Randomised Controlled Trial of Gestational Treatment With Ursodeoxycholic Acid Compared to Metformin to Reduce Effects of Diabetes Mellitus
Phase: PHASE4
Conditions: Gestational Diabetes
Sponsor: King's College London

 
EudraCT Number 2019-002880-82, IRAS Number 1003208 
 
 
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PROTOCOL FULL TITLE: 
Randomised controlled trial of Gestational treatment with 
Ursodeoxycholic Acid compared to Metformin to Reduce 
effects of Diabetes mellitus 
 
 
Protocol Short Title/Acronym: 
GUARD 
 
 
Trial Identifiers  
EudraCT Number – 2019-002880-82 
IRAS Number – 1003208 
REC Number – 20/LO/0504 
ISRCTN –  
NIHR portfolio number – 44480 
EDGE ID - 128219 
  
 
 
 
 
 
 
 
Sponsor 
King’s College London   
Representative: Helen Critchley 
King’s Health Partners Clinical Trial 
Office, 16th Floor, Tower Wing, Guy’s 
Hospital, Great Maze Pond, London SE1 
9RT 
Telephone:  020 7188 5732 
Fax: 020 7188 8330  
helen.critchley@kcl.ac.uk 
 
Co-sponsor 
Guy’s and St Thomas NHS Foundation 
Trust 
Representative: Rachel Fay 
Guy’s and St Thomas NHS Foundation 
Trust R&D Department, 16th Floor Tower 
Wing, Great Maze Pond, London SE1 
9RT 
Telephone: 02071889811 
R&D@gstt.nhs.uk 
 
 

 
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Chief Investigator  
Professor Catherine Williamson 
Professor of Women’s Health 
Division of Women and Children’s Health, King’s College London, London SE1 1UL 
020 7848 6350 / 020 7848 6014 
catherine.williamson@kcl.ac.uk 
           
Name and address of Co-Investigators 
 
Prof Helen Murphy  
Professor of Medicine 
Address: St Thomas’ Hospital, London 
helen.1.murphy@kcl.ac.uk 
 
Dr Caroline Ovadia  
Chadburn Lecturer in Obstetrics and 
Gynaecology 
Address: King’s College London, London 
caroline.ovadia@kcl.ac.uk 
 
Dr Alice Mitchell  
Postdoctoral Research Associate 
Address: King’s College London, London 
alice.mitchell@kcl.ac.uk 
 
Dr Annette Briley  
Consultant Midwife 
Address: St Thomas’ Hospital, London 
annette.l.briley@kcl.ac.uk 
 
Ms Claire Singh 
Research Matron – Women’s 
Services  
Address: St Thomas’ Hospital, 
London 
claire.Singh@gstt.nhs.uk 
 
Dr Peter Dixon  
Research Fellow 
Address: King’s College London, 
London 
peter.dixon@kcl.ac.uk 
 
Prof Kennedy Cruickshank 
Professor of Cardiovascular 
Medicine and Diabetes 
Address: King’s College London 
and Guy’s and St Thomas NHS FT, 
London 
Telephone: 02078484270 
kennedy.cruickshank@kcl.ac.uk 
 
 
Statistician 
Mr Paul Seed 
Address: King’s College London, London 
Email: paul.seed@kcl.ac.uk 
 
Clinical Trial Manager 
Ms Sonia Serrano 
NIHR Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust 
Telephone: 020 7188 7188 ext 53369; Sonia.serrano@gstt.nhs.uk 
 
 

 
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1. Study Synopsis 
 
Title of clinical trial  
 
Randomised controlled trial of Gestational treatment 
with Ursodeoxycholic Acid compared to Metformin to 
Reduce effects of Diabetes mellitus  
Protocol Short Title/Acronym 
  
GUARD 
Trial Phase if not mentioned in 
title 
 
 
Pilot Phase 4 RCT 
Sponsor name 
  
King’s College London & Guy’s and St Thomas’ NHS 
Foundation Trust 
Chief Investigator 
  
Professor Catherine Williamson 
EudraCT number 
   
2019-002880-82 
REC number 
  
31/03/2020 
Medical condition or disease 
under investigation  
Gestational Diabetes Mellitus (GDM) 
Purpose of clinical trial 
  
To compare the impact of treatment with 
ursodeoxycholic acid vs metformin on glycaemic 
control in women with GDM 
Primary objective 
  
To assess the efficacy of UDCA compared to 
metformin to improve glycaemic control in GDM. 
 
Secondary objective (s) 
  
-  To evaluate the impact of the treatments on 
maternal and neonatal lipid metabolism. 
 - To assess the acceptability of UDCA compared to 
metformin to women with GDM. 
- To 
establish 
whether 
continuous glucose 
monitoring 
gives 
more 
informative 
overall 
assessment of maternal glycaemic control in 
overweight or obese pregnant women.  
- To evaluate vascular responses in each arm.  
- To compare maternal and fetal outcomes that 
could relate to treatment with UDCA or metformin. 
Trial Design  
 
 
Two-armed, randomised, controlled, open label 
multicentre clinical trial with optional observational 
mechanistic study in a subgroup from each arm 
PICO  
P – Pregnant women of a BMI ≥25 with GDM 
requiring pharmacological treatment 
I – UDCA 500mg BD 
C – Metformin 1000mg BD 
O – Fasting glucose concentration at 36 weeks 
gestation 
Endpoints 
  
- Maternal fasting glucose concentration at 36 
weeks gestation measured with a blood sample. 

 
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- Quality of Life assessment at baseline and 36 
weeks’, and treatment satisfaction scores at 36 
weeks gestation. 
- Biomedical and clinical maternal outcomes  
- Biomedical and clinical neonatal outcomes at birth   
 
Sample Size 
  
Main study 
158 (79 per group) in the randomised controlled trial 
40 additional participants in the mechanistic sub-
study 
 
Mechanistic sub-study (GUARD MEC) 
80 participants will be enrolled in total in the GUARD 
MEC. Of these, 40 will be GUARD participants: 
- 20 women randomised to metformin 
- 20 women randomised to UDCA 
Additionally, 40 controls will be enrolled into two 
additional arms of the mechanistic studies: 
- 20 women with GDM not requiring 
pharmacotherapy 
- 20 pregnant women without GDM 
Summary of eligibility criteria  
  
1. 
Women between 16 and 45 years of age with 
GDM diagnosed at 26+0 to 30+6 weeks’ gestation in 
accordance with the NICE guidelines (one or more 
glucose concentration of ≥5.6 mmol/l fasting or ≥7.8 
mmol/l 2 hours after a standard 75g OGTT, and 
requiring pharmacological treatment).   
2. 
Overweight or obese (Booking BMI ≥25 
kg/m2)  
3. 
Planned 
antenatal, 
intrapartum 
and 
postpartum care at the participating centre (i.e. not 
planning to move before delivery).   
 
IMP, dosage and route of 
administration 
 
 
UDCA oral 500 mg BD 
 
Active comparator product(s) 
  
Metformin oral 1000 mg BD 
Maximum duration of treatment 
of a participant 
 
 
14 weeks + 3 month follow up 
Version and date of protocol 
amendments   
V 1.0 dated 11th March 2020 
 

 
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2. Glossary of Terms  
 
AE 
Adverse Event  
 
AR 
Adverse Reaction  
BD 
Twice a Day 
BMI 
Body Mass Index 
BP 
Blood Pressure  
 
BRC 
Biomedical Research Centre 
CGM 
Continuous Glucose Monitoring 
CI 
Chief Investigator 
CRA 
Clinical Research Associate 
CS 
Caesarean Section 
CTIMP 
Clinical Trial of an Investigational 
Medicinal Product 
CTM 
Clinical Trial Manager 
CTO 
Clinical Trials Office 
eCRF / CRF 
(Electronic) Case Report Form 
FU  
Follow Up 
GCP 
Good Clinical Practice 
GDM 
 Gestational Diabetes Mellitus 
GSTFT 
Guy’s and St Thomas’ NHS 
Foundation Trust 
HBA1C  
Glycated hemoglobin 
 
HDL 
High Density Lipoprotein  
HDPE 
High-density polyethylene 
ICF 
Informed Consent Form 
ICH 
International Conference on 
Harmonisation  
ICP 
Intrahepatic Cholestasis of 
Pregnancy 
IDMC 
Independent Data Monitoring 
Committee 
IMP 
 Investigational Medicinal Product 
ISF 
Investigator Site File 
ITT 
Intention To Treat 
QOLQ 
Quality of Life Questionnair 
 
KCP 
King’s Health Partners 
KCL 
King’s College London 
LCA 
Lithocholic Acid  
LGA 
Large Gestational Age 
LSCS 
 Lower Segment Caesarian Section 
NICE 
 National Institute for Health and 
Care Excellence 
NICU 
 Neonatal Intensive Care Unit 
NIMP 
Non-Investigational Medicinal 
Product 
OGTT 
 Oral Glucose Tolerance Test 
PI 
Principal Investigator 
PIS 
Patient Information Sheet 
PMU 
 Pharmacy Manufacturing Unit 
PPI 
 Patient and Public Involvement 
PWV 
 Maternal Pulse Wave Velocity 
RCT 
Randomised Controlled Trial 
SAE 
Serious Adverse Event 
SAR 
 Suspected Adverse Reaction 
SMBG 
 Self-Monitoring of Blood Glucose 
SmPC 
 Summary of Product 
Characteristics 
SUSAR 
 Suspected Unexpected Adverse 
Reaction 
SVD 
 Spontaneous Vaginal Delivery 
T2DM 
Type 2 Diabetes Mellitus 
TMF 
Trial Master File 
TSC 
Trial Steering Committee 
UDCA 
 Ursodeoxycholic Acid 
U&E 
Urea & Electrolytes 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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CONTENTS 
1. 
Study Synopsis ....................................................................................................................................... 3 
2. 
Glossary of Terms .................................................................................................................................. 5 
3. Background & Rationale ............................................................................................................................ 8 
3.1 Effectiveness of current treatments .................................................................................................. 8 
3.2 Rationale ........................................................................................................................................... 9 
3.3 Pilot data ..........................................................................................................................................10 
3.4. Rationale for using continuous glucose monitoring (CGM), dietary assessment and vascular 
studies ....................................................................................................................................................11 
3.5 Future work .....................................................................................................................................12 
4. Trial Objectives and Design ......................................................................................................................12 
4.1. Trial Objectives ..............................................................................................................................12 
4.1.1 Primary objective ..........................................................................................................................12 
4.1.2 Secondary objectives (endpoints detailed below in 4.2.2) ............................................................13 
4.2 Trial endpoints .................................................................................................................................13 
4.2.1 Primary endpoint ..........................................................................................................................13 
4.2.2 Secondary endpoints .....................................................................................................................13 
4.3 Trial Design .....................................................................................................................................14 
4.4 Trial Flowchart ................................................................................................................................15 
5. Trial Medication ........................................................................................................................................16 
5.1 Investigational Medicinal Product ...................................................................................................16 
5.1.1 UDCA ...........................................................................................................................................16 
5.1.2 Metformin .....................................................................................................................................16 
5.2 Dosing Regimen ..............................................................................................................................16 
5.3 IMP Risks ........................................................................................................................................17 
5.4 Drug Accountability ........................................................................................................................17 
5.5 Storage of IMP ................................................................................................................................18 
5.6 Participant Compliance....................................................................................................................18 
5.7 Concomitant Medication .................................................................................................................18 
6. Selection and Withdrawal of Participants ..................................................................................................18 
6.1 
Inclusion Criteria .........................................................................................................................18 
6.2 Exclusion Criteria ............................................................................................................................19 
6.3 Selection of Participants ..................................................................................................................19 
6.4 Randomisation Procedure / Code Break ..........................................................................................20 
6.5 Withdrawal of Subjects ...................................................................................................................20 
6.6 Expected Duration of Trial ..............................................................................................................21 
7. 
Trial Procedures.....................................................................................................................................22 
7.1 By Visit ............................................................................................................................................23 
7.1.1 Identification and Informed Consent ............................................................................................23 
7.1.2 Baseline ........................................................................................................................................24 
7.1.3 Follow up 1 ...................................................................................................................................24 
7.1.4 Follow up 2 ...................................................................................................................................25 
7.1.5 Birth and immediate postpartum period .......................................................................................25 
7.1.6 Post birth .......................................................................................................................................26 
7.2 Laboratory Tests ..............................................................................................................................26 
8. Assessment of Efficacy .............................................................................................................................27 
8.1 Primary Efficacy Parameters ...........................................................................................................27 
8.2 Secondary Efficacy Parameters .......................................................................................................27 
8.3 Procedures for Assessing Efficacy Parameters ................................................................................27 
9. Assessment of Safety .................................................................................................................................28 
9.1 Specification, Timing and Recording of Safety Parameters ............................................................28 
9.2 Procedures for Recording and Reporting Adverse Events...............................................................29 
9.2.1 Reporting Responsibilities ............................................................................................................29 
9.2.2 Definition of causality ..................................................................................................................30 
9.2.3 Severity .........................................................................................................................................30 

