CASP checklist: 10 questions help make sense of Systematic review

Paper: Lights and Shadows on the use of metformin in pregnancy: from the
preconception phase to breastfeeding and beyond. (Tosti et al., 2023)
Section A: Are the results of the review valid?
1. Did the review address a clearly focused question?
(HINT; ‘focused’ in terms of population studied, intervention given, outcome considered)
YES
Women with GDM who were taking metformin as treatment for gestational diabetes. The
inclusion criteria was women fed 18-45years, diagnosis of GDM with a single fetus
between 20-33/40, received lifestyle advice and had more than 1 postprandial blood
glucose measurement of above 120.6 mg/dl.
All studies involved showed preference of metformin treatment than insulin treatment.
2. Did the authors look for the right type of papers?
(HINT; best sort of studies address views question, have appropriate study design (usually
RCTs)).
YES
The aim of this literature is to analyse the main evidence on the use of metformin drug
throughout & beyond pregnancy.
There was RCT studies used with adequate sample sizes. RCTs are known to test the
effectiveness of different treatments, in this case it’s metformin against insulin as a
treatment of gestational diabetes.
3. Do you think all the important, relevant studies were included?
(HINT; look for which bibliographic databases used, follow up from reference lists, personal
contact with experts, unpublished as well as published studies, non-English language studies)
CAN’T TELL
They used a study from the New England Journal of Medicine in 2008, the databases used
have not been displayed. A variety of RCTs have been used.
4. Did reviews authors do enough to assess quality of the included studies?
(HINT; authors consider rigour of studies identified, lack of rigour may affect studies results)
CAN’T TELL
There is no section discussing how each of the studies were reviewed and reduced from an
initial gathering of reviews.
5. If the results of the review have been combined, was it reasonable to do so?
(HINT; consider whether results similar from study to study, results of all included studies are
clearly displayed, results of different studies are similar, reasons for variations in results are
discussed)
YES
The results have not been pooled together as the impact of metformin has been broken down
into separate aspects of the pregnancy journey. However regarding the metformin &
breastfeeding section a recent study found there is an increase in milk production in
participants assigned metformin compared to the placebo group.
It is important to take into account, how not many studies have been used on the
breastfeeding discussion, only 3 have been compared.
Section B: What are the results?
6. What are the overall results of the review?
(HINT; consider if clear about reviews ‘bottom line’ results, what these are, how were results
expressed)
Metformin can increase milk production in women with GDM. This falls in line with a
studies hypothesis of an intervention of targeting insulin action could improve milk
production. Metformin is considered compatible with lactation, with low detection in
breastmilk. The metformin group had metformin dosage which increased every week for 3
weeks, they found maximum milk production improved from the baseline in 60% in women
assigned metformin compared to those who weren’t (20%).
7. How precise are the results?
(HINT; look at confidence intervals, if given)
Confidence intervals have not been given so preciseness of results cannot be considered.
Section C: will the results help locally?
8. Can the results be applied to the local population?
(HINT; consider whether patients covered by review are sufficiently different to population to
cause concern, your local setting is likely differ much from review)
The results Can only be applied to women who have been taking metformin as a form of
treatment for GDM, however they cannot be applied to a general population of all GDM
women, only those on treatment.
9. Were all important outcomes considered?
(HINT; consider whether there’s other information you would have liked to have seen)
The impact of metformin on breastfeeding was considered. However, support for mothers
taking metformin has not been considered in the extended postpartum period. Also, the
impact of metformin on mental health has not been discussed.
 10. Are the benefits worth the benefits & costs?
(HINT; consider even if this is not addressed by the review, what do you think?)
It has allowed for recognition of the benefits of metformin on pregnancy to be discussed,
however the above topics are not discussed so it may limit the quality of results.