 3 Lowe Jr WL, Scholtens DM, Lowe LP. et al; HAPO Follow-up Study Cooperative Research Group. Association of gestational diabetes with maternal disorders of glucose metabolism and childhood adiposity. JAMA 2018; 320 (10) 1005-1016
    CrossrefPubMedGoogle Scholar
  • 4 Landon MB, Spong CY, Thom E. et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. A multicenter, randomized trial of treatment for mild gestational diabetes. N Engl J Med 2009; 361 (14) 1339-1348
    CrossrefPubMedGoogle Scholar
  • 5 Venkatesh KK, Khan SS, Powe CE. Gestational diabetes and long-term cardiometabolic health. JAMA 2023; 330 (09) 870-871
    CrossrefPubMedGoogle Scholar
  • 6 Venkatesh KK, Lynch CD, Powe CE. et al. Risk of adverse pregnancy outcomes in gestational diabetes by race and ethnicity in the United States, 2014–2020. JAMA 2022; 327 (14) 1356-1367
    CrossrefPubMedGoogle Scholar
  • 7 Balsells M, García-Patterson A, Solà I, Roqué M, Gich I, Corcoy R. Glibenclamide, metformin, and insulin for the treatment of gestational diabetes: a systematic review and meta-analysis. BMJ 2015; 350: h102
    CrossrefPubMedGoogle Scholar
  • 8 Rowan JA, Hague WM, Gao W, Battin MR, Moore MP. MiG Trial Investigators. Metformin versus insulin for the treatment of gestational diabetes. N Engl J Med 2008; 358 (19) 2003-2015
    CrossrefPubMedGoogle Scholar
  • 9 Venkatesh KK, Chiang CW, Castillo WC. et al. Changing patterns in medication prescription for gestational diabetes during a time of guideline change in the USA: a cross-sectional study. BJOG 2022; 129 (03) 473-483
    CrossrefPubMedGoogle Scholar
  • 10 Brown J, Grzeskowiak L, Williamson K, Downie MR, Crowther CA. Insulin for the treatment of women with gestational diabetes. Cochrane Database Syst Rev 2017; 11 (11) CD012037
    PubMedGoogle Scholar
  • 11 Tarry-Adkins JL, Aiken CE, Ozanne SE. Neonatal, infant, and childhood growth following metformin versus insulin treatment for gestational diabetes: a systematic review and meta-analysis. PLoS Med 2019; 16 (08) e1002848
    CrossrefPubMedGoogle Scholar
  • 12 Rowan JA, Rush EC, Plank LD. et al. Metformin in gestational diabetes: the offspring follow-up (MiG TOFU): body composition and metabolic outcomes at 7-9 years of age. BMJ Open Diabetes Res Care 2018; 6 (01) e000456
    CrossrefPubMedGoogle Scholar
  • 13 Venkatesh K, Landon M. Diagnosis and management of gestational diabetes. Contemp Ob Gyn 2021; 66 (05) 9-15
    PubMedGoogle Scholar
  • 14 Society for Maternal-Fetal Medicine. SMFM Statement: pharmacological treatment of gestational diabetes. SMFM Publications Committee. Accessed August 4, 2020 at: https://www.smfm.org/publications/252-smfm-statement-pharmacological-treatment-of-gestational-diabetes
    PubMed
  • 15 American Diabetes Association Professional Practice Committee. 15. Management of diabetes in pregnancy: standards of medical care in diabetes-2022. Diabetes Care 2022; 45 (Suppl. 01) S232-S243
    CrossrefPubMedGoogle Scholar
  • 16 Mullins CD, Abdulhalim AM, Lavallee DC. Continuous patient engagement in comparative effectiveness research. JAMA 2012; 307 (15) 1587-1588
    CrossrefPubMedGoogle Scholar
  • 17 Venkatesh KK, Germann K, Joseph J. et al. Association between social vulnerability and achieving glycemic control among pregnant individuals with pregestational diabetes. Obstet Gynecol 2022; 139 (06) 1051-1060
    CrossrefPubMedGoogle Scholar