 
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9.2.4 Expectedness ................................................................................................................................30 
9.2.5 Adverse events that do not require reporting ................................................................................30 
9.3 Treatment Stopping Rules ...............................................................................................................31 
10. Statistics...................................................................................................................................................31 
10.1 Sample Size ...................................................................................................................................32 
10.2 Randomisation ...............................................................................................................................32 
10.3 Analysis .........................................................................................................................................32 
10.4 Procedures for dealing with missing data, unused data and false data52 ........................................33 
11. Trial management and oversight .............................................................................................................33 
11.1 Overview of trial management ......................................................................................................33 
11.2 Trial Management Group ..............................................................................................................34 
11.3 Trial Steering Committee ..............................................................................................................34 
11.4 Independent Data Monitoring Committee .....................................................................................34 
11.5 Patient and Public Involvement .....................................................................................................35 
12. Ethics & Regulatory Approvals ...............................................................................................................35 
12.1 Ethical issues .................................................................................................................................35 
13. Quality Assurance ...................................................................................................................................36 
13.1 Direct Access to Source Data and Documents ..............................................................................36 
13.2 Trial monitoring .............................................................................................................................36 
14. Data Handling ..........................................................................................................................................36 
15. Data Management ....................................................................................................................................37 
16. Publication Policy ....................................................................................................................................38 
17. Insurance / Indemnity ..............................................................................................................................38 
18. Financial Aspects.....................................................................................................................................38 
19. Mechanistic Sub-study: GUARD MEC ...................................................................................................39 
19.1 Objectives ......................................................................................................................................39 
19.2 Exploratory endpoints....................................................................................................................39 
19.3 Design ............................................................................................................................................39 
19.4 Inclusion Exclusion criteria ...........................................................................................................40 
19.5 Recruitment & assessments ...........................................................................................................41 
19.6 Laboratory details ..........................................................................................................................44 
19.7 Reporting of Adverse Events .........................................................................................................44 
20. References ...............................................................................................................................................46 
21. Appendixes ..............................................................................................................................................50 
22. Record of protocol amendments ..............................................................................................................52 
23. Signatures ................................................................................................................................................53 
 
 
 
 

 
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3. Background & Rationale 
 
Each year in the UK approximately 35,000 women develop diabetes during 
pregnancy, a condition called gestational diabetes mellitus (GDM), which increases the 
risk of adverse outcomes for both mother and child1. Complications for the mother include 
increased risk of hypertensive diseases of pregnancy, including preeclampsia2, and higher 
rates of cardiovascular disease and type 2 diabetes mellitus (T2DM) in later life3–5. Aside 
from hyperglycaemia, GDM is further complicated by maternal dyslipidaemia. Specifically, 
triglyceride and free fatty acid concentrations are increased in maternal blood, whilst high 
density lipoprotein (HDL)-cholesterol is reduced6,7. Modern metabolomic studies show 
disturbances of lipid metabolism, particularly intermediary metabolites (e.g. acyl-
carnitines, phospholipids)7,8. Early decline in plasma adiponectin, an indicator of poorer 
mitochondrial oxidation in overweight and obese women, is an almost universal finding in 
GDM pregnancy9. Thus, GDM is a potentially vasculotoxic condition, associated with 
abnormal lipid and glucose metabolism10. 
 
GDM is also associated with accelerated fetal growth and increased risk of being 
large for gestational age (LGA), defined as birth weight above the 90th percentile for sex 
and gestational age1,11. GDM is also complicated by higher rates of preterm birth, 
caesarean section and birth injuries, including shoulder dystocia, which is particularly 
increased with LGA1,2,12. Due to the complications of preterm delivery and LGA, GDM 
offspring are more likely to require admission to neonatal intensive care units for treatment 
of hypoglycaemia, jaundice and respiratory distress11. GDM causes fetal dyslipidaemia, 
with increased free fatty acids and triglycerides in the umbilical cord blood; this is also 
associated with increased risk of LGA13–15. The children of women with GDM have 
increased rates of obesity, childhood cardiovascular disease and T2DM in later life, likely 
related to exposure both to maternal hyperglycaemia and maternal hyperlipidaemia in 
utero16,17. 
 
3.1 Effectiveness of current treatments 
 
In the UK, women with risk factors for GDM have a 75g oral glucose tolerance test 
(OGTT) at 24-28 weeks’ gestation. Those that test positive (fasting glucose concentration 
≥5.6 and/or 2-hr ≥7.8mmol/L) start self-monitoring of blood glucose (SMBG) and are given 
dietary and lifestyle advice. If unable to achieve the National Institute for Health and Care 
Excellence (NICE) recommended glucose control targets (fasting glucose <5.3, 1hr 
<7.8mmol/L and/or 2hr <6.7mmol/L), they are prescribed either pharmacological oral 
glucose lowering medications, e.g. metformin/glibenclamide, or subcutaneous insulin 
injections. Metformin is the most commonly used first line pharmacological treatment. 
However, there is increasing concern about its widespread use during pregnancy, both 
because of its limited efficacy and because of potential safety concerns. Metformin 
crosses the placenta, has growth inhibitory properties and suppresses mitochondrial 
respiration which could theoretically adversely affect the developing fetus18,19. The 
Metformin in Gestational Diabetes (MiG) trial demonstrated that mothers randomised to 
metformin, compared to insulin, had reduced maternal weight gain and gestational 
hypertension20. However, the rate of LGA was not affected and the offspring had more 
subcutaneous fat at 2 years of age21. A study of maternal metformin treatment for women 

 
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with polycystic ovary syndrome also did not show an impact on LGA, and the offspring 
were heavier at 1 year of age22. Thus, the current data have raised concerns that 
metformin, currently used by many women with GDM, does not adequately prevent 
adverse outcomes such as LGA, and may have negative long-term effects on the 
metabolic health of the children23,24. This may be, at least in part, because metformin has 
less effect on serum triglyceride concentrations than insulin20. It is noteworthy that in the 
MiG trial, metformin alone was inadequate for achieving glycaemic targets in 
approximately 50% of women, necessitating supplementary treatment with insulin20. 
Indeed, even insulin treatment (the “gold standard” pharmacological approach) was not 
shown to be of definitive benefit for GDM offspring in the most recent Cochrane review, 
and was thought to possibly increase the risk of raised blood pressure compared to oral 
treatments25. Glibenclamide is the other oral hypoglycaemic agent used to treat GDM. It 
has not been shown to be superior to insulin treatment used in randomised trials26, or as 
an add-on therapy to metformin27. Therefore, there is an urgent unmet need for additional 
therapies that improve maternal-fetal glucose and lipid metabolism, and the longer-term 
health outcomes of GDM exposed offspring. 
 
Ursodeoxycholic acid (UDCA) is currently not an established/licensed treatment for 
GDM. However, a meta-analysis that included data from 7 trials that reported the impact 
of UDCA on glycaemic markers showed that it improved fasting glucose, insulin and 
HbA1c concentrations55. Furthermore, our pilot data from studies of UDCA treatment of 
women with intrahepatic cholestasis of pregnancy have demonstrated improved insulin 
resistance, indicating that it has the potential to be an effective treatment to improve 
glycaemic control in GDM (see Appendix 2 for more details). UDCA is commonly used in 
pregnancy for the treatment of ICP, and a recent randomised, placebo-controlled trial did 
not show any increase in adverse events, including gastrointestinal symptoms, in women 
treated with UDCA compared to placebo56. Our pilot data also show that UDCA improves 
fetal serum lipid parameters (see Appendix 2), so it may be more effective than metformin 
at reduction of the frequency of large for gestational age infants in GDM.  
 
  
3.2 Rationale 
 
Our trial will compare the impact of treatment with ursodeoxycholic acid (UDCA) -a 
drug with pilot data to support its effectiveness to treat GDM- to metformin on glycaemic 
control (primary outcome) in women with GDM (see Appendix 1). We will evaluate 
maternal and fetal lipid and glucose metabolism, and maternal vascular outcomes, using 
biochemical and imaging assays and simple arterial measures. Neonatal health outcomes 
will also be studied, including the proportion of LGA offspring. Table 1 summarises the 
mechanisms by which UDCA and metformin influence glucose and lipid metabolism.  
 
Table 1. Proposed mechanisms of action of UDCA and metformin in GDM  
  
 
UDCA 
Metform
in 
Inhibition of the mitochondrial respiratory chain complex 1; leads to 
activation of hepatic AMPK, reducing SRBEP1c which controls glucose-
stimulated genes associated with lipid, glucose and protein formation, and 
stimulates fatty acid oxidation and glucose uptake  
X 
✓ 

 
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Activation of hepatic FXR, reducing SRBEP1c which controls glucose-
stimulated genes associated with lipid, glucose and protein formation, and 
stimulates fatty acid oxidation and glucose uptake  
✓ 
X 
Brown adipose tissue activation of AMPK, breakdown of VLDL-TG, 
mitochondrial content  
X 
✓ 
Brown adipose tissue signalling via TGR5 to increase energy expenditure 
by increasing UCP1  
✓ 
X 
Increased skeletal muscle insulin sensitivity and insulin-mediated glucose 
uptake   
X 
✓ 
GLP-1 receptor increase and reduced GLP-1* breakdown  
X 
✓ 
GLP-1* release increase  
✓ 
X 
Reduction of endoplasmic reticulum stress in obese individuals, reducing 
insulin resistance  
✓ 
X 
* Glucagon-like peptide 1 (GLP-1) is thought responsible for 70% of the insulin release following meals, and 
levels are lower in GDM than unaffected pregnancies28  
 
There is increasing evidence that the gut microbiota plays a role in maternal glucose 
and lipid metabolism. When faeces from pregnant women were transplanted into germ-
free mice there were phenotypic differences in mice receiving faeces from women in the 
3rd vs 1st trimester of pregnancy. The 3rd trimester faeces had a greater abundance of the 
pro-inflammatory Proteobacteria and Actinobacteria and the recipients had more weight 
gain and insulin resistance29. Women with GDM also have alterations in the gut microbiota. 
At the time of diagnosis, there is enrichment with a number of microbes, e.g. Desulfovibrio, 
the prevalence of which is also higher in T2DM30. Similar changes in the composition of 
the gut microbiota occur in women who are overweight in pregnancy31. Studies of the gut 
microbiota in T2DM have reported reductions in butyrate-producing bacteria in untreated 
compared to metformin-treated patients32. Butyrate is a metabolically-active short chain 
fatty acid (SCFA), increased levels of which are associated with improved glucose 
control33.   
 
We propose that UDCA is a new potential treatment for GDM. UDCA alters gut 
metabolites (via microbial modification of the drug). We hypothesise that this will result in 
increased release of gut hormones (GLP-1 and FGF19) that improve maternal/fetal blood 
concentrations of lipids, e.g. triglycerides, glycaemic control and reduce rates of obstetric 
and neonatal complications. We have pilot data to support this hypothesis from studies of 
women with intrahepatic cholestasis of pregnancy (ICP) treated with UDCA.   
 
3.3 Pilot data 
 
UDCA treatment improves HOMA-IR and GLP-1 secretion in the mother in women 
with ICP  
 
Women with ICP have increased rates of GDM (odds ratio 2.81, 95% CI 2.32-3.41)34. 
Using continuous glucose monitoring, we demonstrated ICP-associated elevations in 
prandial glucose concentrations, abnormal glucose tolerance and reduced secretion of the 
gut hormone glucagon-like peptide-1 (GLP-1)35, which acts to enhance glucose-mediated 
insulin secretion36. We have shown improvement in GLP-1 in women with ICP treated with 

 
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UDCA35. Of note, GLP-1 is thought responsible for 70% of the insulin release following 
meals, and levels are lower in GDM than unaffected pregnancies28. 
 
Research to support study of the gut microbiome 
To understand the mechanism of action of UDCA treatment in ICP, we have 
performed a pilot study of faecal gut microbiota and bile acid profiles see Appendix 1.  
 
 
UDCA treatment improves ICP-associated maternal and fetal dyslipidaemia   
 
Women with ICP have dyslipidaemia in addition to increased susceptibility to ICP-
associated GDM. This is characterised by elevated serum concentrations of total 
cholesterol and low density lipoprotein (LDL)-cholesterol. Our pilot data show 
improvement in maternal total cholesterol and LDL-cholesterol following UDCA treatment 
(see Appendix 2) 
 
A recent study of UDCA treatment of 20 people with T2DM and hepatic impairment 
showed reduced weight and HbA1c (glycosylated haemoglobin) after treatment for 12 
weeks (a similar duration to that proposed for this study)38. Furthermore, a recently 
published meta-analysis in people with non-alcoholic fatty liver disease (a disorder that is 
commonly associated with T2DM, previous GDM)39,40 reported that UDCA treatment was 
associated with significant reduction in fasting glucose, HbA1c and plasma insulin 
concentration. UDCA is therefore a biologically plausible treatment but has not yet been 
evaluated in GDM. We believe it is important and timely to evaluate the impact of 
UDCA on maternal and fetal outcomes in GDM.  
 
Dose rationale 
 
The dose of UDCA taken by most women with ICP is 500mg BD, including those 
from whom the pilot data in Appendix 2 were obtained. Similarly, the recent PITCHES trial 
that compared UDCA to placebo treatment for ICP proposed a starting dose of 500mg BD 
that could be increased to a maximum of 2g daily56. There was no increase in adverse 
outcomes in women treated with UDCA compared to those that received placebo. The 
reason for increasing the dose in women with ICP is typically due to severity of the 
symptom of pruritus or worsening liver function tests. There is no evidence that an increase 
of UDCA dose will improve glycaemic control more than treatment with 500mg BD, and 
therefore we propose to only use a UDCA dose of 500mg BD for the GUARD Trial. This 
does not need to be increased as the lower dose was sufficient to have an impact on 
maternal insulin sensitivity and serum lipids.  
 
 
3.4. Rationale for using continuous glucose monitoring (CGM), dietary 
assessment and vascular studies 
 
CGM will be used in this trial alongside conventional capillary glucose monitoring to 
compare the impact of UDCA and metformin on maternal glycaemic control. CGM 
measures interstitial glucose concentration every five minutes through a sensor that is 
placed subcutaneously. With 288 glucose measurements/day, CGM provides detailed 
glucose information about overnight and post-prandial glucoses, providing direct insight 
into foetal exposure to maternal glycaemia41. A recent large international consensus paper 

 
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highlighted CGM as a robust research tool and emphasised the accuracy of contemporary 
sensors, the detailed information they provide and non-invasive nature compared to 
frequent capillary glucose monitoring42.  
 
There is evidence that the diet composition of pregnant women influences their 
susceptibility to GDM57. Therefore women will be asked to complete a 4 day dietary 
assessment at 36 weeks’ gestation. This will enable evaluation of diet composition and 
whether this could influence treatment response. The diet will also affect the gut 
microbiota, so the 4 day diet questionnaire will be completed by all participants in the 
GUARD MEC study. 
 
For vascular studies we will use a calibrated cuff-based blood pressure instrument, 
the Arteriograph, as recently used in a maternal hypertension trial46. We include vascular 
health as a secondary outcome of the proposed trial because arterial function measures 
are more powerful than, and independent of, standard blood pressure for later prognosis47–
49. The arteriograph works by a minor supra-systolic inflation so that the cuff senses the 
waveform from each heartbeat for 4-6 beats, thereby providing both a BP measure and 
for arterial stiffening through sensing the waveforms. It has a British Hypertension Society 
(BHS) A/A grading for its BP measurement. 
3.5 Future work 
 
If we generate convincing evidence that UDCA improves maternal glycaemic control 
we intend to apply for funds to perform a large multicentre trial where we can personalise 
decisions about which women will respond to UDCA to improve maternal and baby 
outcomes.   
 
Many women with GDM are susceptible to T2DM, a condition with a higher rate of 
the adverse outcomes associated with GDM and also increased risk of stillbirth. The 
underlying pathology is similar in many cases. At present not all women of reproductive 
age are aware that they have T2DM and some are only diagnosed in early pregnancy. If 
UDCA is effective in GDM, we will also apply to study UDCA as a potential therapy for 
treatment of women with established T2DM in pregnancy.   
 
The children of women with GDM have increased rates of obesity, diabetes and 
cardiovascular disease in later life. If UDCA improves fetal metabolic parameters, e.g. 
umbilical cord blood LDL-cholesterol, triglycerides or free fatty acids, we also intend apply 
for future funds to evaluate offspring metabolic health as the drug may not only improve 
perinatal outcomes but also the future health of the children that were treated in utero.  
 
 
4. Trial Objectives and Design  
4.1. Trial Objectives 
4.1.1 Primary objective 
To assess the efficacy of UDCA compared to metformin to improve glycaemic control in 
GDM. 

 
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4.1.2 Secondary objectives (endpoints detailed below in 4.2.2) 
-  To evaluate the impact of the treatments on maternal and neonatal lipid metabolism. 
 
 - To assess the acceptability of UDCA compared to metformin to women with GDM. 
 
- To establish whether continuous glucose monitoring gives more informative overall 
assessment of maternal glycaemic control in overweight or obese pregnant women,  
 
- To evaluate vascular responses in each arm (optional element).  
 
- To compare maternal and fetal outcomes that could relate to treatment with UDCA or 
metformin. 
 
For objectives of the GUARD MEC sub-study please see section 19. Mechanistic Sub-
study: GUARD MEC. 
 
4.2 Trial endpoints 
4.2.1 Primary endpoint 
 
Maternal fasting glucose concentration at 36 weeks’ gestation measured with a blood 
sample. 
 
 
4.2.2 Secondary endpoints 
 
- Quality of Life assessment (EQ-5D-5L) at baseline and 36 weeks, and treatment 
satisfaction scores at 36 weeks.  
 
- Biomedical and clinical maternal outcomes:   
1. Glucose metabolism at baseline, Follow up 1 and 2 assessed by:  
a) Continuous glucose monitoring (CGM) to assess glycaemic control. This will 
determine the percentage time spent within target (glucose levels 3.5-
7.8mmol/L), percentage time spent above target (>7.8mmol/l and ≥6.7mmol/l), 
time spent below target (≤3.5 and ≤3.0 mmol/l), measures of glucose variability 
including glucose standard variation (SD), co-efficient of variation (CV), 
frequency and duration of glycaemic excursions measured by the area under the 
curve (AUC) for the pre-specified glucose thresholds.   
b) Serum concentrations of 1,5-anhydroglucitol; a novel marker of short-term 
glycaemia 4,43  
c) HbA1c concentration; a conventional marker of medium-term glycaemia (except 
at Follow up 1) 
2. Lipid metabolism at Follow up 2 assessed by blood triglyceride, total cholesterol, 
calculated LDL-cholesterol, HDL-cholesterol and free fatty acid concentrations  

 
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3. Biochemical analysis of maternal blood for liver function tests at Follow up 2  (ALT, 
bilirubin, ALP), bile acids, C reactive protein (including highly sensitive analyses)   
4. Proportion of women requiring insulin treatment (time until treatment and total dose 
of insulin required) 
5. Maternal gestational weight change at 36 weeks compared to weight at first 
trimester screening visit.  
6. Measurement of vascular responses at Follow up 1 and 2, including: i) maternal 
pulse wave velocity (PWV), with systolic and diastolic blood pressure, ii) central 
arterial pressure (cP), and iii) augmentation index (AIx) 
7. Estimated blood loss at time of delivery. 
 
- Biomedical and clinical neonatal outcomes at birth:   
1. Mode of birth (rates of caesarean section (CS), (elective & emergency), assisted 
vaginal birth and spontaneous vaginal delivery (SVD))  
2. Gestational age at birth 
3. Apgar scores @ 5 minutes post birth 
4. Occurrence of shoulder dystocia 
5. Cord blood C-peptide, triglyceride, total cholesterol, calculated LDL-cholesterol, 
HDL-cholesterol and free fatty acid concentrations  
6. Infant birth weight (customised birth weight percentile51, proportion of  babies born 
large for gestational age (LGA), proportion of babies born small for gestational age 
(SGA)   
7. Neonatal morbidity (treatment for neonatal hypoglycaemia, neonatal jaundice, 
respiratory distress or birth trauma)  
8. Neonatal intensive care and special care unit admission (duration of hospital stay)  
9. Stillbirth and neonatal death 
 
For endpoints of the GUARD MEC sub-study please see section 19. Mechanistic Sub-
study: GUARD MEC. 
 
4.3 Trial Design  
 
GUARD is a pilot phase IV two-armed, open label, multi-centre randomised, 
controlled trial, designed to discover possible new uses for UDCA, a drug commonly used 
in pregnancy for other conditions.  
 
158 overweight or obese women with a clinical diagnosis of GDM that requires 
management with pharmacological intervention will be recruited and randomised to one of 
two trial interventions in the UK. 
 