  • 18 Kelley K, Clark B, Brown V, Sitzia J. Good practice in the conduct and reporting of survey research. Int J Qual Health Care 2003; 15 (03) 261-266
    CrossrefPubMedGoogle Scholar
  • 19 Shillington AC, Col N, Bailey RA, Jewell MA. Development of a patient decision aid for type 2 diabetes mellitus for patients not achieving glycemic control on metformin alone. Patient Prefer Adherence 2015; 9: 609-617
    CrossrefPubMedGoogle Scholar
  • 20 O'Connor AM. Validation of a decisional conflict scale. Med Decis Making 1995; 15 (01) 25-30
    CrossrefPubMedGoogle Scholar
  • 21 Karagiannis T, Liakos A, Branda ME. et al. Use of the diabetes medication choice decision aid in patients with type 2 diabetes in Greece: a cluster randomised trial. BMJ Open 2016; 6 (11) e012185
    CrossrefPubMedGoogle Scholar
  • 22 Egan AM, Bogdanet D, Griffin TP. et al; INSPIRED research group. A core outcome set for studies of gestational diabetes mellitus prevention and treatment. Diabetologia 2020; 63 (06) 1120-1127
    CrossrefPubMedGoogle Scholar
  • 23 Sullivan GM, Artino Jr AR. Analyzing and interpreting data from Likert-type scales. J Grad Med Educ 2013; 5 (04) 541-542
    CrossrefPubMedGoogle Scholar
  • 24 Pham A, Wiese AD, Spieker AJ. et al. Social vulnerability and initiation of pharmacotherapy for gestational diabetes mellitus in a Medicaid population. Womens Health Issues 2023; 33 (03) 273-279
    CrossrefPubMedGoogle Scholar
  • 25 Harrison RK, Johnson C, Cruz M, Wong A, Davitt C, Palatnik A. Provider-based initiation and management of pharmacologic therapy for gestational diabetes mellitus. J Matern Fetal Neonatal Med 2022; 35 (23) 4478-4484
    CrossrefPubMedGoogle Scholar
  • 26 Barbour LA, Scifres C, Valent AM. et al. A cautionary response to SMFM statement: pharmacological treatment of gestational diabetes. Am J Obstet Gynecol 2018; 219 (04) 367.e1-367.e7
    CrossrefPubMedGoogle Scholar
  • 27 Yu YH, Platt RW, Reynier P, Yu OHY, Filion KB. Use of metformin and insulin among pregnant women with gestation diabetes in the United Kingdom: a population-based cohort study. Diabet Med 2023; 40 (08) e15108
    CrossrefPubMedGoogle Scholar
  • 28 Davitt C, Flynn KE, Harrison RK, Pan A, Palatnik A. Current practices in gestational diabetes mellitus diagnosis and management in the United States: survey of maternal-fetal medicine specialists. Am J Obstet Gynecol 2021; 225 (02) 203-204
    CrossrefPubMedGoogle Scholar
  • 29 Palatnik A, Harrison RK, Thakkar MY, Walker RJ, Egede LE. Correlates of insulin selection as a first-line pharmacological treatment for gestational diabetes. Am J Perinatol 2022; 39 (01) 8-15
    Article in Thieme ConnectPubMedGoogle Scholar
  • 30 Draffin CR, Alderdice FA, McCance DR. et al. Exploring the needs, concerns and knowledge of women diagnosed with gestational diabetes: a qualitative study. Midwifery 2016; 40: 141-147
    CrossrefPubMedGoogle Scholar
  • 31 Bandyopadhyay M, Small R, Davey MA, Oats JJ, Forster DA, Aylward A. Lived experience of gestational diabetes mellitus among immigrant South Asian women in Australia. Aust N Z J Obstet Gynaecol 2011; 51 (04) 360-364
    CrossrefPubMedGoogle Scholar
  • 32 Tarry-Adkins JL, Aiken CE, Ozanne SE. Comparative impact of pharmacological treatments for gestational diabetes on neonatal anthropometry independent of maternal glycaemic control: a systematic review and meta-analysis. PLoS Med 2020; 17 (05) e1003126
    CrossrefPubMedGoogle Scholar