 
 

 
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4.4 Trial Flowchart 
 
 

 
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5. Trial Medication 
5.1 Investigational Medicinal Product 
 
The Pharmacy Manufacturing Unit, Guy’s and St Thomas’ NHS Foundation Trust 
(GSTFT PMU) Pharmaceuticals are licensed to support clinical trials under an MIA (IMP) 
licence granted by the MHRA license. They have a long standing history of servicing the 
clinical trials market, and are specialised in the manufacture, storage and distribution for 
trials. GSTFT PMU will supply, re-package, label and distribute both IMPs for this clinical 
trial. Analytical testing, Annex 13 compliant labelling, and temperature controlled and 
monitored storage and shipment will be implemented. 
 
5.1.1 UDCA 
 
Ursodeoxycholic acid 500mg film-coated tablets (Ursofalk®, Dr Falk) will be packed 
into packs of 28 tables (2 weeks’ supply) in a high-density polyethylene (HDPE) container 
with child-resistant, tamper evident closure. 
 
5.1.2 Metformin 
 
Metformin 500 mg tablets (Medley) will be packed into packs of 56 tablets (2 weeks’ 
supply) in an HDPE container with child-resistant, tamper-evident closure with integrated 
silica gel desiccant tablets. 
 
The investigator should ensure that the participant has sufficient tables of the 
allocated treatment to last until the following scheduled appointment. Patients will return 
unused doses at the final visit.  
 
5.2 Dosing Regimen 
 
Starting treatment for UDCA is 500 mg twice a day (BD) orally with the morning and 
evening meals.  
 
Metformin will be started following a dose escalation scheme to minimise side effects, 
until a dose of 1000 mg BD is reached:  
- Days 1 & 2: 500 mg with evening meal 
- Days 3 & 4: 500 mg with breakfast and 500 mg with evening meal 
- Days 5 & 6: 500 mg with breakfast and 1000 mg with evening meal 
- Day 7 and remaining: 1000 mg with breakfast and 1000 mg with evening meal 
 
In both cohorts, participants will take the first dose within 2 days of the baseline visit, 
and will continue self-administration at home, while they undergo regular glucose control 
checks in line with current clinical practice.  
 
The glucose control targets will follow NICE pregnancy guidelines (i.e. aiming to 
maintain all capillary glucose levels between 3.9-7.8mmol/l). The specific pre- and post-meal 

 
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SMBG targets are ≤5.3mmol/L before breakfast, ≤7.8mmol/L 1-hr post meal and ≤6.7mmol/L 
2-hr post meal. All participants will be given education regarding diet and lifestyle as part of 
their standard clinical care pathway. Insulin may be added as a rescue medication if oral 
treatment does not control blood glucose levels, in accordance with standard antenatal 
clinical practice. Insulin will constitute a non-investigational medicinal product (nIMP). Also 
following clinical practice, doses could be reduced or temporarily discontinued if deemed 
appropriate by the patient’s clinician.    
 
Compliance will be checked with study participants at follow up visits by reviewing 
diary cards.  
 
Last dose will be taken at the time of delivery, as per clinician instructions. 
  
 
5.3 IMP Risks  
 
For a list of up-to-date risks, latest Summary of Product Characteristics (SmPC) should 
be consulted. None of the two IMP are licensed for use in pregnancy, therefore this data is 
not based in pregnancy data. 
 
Frequency of occurrence is defined as follows: very common: 1/10; common>1/100, 
<1/10; uncommon>1/1,000, <1/100; rare>1/10,000, <1/1,000; very rare<1/10,000, not 
known. 
 
Metformin: The most common adverse reactions are nausea, vomiting, diarrhoea, 
abdominal pain, loss of appetite (very common) and taste disturbance (common), which 
usually resolve spontaneously. To prevent these a gradual dose increase is used. Very rare 
effects are skin reactions, lactic acidosis and liver function tests abnormalities or hepatitis. 
 
UDCA: Pasty stools or diarrhoea are common adverse reactions. Nausea, vomiting 
and pruritus might be effects but the frequency is unknown. Very rare effects are: 
calcification of gallstones and urticaria.  
 
Should the research team have concerns about any new symptoms when taking the 
IMP, they will act on it as per clinical standard, which might need consulting with the 
investigator. 
 
5.4 Drug Accountability 
 
The Co-Sponsors will arrange transfer of active IMP from GSTFT PMU to the 
participating sites’ pharmacies. The Principal Investigator will then take responsibility for IMP 
accountability by ensuring that: the IMP is stored in a secure location, segregated from other 
medicines, used and returned medication is kept separate from unused medication, storage 
conditions are monitored and recorded, IMP is dispensed to participants in accordance with 
the trial protocol and any randomization list, and unused medication is returned to the study 
team or destroyed if requested by the sponsor. Full accountability records will be kept for all 

 
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aspects of IMP handling in pharmacy. IMP accountability records will be monitored by the 
Clinical Research Associate (CRA).  
 
5.5 Storage of IMP 
 
Both IMPs will be stored by pharmacy, kept at 15-25oC and dispensed after each study 
visit. Temperatures will be monitored within the pharmacy departments but this data will not 
be collected.  
 
5.6 Participant Compliance 
 
Participant attendance and compliance will be recorded for all visits.  
Women will receive a diary card to record taken/not taken doses. Drug accountability 
will be conducted at each study visit by asking patients if they missed any doses and 
reviewing the diary card. If discrepancies are identified, this should be discussed with the 
participant. Any reported missed doses will be recorded in the eCRF.  
 
5.7 Concomitant Medication 
 
A complete listing of all concomitant medication received from baseline to birth or 
study discontinuation must be recorded in the medical notes and eCRF, with the exception 
of standard medications given during labour. 
 
Avoidance of the following concomitant medications is recommended: 
- Metformin: Trimethoprim and vancomycin, which could theoretically cause acidosis 
- Ursodeoxycholic acid should not be administered concomitantly with charcoal, 
colestyramine, colestipol or antacids containing aluminium hydroxide and/or smectite 
(aluminium oxide), because these preparations bind ursodeoxycholic acid in the intestine 
and thereby inhibit its absorption and efficacy 
 
Each drug’s SmPC should be reviewed for current information about management of 
concomitant medications.  
 
6. Selection and Withdrawal of Participants  
6.1 Inclusion Criteria  
 
1. Women between 16 and 45 years of age with GDM diagnosed at 26+0 to 30+6 weeks’ 
gestation in accordance with the NICE guidelines (one or more glucose concentrations 
of ≥5.6 mmol/l fasting or ≥7.8 mmol/l 2 hours after a standard 75g OGTT, and requiring 
pharmacological treatment).  

 
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2. Overweight or obese (Booking BMI ≥25 kg/m2)  
3. Planned antenatal, intrapartum and postpartum care at the participating centre (i.e. 
not planning to move before delivery).   
 
6.2 Exclusion Criteria  
 
1. Unwilling/unable to give written informed consent and comply with the requirements 
of the study protocol 
2. Multiple pregnancies (twins, triplets etc) in current pregnancy 
3. Congenital anomaly on ultrasound requiring fetal medicine input 
4. Previous diagnosis of diabetes outside pregnancy   
5. HbA1c at booking >48 mmol/mol or ≥6.5% during current pregnancy (if available)  
6. Significant pre-pregnancy comorbidities that increase risk in pregnancy, for example 
renal failure, severe liver disease, transplantation, cardiac failure, psychiatric 
conditions requiring in-patient admission (within previous year) in the opinion of the 
responsible clinician or the CI.  
7. Significant co-morbidity in the current pregnancy, nephropathy (estimated GFR 
<60ml/min), other physical or psychological conditions likely to interfere with the 
conduct of the study and/or interpretation of the trial results in the opinion of the 
responsible clinician or the CI.  
8. Not fluent in English and absence of interpreter or translation services (ie telephone 
translation services)  
9. Participating in another intervention study where the results could influence GDM-
related endpoints, in the opinion of the responsible clinician or the CI, or participation 
in a CTIMP during current pregnancy. 
10. Known allergy/hypersensitivity/intolerance to the active substance or excipients, or 
patients taking any medications which are contraindicated as per IMP SmPC (as per 
Section 5.7). 
 
The Inclusion/Exclusion for the sub-study GUARD MEC will be specified in section 19. 
Mechanistic Sub-study: GUARD MEC. 
 
6.3 Selection of Participants  
 
Women will be selected from the antenatal diabetes clinics at participating hospitals 
with specialist obstetric/diabetes multidisciplinary teams, expert in the management of GDM.   
Women with a clinical diagnosis of GDM who require pharmacological intervention will 
be asked to provide written informed consent, recruited and randomised to one of the two 
trial interventions.  

 
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Women recruited into GUARD will subsequently be offered the opportunity to 
participate in the GUARD MEC sub study. Women with a clinical diagnosis of GDM who do 
not require medication to control the condition, and pregnant women without GDM, will be 
invited to participate in the GUARD MEC only.   
 
6.4 Randomisation Procedure / Code Break 
 
Allocation of treatment arm will be randomised by secure computerised web-based 
programme, provided by MedSciNetLtd. The groups will be minimised by; 
* BMI category (25-29.9, 30-34.9, ≥35),  
* Previous history of GDM,  
* Disease severity (baseline fasting glucose <6.2 or ≥6.2), 
* Centre  
 
Regular checks during the recruitment phase will be carried out to confirm that the 
minimisation procedure has been applied correctly. 
Once a participant has provided informed written consent, baseline details will be 
entered into the eCRF. As soon as eligibility has been confirmed, treatment allocation will 
be assigned via the database, and the study ID created. All parties will be aware of the 
participants’ allocation. The pharmacy department will be informed so they can supply the 
appropriate IMP for the participant.   
Emergency code breaking is not required as the treatment is open label.  
 
6.5 Withdrawal of Subjects  
 
Participants have the right to withdraw from the study at any time for any reason.  The 
investigator also has the right to withdraw patients from the study drug in the event of inter-
current illness, AEs, SAE’s, SUSAR’s, protocol violations, cure, administrative reasons or 
other reasons.  It is understood by all concerned that an excessive rate of withdrawals can 
render the study un-interpretable; therefore, unnecessary withdrawal of patients should be 
avoided. Should a patient decide to withdraw from the study, all efforts will be made to report 
the reason for withdrawal as thoroughly as possible. 
 
Should a patient withdraw from study drug only (and not from trial participation), efforts 
will be made to continue to obtain follow-up data, with the permission of the patient. 
Participants who withdraw from trial medication will be asked to confirm whether they are 
still willing to provide: i) trial specific data, including samples at delivery, ii) data collected as 
per routine clinical practice. 
 
In case of withdrawn participants, they will be asked to return all unused IMP to the 
study team.  
 

 
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Patients can withdraw from GUARD MEC and still continue participating in GUARD 
study.  
 
6.6 Expected Duration of Trial 
 
It is expected that each participant will be in the treatment period for a maximum of 
approximately 14 weeks, with an additional data point collected 3 months post birth from the 
local GP (the result of the HbA1c sample only). Participants will be asked for permission to 
be contacted in the future for follow up of their offspring. Methods of, ‘keep in touch’ such as 
Christmas cards, newsletters etc, will be used to keep participants engaged after their 
participation is completed. Any follow up procedures will have all appropriate regulatory 
approvals in place.   
 
The end of the trial will be defined as database lock, once all recruits have completed 
all the study related visits, and the data has been entered in the eCRF and cleaned.  
 
 

 
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7. Trial Procedures  
 
Visit name & approximate 
pregnancy week  
Participant 
identificatio
n 
Baseline 
Follow up  
1 
Follow up 
2 
Birth 
Post-birth 
26+0-30+6 
27+0-31+6 
a 
32+0 ± 1 b 
36+0 ± 1 b 
 
3 month 
post birthc 
Patient information * 
X h 
 
 
 
 
 
Informed consent * 
 
X 
 
 
 
 
Inclusion / exclusion criteria* 
 
X 
 
 
 
 
Demographics * 
 
X 
 
 
 
 
Medical and obstetric 
personal and family history * 
 
X 
 
 
 
 
Adverse events* 
 
X 
X 
X 
X n 
 
Concomitant medication * 
 
X 
X 
X 
X o 
 
Weight * 
 
X 
X 
X 
 
 
Blood pressure and pulse d 
 
X  
X 
X 
 
 
Fasted glucose 
X u 
 
 
X 
 
 
HbA1c 
X i 
X j 
 
X 
 
X t 
Liver function tests, bile 
acids and high sensitivity C-
reactive protein, U&E 
 
X 
 
X 
 
 
Fasting lipid profile 
 
 
 
X 
 
 
1,5-Anhydroglucitol and non-
fasting metabolic hormonese 
 
X 
X 
 
 
 
1,5-Anhydroglucitol and 
fasting free fatty acids & 
metabolic hormones e 
 
 
 
X 
 
 
Optional faecal sample e * 
 
 
 
X k 
 
 
Optional GUARD MEC 
Blood samples after a 
breakfast e * 
 
 
 
X l 
 
 
Cord blood samples e 
 
 
 
 
X 
 
Meconium collection e 
 
 
 
 
X 
 
Randomisation 
 
X 
 
 
 
 
IMP dispensing 
 
X 
X 
X 
 
 
IMP administration 
 
X (continuously) 
 
Dispense diary card 
 
X 
 
 
 
 
Drug diary review  
 
 
X 
X 
X 
 
Continuous Glucose 
Monitoring f * 
 
X  
X 
X 
 
 
Download CGM data * 
 
 
X 
X 
X 
 
Optional vascular studies g * 
 
X  
X 
X 
 
 
Quality of life questionnaires 
(EQ-5D-5L)  
 
X 
 
X 
 
 
Treatment satisfaction 
questionnaires (DTSQs) 
 
 
 
X 
 
 
4-day food diary * 
 
 
m 
X m 
 
 
Labour and birth data * 
 
 
 
 
X p 
 
Neonatal anthropometry * 
 
 
 
 
X q r 
 
Neonatal data * 
 
 
 
 
X r s  
 
 
* - assessments applicable to patients in GUARD MEC, to be done during the GUARD MEC study visit.  
a - If participants are recruited earlier or later than expected, follow up visits will be adjusted according to 
clinical pathways and to ensure the participant has been receiving IMP for at least 2 weeks. 
b - Women must fast for at least 3 hours 
c - To occur at local GP practice approximately 3 months post-delivery (as per standard of care). 
d - Blood pressure in triplicate and pulse only for woman who don’t consent to the vascular studies. Use non-
dominant arm. 

 
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e - Research samples, for storage.  
f - CGM will be in place for 10 days after each study visit. Women to be trained to remove the device 
themselves. 
g - Vascular studies: blood pressure pulse wave velocity, central arterial pressure, augmentation index. 
h - PIS to be given after OGTT appointment. 
i - Pre-enrolment HbA1c and glucose: samples analysed within 3 weeks before baseline can be used. If no 
results are available, an HbA1c sample must be collected at baseline. 
j - Only collect if no previous results within 3 weeks are available  
k - Faecal samples are optional and should be produced at approximately 36 weeks. If the woman is unable to 
give a faecal sample on the day, a stool sample collection kit may be provided and the sample collected by 
courier from the participant’s home. 
l – Optional GUARD MEC: a hospital standardised breakfast will be provided. Four blood samples will be taken 
at the following timepoints: before breakfast, 15 minutes, 1 hour and 2 hours postprandially.  
m - Food diaries should be given to patients at FU 1 to be completed the 4 days prior to FU 2. This should 
occur prior to providing a faecal sample (if applicable). 
n - Adverse event data will be collected at each visit from baseline to discharge from hospital of mother and 
infant.  
o - Standard of care concomitant medication given at labour do not need to be recorded.  
p - Labour and birth data: onset of labour, genital tract trauma, post-partum haemorrhage, mode of birth, 
gestational age at delivery, NICU admission, morbidity, feeding at discharge. 
q - Neonatal anthropometry: birth weight and the following measurements in triplicate: 
 
With blank tapes (then checked measured these with a steel rule): head circumference, chest 
circumference, abdominal circumference, midarm circumference  
 
Skinfold thicknesses in triplicate: subscapular and triceps 
 
Crown rump length, crown foot length 
r - Neonatal assessments will be performed on the day of delivery, or as soon as feasible.   
s - Apgar scores: 5 min post-birth 
t - HbA1c samples will be drawn at the local GP and samples requested where clinically available  
u – Fasted and 2 hours post prandial glucose taken from the OGTT appointment 
 
7.1 By Visit 
7.1.1 Identification and Informed Consent 
 
Women who test positive at their routine OGTT visit (usually at 26-28 weeks’ 
gestation) will be provided with the main study and sub-study PIS/ICF by a member of the 
clinical research team, altogether with an explanation of the trial. At 28-30 weeks patients 
will be reviewed as per standard of care, and those formally diagnosed with GDM who 
require pharmacological treatment will be offered the opportunity to participate in the main 
study and the optional sub-study.   
 
Patients without GDM, or those whose glucose is well controlled by diet and hence 
not requiring pharmacological treatment are not eligible to participate in the main study. 
These patients will be given the opportunity to participate in the sub-study GUARD MEC as 
controls (see more details in GUARD MEC section 19.5 Recruitment & assessments).   
 
The trial will be explained in detail by trained and delegated clinical or research staff, 
as per local procedure. Should the patient agree to participate to any part of the research, a 
copy of the ICF will be signed by the patient and the investigator at that visit (or delegated 
member according to local standard practice), and a copy given to the patient. A copy will 
be uploaded into the woman’s electronic maternity records or filed in the patient medical 
records. The investigator’s original will be filed in the ISF.  
 

 
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7.1.2 Baseline 
 
Following informed consent, screening procedures will begin to assess patient’s 
eligibility. The following assessments will take place: 
- Demographic (including post-code, which is not stored in the eCRF), family, medical 
and obstetric data will be collected (including data from OGTT appointment) 
- Concomitant medication 
- Adverse event data 
- Inclusion/exclusion assessment 
- Weight (height to be obtained from medical records) 
- Blood sample for in-hospital analysis: LFT, total bile acids, U&E and high sensitivity 
C-reactive protein 
- HbA1c (if none available within the last 3 weeks) 
- Plasma sample to be stored for 1,5 anhydroglucitol and metabolic hormones 
- Continuous Glucose Monitoring implementation and education  
- Optional Vascular studies: blood pressure pulse wave velocity, central arterial 
pressure, augmentation index. 
- Blood pressure and pulse (if not consented for the vascular studies) 
- Quality of life questionnaire (EQ-5D-5L) 
- Randomisation via the eCRF 
- Dispense IMP and provide enough supply until following visit 
- Dispense diary card for IMP 
 
7.1.3 Follow up 1 
 
Follow-up 1 will be scheduled to coincide with antenatal clinics/scans at approximately 
32+0 weeks’ gestation (±1 week). The following assessments will take place: 
- Concomitant medications check 
- Adverse event data 
- Weight 
- Blood sample to be collected, processed and stored for 1,5-anhydroglucitol and 
metabolic hormones analysis 
- Download CGM data and new equipment supply 
- Optional Vascular studies: blood pressure pulse wave velocity and augmentation 
index 
- Blood pressure and pulse (if not consented for the vascular studies) 
- Dispense IMP and provide enough supply until following visit 
- Diary card checks 
- 4 day food diary to be provided and training given so it can be completed in 
anticipation to follow up 2. 
 

 
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7.1.4 Follow up 2 
 
Follow-up visit 2 will be scheduled to coincide with antenatal clinics/scans at 
approximately 36+0 weeks’ gestation (±1 week). The following assessments will take place: 
- Concomitant medications check 
- Adverse event data 
- Weight 
- Blood samples collected for in-hospital analysis (minimum 3 hour fast): serum 
glucose,  LFT, U&E, total bile acids, high-sensitivity C-reactive protein, HbA1c and fasting 
lipid profile.  
- Blood sample to be collected, processed and stored for 1,5-anhydroglucitol, 
metabolic hormones and free fatty acid analysis 
- Download CGM data and new equipment supply 
- Optional Vascular studies: blood pressure pulse wave velocity and augmentation 
index 
- Blood pressure and pulse (if not consented for the vascular studies) 
- Dispense IMP and provide enough supply until following visit 
- Diary card checks 
- Quality of Life questionnaires (EQ-5D-5L) and treatment satisfaction (DTSQs)  
- Collect 4-day food diary from participant 
- Optional faecal sample (can be produced at the participant’s home and shipped to 
hospital)  
- Optional and separately consented mechanistic samples. See section 19. 
Mechanistic Sub-study: GUARD MEC for further information. 
 
7.1.5 Birth and immediate postpartum period 
 
Participants are expected to take the last dose of IMP on the day they give birth, where 
possible. The following assessments and data will take place on that visit and during the 
subsequent days, if at all possible: 
 
- Adverse event data  
- Concomitant medication (except any standard medication given when in labour) 
- CGM data download and collection of device 
- Collect remaining IMP and diary card check 
- Cord blood samples (SST vacutainer; for storage and subsequent analysis of lipids 
and C-peptide) 
- Meconium collection from nappy 
- Labour and birth data: onset of labour, genital tract trauma, post-partum 
haemorrhage, mode of birth.  
- Neonatal data: Apgar scores: 5 min post-birth, gestational age at birth, gender, 
NICU/SCBU admission, morbidity, feeding method at birth and discharge, inpatient night, 
shoulder dystocia and manoeuvres required for delivery. 

 
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- Neonatal anthropometry will be measured taken on day of delivery or as soon as 
feasible: birth weight and the following measurements in triplicate: 
a) With blank tapes (then checked measured these with a steel rule): head 
circumference, chest circumference, abdominal circumference, midarm circumference  
b) Skinfold thicknesses in triplicate: subscapular and triceps 
c) Crown rump length, crown foot length 
 
There may be instances where patients are unable to bring back material such as 
leftover IMP, diary card or CGM device. If women are not to return to hospital in the near 
future, a pre-paid postal package will be provided for them to send the material back. If 
substantial study data is missed from labour, the research midwife might call participants to 
enquire for missing information.  
 
7.1.6 Post birth 
 
As per standard care patients will have an HbA1c measurement at their local GP 
approximately 3 months post-delivery. This data will be obtained by the study team.     
 
7.2 Laboratory Tests 
 
 
At each visit we will require a different volume of blood, to a max of approximately 28 
mL (FO, SST, EDTA vacutainers). Standard clinical measures for serum glucose, HbA1c, 
lipids (total, HDL- and LDL-cholesterol, triglycerides), liver function tests, U&E, total bile 
acids and high-sensitivity C-reactive protein tests will be performed at the local hospital 
laboratory. From the total volume, 6 mL from an EDTA vacutainer will be collected and 
processed at each visit, and the plasma stored for further analysis of metabolic hormones 
and 1,5 anhydroglucitol, a novel marker of short-term glycaemia. At Follow-Up 2, 5 mL from 
an SST vacutainer will be collected and processed, and the serum stored for further analysis 
of free fatty acids. The table below details the volume of blood and the vacutainer required 
for collection at each visit. 
 
 
Baseline 
Follow-Up 1 
Follow-Up 2 
FO 
N/A 
N/A 
4 mL 
SST 
7 mL 
N/A 
12 mL (5 mL storage) 
EDTA 
12 mL (6 mL storage) 
6 mL (storage)  12 mL (6 mL storage) 
Estimated total 
volume blood 
required: 
19 mL 
6 mL 
28 mL 
 
 
 
We will also evaluate gut microbes and metabolites in the maternal faeces to 
investigate the effect of UDCA/metformin on gut signals that can influence maternal 
metabolism and susceptibility to GDM and dyslipidaemia. Women will be asked to donate 
an optional faecal sample for the gut hormone studies at approximately week 36. This 

 
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sample will need to be frozen immediately. Gut microbiota will be determined in the faeces 
samples by 16S rRNA sequencing. Faecal bile acid profiles will be obtained using UPLC-
MS/MS and SCFAs will be quantified by gas-liquid chromatography (GLC). Additional 
aliquots of faecal samples will be stored at -80oC, as, if a change in maternal gut microbiota 
composition is observed, they will be used for future experiments.  
 
Cord blood samples will be obtained for measurement of lipid and C-peptide levels 
(approximately 4 ml SST tube) and stored locally. Meconium will be collected from the nappy 
where possible and stored locally. 
 
Stored samples will be shipped to KCL in batches and analysed centrally, either by 
courier or in person. Collection and shipping logs will be completed by the site staff.   
 
Details about the collection, handling, shipment and analyses of research samples are 
described in the lab manual. Details about the sampling collection of the GUARD MEC will 
be described in section 19.6 Laboratory details and the lab manual. All details about sample 
processing will be described in the lab manual. 
 
8. Assessment of Efficacy  
8.1 Primary Efficacy Parameters 
 
Glucose control at 36 weeks is the primary efficacy parameter. This will be measured 
by a fasted blood sample obtained via venepuncture at the follow up clinic.  
 
8.2 Secondary Efficacy Parameters 
 
1. Biomedical maternal 
Glucose metabolism  
Lipid metabolism  
Biochemical analysis of maternal blood  
Maternal gestational weight change (randomisation to 36 weeks)  
Blood pressure 
 
2. Biomedical neonatal 
Gestational age at delivery, frequency of preterm birth 
Neonatal adjusted birth weight 
Cord blood analysis 
Apgar scores 
Neonatal morbidity 
Neonatal intensive care unit admission 
 
 
8.3 Procedures for Assessing Efficacy Parameters 
 
Maternal 

 
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- Venepuncture at follow up visits for the analyses of: glucose, HbA1C, lipids 
(triglycerids, total cholesterol, LDL-cholesterol, HDL-cholesterol), liver function tests, bile 
acids, C-reactive protein (including highly sensitive analyses), 1,5- anhydroglucitol, 
metabolic hormones and free fatty acids. When possible, these will be collected at the same 
time as any other required clinical samples. 
- Continuous glucose monitoring (CGM) to assess glycaemic control.  
- Quality of Life (at baseline and Follow up 2). 
- Measurements of blood pressure with an arteriograph for the vascular studies.  
 
 
Neonatal 
Routinely collected clinical birth details will be collected for the trial, these will include;  
 
- Birth data 
 Mode of birth (rates of primary & repeat CS, elective & emergency LSCS).  
 Gestational age at delivery, frequency of preterm birth.   
 Infant birth weight (customised birth weight percentile, proportion of large for 
gestational age infants (LGA), proportion of small for gestational age  infants 
(SGA))   
 Apgar scores at 5 minutes. 
 Neonatal morbidity (treatment for neonatal hypoglycaemia, neonatal jaundice, 
respiratory distress or trauma).  
 Stillbirth 
 Neonatal special and intensive care unit admission (duration of hospital stay, 
highest level care).  
 
- Cord blood for the analyses of C-peptide, triglyceride, total cholesterol, LDL-
cholesterol, HDL-cholesterol and free fatty acid concentrations. 
- Infant feeding method at hospital discharge (breast, bottle, mixed). 
 
 
9. Assessment of Safety  
9.1 Specification, Timing and Recording of Safety Parameters  
 
Adverse event data will be collected at each visit from baseline to discharge from 
hospital of mother and infant.  
 
Blood pressure will be measured at each visit. 
 
U&E will be performed at follow up 2 to monitor renal function. Liver function tests 
are also measured at this visit.  
 
Other safety assessments will be performed as per standard of care down to the 
clinician’s decision. 
 

 
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9.2 Procedures for Recording and Reporting Adverse Events 
 
The Medicines for Human Use (Clinical Trials) Regulations 2004 and Amended 
Regulations 2006 gives the following definitions: 
 
Adverse Event (AE): Any untoward medical occurrence in a subject to whom a 
medicinal product has been administered including occurrences which are not necessarily 
caused by or related to that product. 
Note 1: This definition includes events related to the investigational medical device 
or the comparator.  
Note 2: This definition includes events related to the procedures involved.  
 
Adverse Reaction (AR): Any untoward and unintended response in a subject to an 
investigational medicinal product which is related to any dose administered to that subject. 
Unexpected Adverse Reaction (UAR): An adverse reaction the nature and 
severity of which is not consistent with the information about the medicinal product in 
question set out in the summary of product characteristics (SmPC) for metformin 
and UDCA 
Serious adverse Event (SAE), Serious Adverse Reaction (SAR) or Unexpected 
Serious Adverse Reaction (USAR): Any adverse event, adverse reaction or unexpected 
adverse reaction, respectively, that 
 
Results in death (including neonatal); 
 
Is life-threatening; 
 
Required hospitalisation or prolongation of existing hospitalisation; 
 
Results in persistent or significant disability or incapacity; 
 
Consists of a congenital anomaly or birth defect. 
Important Medical Events (IME) 
Events that may not be immediately life-threatening or result in death or 
hospitalisation but may jeopardise the patient or may require intervention to prevent one 
of the other outcomes listed in the definition above should also be considered serious.  
 
 
9.2.1 Reporting Responsibilities  
KCL & GSTFT have delegated the delivery of the Sponsor’s responsibility for 
Pharmacovigilance (as defined in Regulation 5 of the Medicines for Human Use (Clinical 
Trials) Regulations 2004 to the King’s Health Partners Clinical Trials Office (KHP-CTO).  
 
All Adverse Events will be recorded in the medical notes.  
 
All SAEs, SARs and SUSARs (excepting those specified in this protocol as not 
requiring reporting) will be reported immediately (and certainly no later than 24hrs) by the 
Investigator to the KHP-CTO and CI for review in accordance with the current 
Pharmacovigilance Policy, and subsequently recorded in the eCRF. All SAEs will be 
reported using MedDRA coding, in liaison with the study CRA.  
 

 
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The KHP-CTO will report SUSARs to the regulatory authorities (MHRA, competent 
authorities of other EEA (European Economic Area) states in which the trial is taking 
place. The Chief Investigator will report to the relevant Ethics Committee. Reporting 
timelines are as follows: 
- SUSARs which are fatal or life-threatening must be reported not later than 7 days 
after the sponsor is first aware of the reaction. Any additional relevant information must 
be reported within a further 8 days. 
- SUSARs that are not fatal or life-threatening must be reported within 15 days of 
the sponsor first becoming aware of the reaction.   
- The Chief Investigator and KHP-CTO (on behalf of the co-sponsors), will submit 
a Development Safety Update Report (DSUR) relating to this trial IMP, to the MHRA and 
REC annually.  
 
9.2.2 Definition of causality 
The assignment of the causality should be made by the investigator responsible for 
the care of the participant as: definitely, likely, possibly, unlikely, not related or related to 
other study procedure.  
 
An AE whose causal relationship to the study drug or study procedure is assessed 
by the investigator as “possibly”, “likely” or “definitely” is an Adverse Drug Reaction. All 
events judged by the investigator to be “possibly”, “likely” or “definitely” related to the 
therapy or study procedure, graded as serious and unexpected should be reported as a 
SUSAR.  
 
9.2.3 Severity 
Regardless of the classification of an AE as serious or not, its severity must be 
assessed according to medical criteria alone using the following categories:  
Mild: does not interfere with routine activities  
Moderate: interferes with routine activities  
Severe: very difficult or impossible to perform routine activities 
 
9.2.4 Expectedness 
If there is at least a possible involvement of the trial medications, the investigator and 
sponsor must assess the expectedness of the event. An unexpected adverse reaction is 
one that is not reported in the current SPC, or one that is more frequently reported or more 
severe than previously reported. See SPC for a list of expected toxicities associated with 
the drugs being used in this trial. If a SAR is assessed as being unexpected, it becomes a 
SUSAR and it must be reported to the competent authority by the sponsor.  
 
9.2.5 Adverse events that do not require reporting 
All adverse events will be reported from baseline until discharge from hospital for 
mother and infant.  

 
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Events that are reported as outcomes in the eCRF, or those which are expected in 
this population or as result of routine care/treatment do not need to be reported as AEs or 
SAEs. This includes but is not limited to:   
- Birth by C-Section  
- Planned hospital admissions (including to give birth), including for treatment planned 
prior to trial entry, or for elective treatment of a pre-existing condition.   
- Post-partum haemorrhage  
- Genital tract trauma 
- Antepartum haemorrhage (approx. > 100 ml) 
- Postpartum haemorrhage (approx. > 500 ml) 
- Neonatal admission to high level of neonatal care for less than 48 hours 
- Shoulder dystocia 
- Neonatal hypoglycaemia, neonatal jaundice, respiratory distress or birth trauma  
 
Those events will only be reported to the sponsor if the investigator believes the event 
is a result of the GUARD intervention. All unexpected SAR will be reported.  
 
Further information in the reporting of AE for participants of GUARD MEC are 
described in section 19.7. 
 
9.3 Trial Stopping Rules 
 
The trial may be prematurely discontinued by the Sponsor, Chief Investigator or 
Regulatory Authority on the basis of new safety information or for other reasons given by 
the Independent Data Monitoring Committee / Trial Steering Committee, regulatory 
authority or Ethics Committee concerned. 
 
If the trial is prematurely discontinued, active participants will be informed and no 
further participant data will be collected. The Competent Authority and Research Ethics 
Committee will be informed within 15 days of the early termination of the trial. 
 
10. Statistics 
 
Appropriate summary statistics (means, medians, percentages and measures of 
dispersion such as the standard deviation and interquartile range) will be generated 
according to treatment assignment for important baseline covariates and for primary and 
secondary outcomes.  At all follow-up visits, summary statistics for the observed values and 
for changes from baseline will be computed and tabulated for all primary, secondary and 
safety outcomes. In the event that a participant stops the intervention, they will be 
encouraged to continue to be part of the study. These participants will form part of the final 
analysis on an intention to treat basis.  
 

 
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10.1 Sample Size 
 
A study size of 158 participants will provide sufficient statistical power whilst allowing 
for a 20% withdrawal rate. This gives 90% power to detect the primary outcome of a 
difference in maternal fasting glucose at 36 weeks of 6% (0.28mmol/L). This sample size 
calculation was performed using data obtained from a previous study that reported 
differences with UDCA treatment for non-alcoholic fatty liver disease (NAFLD) in a 
population of similar body mass index and age to our study group44, and the difference in 
glucose level is thought clinically relevant as it is equivalent to the difference in glucose 
categories between which differences in LGA, primary caesarean section, cord blood serum 
C-peptide level >90th centile and clinical neonatal hypoglycaemia were evident in the HAPO 
study43. Using two-sided calculations with alpha 0.05, 63 women per arm would be required 
to determine this reduction with 90% power. Thus, allowing for approximately 20% dropouts, 
the numbers rise to 158 women in total.  
 
 
10.2 Randomisation 
 
Randomisation will be minimised in groups by four variables: BMI, by previous history 
of GDM, severity and by centre. 
Due to the large pill size and different dosage, this will be an open label study. 
 
 
10.3 Analysis 
 
Interim analysis will be conducted as described in section 11.4.The stopping rule will 
be based on the Peto principle53, that the trial should continue except in the face of 
overwhelming evidence (P<0.0001), sufficient to make a recommendation affecting all future 
obese or overweight pregnant women.   
 
The main analysis will follow the intention to treat (ITT) principle, using all available 
data on randomised women, according to the intended treatment option (The ITT database).  
Should there be a large number of women (over 20%) not following the randomised 
treatment, a per protocol (PP) dataset limited to women following the intended treatment will 
also be established and a secondary PP analysis will be conducted. 
 
All comparisons by treatment group will be adjusted for all variables used in the 
randomisation. Data derived from the CGM will be analysed at 36 weeks. The differences 
caused by the randomised treatment, adjusting for the baseline randomisation 
measurements by multiple regression. This method (also known as ANCOVA) will increase 
the power and accuracy of these comparisons. 
 
UDCA will be declared non-inferior to metformin if metformin does not have a 
significant advantage, and the largest plausible advantage (by 95% Confidence Interval) is 
less than 0.28 mmol/L. If neither treatment shows a significant advantage, and the difference 
and CI are less than 0.28 mmol/L, the treatments will be regarded as equivalent54.  
 
 

 
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10.4 Procedures for dealing with missing data, unused data and false 
data52   
 
Missing data. We will follow a four-point framework for dealing with incomplete 
observations which will allow the correct method to be chosen and subsequently 
implemented 52.  
1. Attempt to follow up all randomized participants, even if they withdraw from 
allocated treatment  
2. Perform a main analysis of all observed data that is valid under a plausible 
assumption about the missing data. Specifically, we will assume data is missing at random 
(MAR). Under this assumption, imbalances between treatment groups due to dropout can 
be corrected by appropriate multiple regression models.  
3. Perform a sensitivity analyses to explore the effect of departures from the 
assumption made in the main analysis. The MNAR (missing not at random) analysis will use 
the method of White et al. (2011)52 as implemented in the Stata command rctmiss.  
4. Account for all randomized participants, at least in the sensitivity analyses  
This framework highlights the importance of using plausible assumptions with regards 
to the nature of the missing data. These assumptions will then be tested using appropriate 
sensitivity analyses on observed data using complete cases analysis. For the purpose of 
the main analysis we will make the assumption that missing data is missing at random and 
the effect of the intervention is the same in those with and without the observations. 
Furthermore, we will check whether there is an imbalance or is similar the percentage of 
missing data within each treatment allocation.  
 
Unused data. The principal analysis will follow the intention to treat principle. All 
consenting women randomised for whom adequate data is collected will be included in the 
primary and main secondary endpoints.  A secondary, per protocol analysis of the primary 
outcome will be limited to women who take the majority of their randomised medication. 
 
False data. We will take all reasonable precautions to minimise the number of data 
errors. Everyone responsible for collecting data will be trained in the procedures to followed. 
All data entered will be checked by the study team as per the Data Monitoring Plan and Data 
Management Plan; and again by the statistician at the time of analysis; and corrections 
made wherever possible. 
 
A detailed SAP, including dummy tables, will be prepared as a separate document.  
 
11. Trial management and oversight 
11.1 Overview of trial management  
 
The conduct of the trial will be overseen by a Trial Steering Committee (TSC). The 
Trial Manager along with the Chief Investigator and Research Associate will be responsible 
on a day to day basis for overseeing and co-ordinating the work of the multi-disciplinary trial 
team.  
 

 
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The TMG will outsource services of an electronic data capture and randomisation 
services. The CRA and trial statistician will be responsible for monitoring data collection, 
processing data and conducting data validation.  
 
The KHP-CTO acts on the behalf of the sponsor and provides quality assurance and 
trial monitoring.   
 
The minutes from discussions of the study committees will be formally documented 
and a record kept in the TMF. 
 
11.2 Trial Management Group 
 
The Trial Management Group (TMG) will be chaired by the trial manager, and will 
include the Chief Investigator, CTM, selected co-investigators (or delegated individuals), a 
consultant midwife and a research matron, Statistician and CRA. For selected meetings, the 
TMG may additionally include the Trial Pharmacist, representatives from KHP-CTO and the 
Trial Sponsors as required. This group will have responsibility for the day to day operational 
management of the trial. Regular meetings of the TMG will be held to discuss and monitor 
trial progress and solve problems.  
 
11.3 Trial Steering Committee  
 
A TSC will be established prior to the start of the study, with a mix of independent and 
study team members. The TSC will be an executive committee, responsible for the overall 
supervision on behalf of the Sponsor and the Funder, and will ensure that the trial is 
conducted in accordance with the rigorous standards set out in the UK Policy Framework 
for Health and Social Care Research and Guidelines for Good Clinical Practice. The TSC 
will consist of an independent chair, the Chief Investigator, the statistician, independent 
members consisting of a group of experienced obstetricians and diabetologists, specialist 
nurses and midwives and PPI members. The TSC will discuss recommendations raised by 
the IDMC. A charter will be agreed by the members, listing the detailed Terms of Reference 
and frequency of meetings. The group will meet at least annually.  
 
11.4 Independent Data Monitoring Committee  
 
An IDMC will be appointed comprising two fully independent clinicians and an 
independent statistician. This group will be an advisory committee to the TSC. The IDMC 
will review outcomes after 40 (25%) of participants have given birth. Interim analysis will be 
performed and reported to the IDMC including rates of adverse pregnancy outcomes and to 
identify causes for participant withdrawal. The IDMC’s responsibility is to safeguard the 
interests of the trial participants and advise the TSC to protect the validity and credibility of 
the trial. During the recruitment period, reports will be provided to the IDMC as per charter, 
which will include information on the AEs reported, recruitment, along with any other data 
that the committee may request. The IDMC will advise the TSC if, in their view, the 
randomised comparisons have provided both (i) 'proof beyond reasonable doubt' that for all, 
or some, the treatment is clearly indicated or clearly contra-indicated and (ii) evidence that 
might reasonably be expected to materially influence future patient management. Following 

 
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a report from the IDMC, the TSC will decide what actions, if any, are required. Frequency of 
meetings will be defined in a charter document.  
 
11.5 Patient and Public Involvement  
 
At least one, and preferably two, service users will be involved in the design and 
management of the trial (i.e. as a member of the TSC), developing participant information 
resources and contributing to the reporting of the research. This approach has been very 
successful in previous trials within the study team.  
 
We performed an internet survey of mothers with GDM to establish whether they would 
be happy to take an alternative drug to metformin (we also asked if they would be happy to 
take both drugs, although this is not of relevance to current study design). The results were 
supportive of the study design. In brief, 30 women with previous GDM responded, 14 of 
whom were treated with metformin. Responses of relevance to this study were:  
 
68% would prefer oral treatments rather than insulin  
 
72% believe additional treatments are needed as well as diet and lifestyle change  
 
68% would be happy to participate in a trial of a new drug that has good safety 
data in pregnancy but that has not been used to treat GDM  
 
58% would be happy to take the new tablet instead of metformin or insulin  
 
12. Ethics & Regulatory Approvals 
 
The trial will be conducted in compliance with the principles of the Declaration of 
Helsinki (1996), the principles of GCP and in accordance with all applicable regulatory 
requirements including but not limited to the UK Policy Framework for Health and Social 
Care Research and the Medicines for Human Use (Clinical Trial) Regulations 2004, as 
amended in 2006 and any subsequent amendments. 
 
This protocol and related documents has been submitted for review to Health 
Research Authority (HRA), Research Ethics Committee (REC), and to the Medicines and 
Healthcare products Regulatory Agency (MHRA) for Clinical Trial Authorisation. 
 
The Chief Investigator will submit a final report at conclusion of the trial to the KHP-
CTO (on behalf of the Sponsor) and the REC within the timelines defined in the Regulations. 
The KHP-CTO or delegate will upload the final report to EudraCT on behalf of the Sponsor. 
 
12.1 Ethical issues 
 
There is a chance that UDCA treatment will not improve GDM control or could worsen 
maternal or fetal lipid profiles or outcomes. However, this is very unlikely given that our pilot 
data in humans and mice indicate that it will be beneficial. Furthermore, previous clinical 
trials by ourselves and others for ICP have not demonstrated adverse maternal or fetal 
outcomes associated with the drug. When UDCA was evaluated in a previous study to 
establish whether it was an acceptable drug for women with ICP (the PITCH pilot trial)45, 13 
(23%) adverse events took place among women randomised to UDCA compared with 10 

 
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(18%) among women randomised to placebo. No woman reported more than one adverse 
event. Most adverse events were mild, with the remainder classified as moderate (eight); 
none were classed as severe by the site principal investigators. Most adverse events related 
to gastrointestinal disturbances (nine in the UDCA arm versus five in the placebo arm). 
Importantly, the majority were thought not, or unlikely, to be caused by the trial drug 
(possible causality in four events in the UDCA arm versus two in placebo arm).  
 
Given the glucose-lowering effects of UDCA, there is a theoretical potential for UDCA 
to lower glucose below safe levels (hypoglycaemia). However, there is no clinical or 
experimental evidence that UDCA treatment causes hypoglycaemia; in murine studies, 
treatment with UDCA lowers blood glucose levels for obese, but not healthy mice, to healthy 
levels50. In human studies, treatment of obese women with 6 weeks of UDCA did not lower 
their fasting glucose below normoglycaemia (2x SD below the mean)44.  
 
13. Quality Assurance  
 
Trial committees (IDMC and TSC) will be appointed to oversee the conduct of the 
study. Monitoring to ensure compliance with Good Clinical Practice and scientific integrity 
will be managed and oversight retained, by the KHP-CTO Quality Team. 
 
13.1 Direct Access to Source Data and Documents 
 
The Investigator will permit trial-related monitoring, audits, REC review, and regulatory 
inspections by providing the Sponsors, Regulators and REC direct access to source data 
and other documents (e.g. patients’ case notes, blood test reports, scan reports etc). 
 
13.2 Trial monitoring 
 
Monitoring of this trial will be performed to ensure compliance with Good Clinical 
Practice, and scientific integrity will be managed and oversight retained, by the KHP-CTO 
Quality Team.  
 
A study specific monitoring plan will be developed by the KHP-CTO on the basis of 
the risk assessment. The KHP-CTO will carry out on-site monitoring to undertake source 
data verification checks and confirm that records are being appropriately maintained by the 
PI and pharmacy teams. The site PI will be responsible for ensuring the findings are 
addressed appropriately. The CTM will ensure relevant findings are discussed with the CI 
and the report is filed in the TMF. 
 
In addition to site monitoring, the CTM and CI will communicate regularly with sites via 
email, telephone and teleconferences, and will perform spot checks in the eCRF.  
 
14. Data Handling  
 

 
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The Chief Investigator will act as custodian for the trial data. The following guidelines 
will be strictly adhered to: 
 
 
Patient data will be pseudo-anonymised. 
 
All pseudo-anonymised data will be stored on a password protected computer 
system.  
 
Data entered onto the eCRF will be pseudo-anonymised and stored on a secure 
server. 
 
Full postcode will be collected and entered into the eCRF, but postcode will not be 
stored (the eCRF will match the postcode with the Census area (LSOA), which is the 
data that will be saved in the eCRF).  
 
All hard copies of source data worksheets and ISFs will be kept in a locked office 
within the trial site.  
 
All trial data will be stored in line with the Medicines for Human Use (Clinical Trials) 
Amended Regulations 2006 and the Data Protection Act 2018 and archived in line 
with the Medicines for Human Use (Clinical Trials) Amended Regulations 2006 as 
defined in the Kings Health Partners Clinical Trials Office Archiving SOP, for at least 
25 years.  
 
Patients will be asked to provide their email addresses if they wish to be informed of 
study results and to be contacted in the future. We will collect these in the ISF and a 
copy will be given to the sponsor at intervals or at the end of the trial. 
 
15. Data Management 
 
Electronic Case Report Forms (eCRFs) will used to capture the data of each subject 
considered in the study. No identifiable data will be collected for people who do not consent 
to participate in the trial, but reasons for not consenting will be collected. These forms will 
be standardised and protocol specific and create a time stamped electronic record of any 
amendments or additions to the document. eCRF pages will be monitored on an ongoing 
basis by the study monitor and the trial manager and queries raised to resolve 
discrepancies. 
 
There will be some instances where data may be inputted into the eCRF directly. In 
those cases, the eCRF will become the source data. Those may be:  
- Medical history & demographics 
- Arteriograph results 
- Time of blood samples 
- Time and date of last meal 
- Questions related to IMP compliance where a diary card has not been completed 
- Reason for withdrawal 
- Research laboratory samples processing information and barcode 
 
This clinical trial will use the industry-standard secure database called MedSciNetLtd. 
All access to the MedSciNetLtd data system is controlled using a Username/Password login. 
Passwords are encrypted before storing to database, using SHA-1 hash (MS .NET 
SHA1CryptoServiceProvider). These are created and controlled by Administrative users of 
the system as identified by the Chief Investigator. The data is stored in the BRC eCRF 
servers and meet all MHRA requirements for CTIMP data storage. Only the server 

 
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administrator has access to this server and the core database, via remote connection. The 
back-up process is twofold: every 24hrs the database is backed-up to the server and every 
7 days the entire server is backed up to an archival tape system. 
 
The trial manager will document database lock prior to the final dataset being sent for 
analyses. A separate Data Management Plan will be prepared for the trial detailing the 
checks to be undertaken. 
 
16. Publication Policy  
 
Ongoing progress of the trial will be disseminated to the wider clinical community 
through relevant professional newsletters, meetings, and national and international 
conferences.  
 
The final report to the funder(s) will present detailed results of the trial. The trial will be 
reported in accordance with the Consolidated Standards of Reporting Trials (CONSORT) 
guidelines (www.consort-statement.org).  
 
A lay persons’ summary of the principal findings of the results will be sent to all patients 
involved in the study at their request. Participants will be asked if they wish to be informed 
of trial results, and if they do, they will be asked to provide a personal email address for this 
purpose.  
 
Articles will be prepared for relevant professional journals as well as for peer- reviewed 
scientific journals. 
 
17. Insurance / Indemnity  
 
The trial is co-sponsored by King’s College London and Guy’s and St. Thomas’ NHS 
Foundation Trust. The co-sponsors will at all times maintain adequate insurance in relation 
to the study independently. King’s College London, through its own professional indemnity 
(Clinical Trials) and no fault compensation and the Trust having duty of care to patients via 
NHS indemnity cover, in respect of any claims arising as a result of clinical negligence by 
its employees, brought by or on behalf of a study patient. 
 
18. Financial Aspects  
 
Funding to conduct the trial is provided by J.P. Moulton Foundation (REF Tommy’s 
Grant 81) and an NIHR Senior Investigators grant (Professor Catherine Williamson).  

 
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19. Mechanistic Sub-study: GUARD MEC 
 
19.1 Objectives 
 
To assess whether UDCA and metformin differentially alter gut microbiome and 
whether this is associated with a change in endocrine signalling, serum glucose levels and 
lipid composition, in women consenting to the mechanistic sub-study. 
 
Optional: some women will also be invited to attend an MR imaging scan of their 
fetus to explore whether UDCA or metformin alters fetal body composition. This is a 
separate study, ethically approved (REC 16/LO/1573), with additional consent form.  
 
 
19.2 Exploratory endpoints 
 
- 16S sequencing to analyse gut microbiome  
- Targeted metabolite profiles to measure individual bile acid composition in faeces 
and serum (UPLC-MS/MS) 
- Hormone assays to measure: GLP-1, FGF19, C4 
- Glucose-related hormones to measure: Insulin, C-peptide, Glucagon 
- Serum measurements (done at the participating sites): glucose, lipid profile, free 
fatty acids 
 
19.3 Design 
 
GUARD MEC is a multi-centre nested observational study. With additional participant 
consent, 80 participants will be enrolled. We will measure maternal gut hormones and 
metabolite profiles (UPLC-MS/MS) in plasma, and gut microbes (16S rRNA sequencing) 
and metabolite profiles (UPLC-MS/MS) in faeces. The metabolite profiles include 
measurement of bile acids (including UDCA), so it will be clear if women have taken (and 
absorbed) the drug. The nested studies will be performed at approximately 36 week’s 
gestation.  
 
These patients will be identified at the same antenatal clinics and divided into four 
arms: 
 
Arm 1: GDM Metformin 
20 patients with GDM who were eligible and have consented to participate in the main  
GUARD trial and were randomised to metformin.  
 
Arm 2: GDM UDCA 
20 patients with GDM who were eligible and have consented to participate in the main 
GUARD trial and were randomised to UDCA.  
 

 
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Arm 3: GDM no pharmacotherapy 
20 patients who test positive at OGTT but in whom the condition is managed with diet 
and lifestyle changes. These participants will have received the main GUARD Trial and sub-
study PIS at diagnosis of GDM but will only be offered to take part in the sub-study.  
 
Arm 4: healthy pregnant 
Pregnant women without GDM will be invited to participate in the ‘healthy’ cohort of 
the mechanistic studies. PIS will be provided by a delegated study team member after the 
OGTT test has taken place, or women who haven’t been diagnosed with GDM. Participants 
will be given sufficient time to consider the study. If deemed appropriate, consent may be 
taken on the same day as PIS was given.  
 
19.4 Inclusion Exclusion criteria 
 
Arm 1 & Arm 2: 
Inclusion Criteria  
1. Women who are eligible and who have consented to participate in GUARD.  
Exclusion Criteria  
1. Use of oral antibiotics during current pregnancy 
2. Known food allergy to nuts or any of the components of the GUARD MEC 
breakfast. 
 
Arm 3:  
Inclusion Criteria  
1. Women with GDM diagnosed at 26+0 to 30+6 weeks’ gestation in accordance with 
the NICE guidelines (one or more glucose concentrations of ≥5.6 mmol/l fasting 
or ≥7.8 mmol/l 2 hours after a standard 75g OGTT, and NOT requiring 
pharmacological treatment).   
2. Overweight or obese (Booking BMI ≥25 kg/m2)  
3. Planned antenatal, birth and postpartum care at the participating centre (i.e. 
not planning to move before delivery).   
Exclusion Criteria  
1. Unwilling/unable to give written informed consent and comply with the 
requirements of the study protocol 
2. Multiple pregnancies (twins, triplets etc) in current pregnancy 
3. Congenital anomaly on ultrasound requiring fetal medicine input 
4. Previous diagnosis of diabetes outside pregnancy   
5. HbA1c at booking >48 mmol/mol or ≥6.5% during current pregnancy (if available)  
6. Not fluent in English and absence of interpreter or translation services (ie 
telephone translation services)  

 
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7. Participating in another intervention study where the results could influence 
GDM-related endpoints, in the opinion of the responsible clinician or the CI, or 
participation in a CTIMP during current pregnancy. 
8. Use of oral antibiotics during current pregnancy 
9. Known food allergy to nuts or any of the components of the GUARD MEC 
breakfast. 
 
 
Arm 4:  
Inclusion Criteria  
1. Pregnant women between 16 and 45 years of age who haven’t been diagnosed 
with GDM by the time of the study visit.  
2. Overweight or obese (Booking BMI ≥25 kg/m2)  
3. Planned antenatal, birth and postpartum care at the participating centre (i.e. 
not planning to move before delivery).   
Exclusion Criteria  
1. Unwilling/unable to give written informed consent and comply with the 
requirements of the study protocol 
2. Multiple pregnancies (twins, triplets etc) in current pregnancy 
3. Congenital anomaly on ultrasound requiring fetal medicine input 
4. Previous diagnosis of diabetes outside pregnancy   
5. HbA1c at booking >48 mmol/mol or ≥6.5% during current pregnancy (if available)  
6. Not fluent in English and absence of interpreter or translation services (ie 
telephone translation services)  
7. Participating in another intervention study where the results could influence 
GDM-related endpoints, in the opinion of the responsible clinician or the CI, or 
participation in a CTIMP during current pregnancy. 
8. Use of oral antibiotics during current pregnancy 
9. Known food allergy to nuts or any of the components of the GUARD MEC 
breakfast. 
 
 
19.5 Recruitment & assessments 
 
Participants will be selected from the antenatal clinics at collaborating hospitals with 
specialist obstetric multidisciplinary teams, expert in the management of GDM.   
Pregnant women who meet the eligibility criteria for any of the four arms will be 
approached with a PIS and be informed about the study. If willing to participant, they will be 
asked to provide written informed consent. For in Arms 1 & 2, only women who participate 
in the main GUARD trial will be invited to participate (see flowchart in Section 7).  
 

 
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Patients who tested negative for GDM, or those whose glucose is well controlled by 
diet and hence not requiring pharmacological treatment are not eligible to participate in the 
main GUARD Trial. These patients will be given the opportunity to participate in the sub-
study GUARD MEC as controls. These women will be identified by a member of the clinical 
team and PIS given.  
 
The study will be explained in detail by trained and delegated clinical or research staff, 
giving as much time for consideration as the patient considers necessary. Should the patient 
agree to participate to this part of the research, a copy of the ICF will be signed by the patient 
and the investigator at that point or at a later visit (or delegated member according to local 
standard practice), and a copy given to the patient. A copy will be filed/uploaded into the 
woman’s electronic maternity records. The investigator’s original will be filed in the ISF. 
 
After signing informed consent, only one study visit will be required for participation in 
GUARD MEC. For patients in GUARD, this will coincide with Follow Up 2. Prior to this visit 
participants will be given a food diary to record their food intake 4 days before their 
appointment. Participants will attend the hospital at 36+0 weeks’ gestation (+/-1 week), after 
an overnight fast and will be given a standardised breakfast with pre-determined lipid and 
glucose content consisting of 50 g of fat, 75 g carbohydrates, ≥750 kcal. Participants unable 
to ingest at least 80% of the breakfast will be withdrawn. Blood samples will be taken at four 
timepoints.  
 
The following assessments will also be performed on those participants: 
- Inclusion/exclusion assessment  
- Demographics (including post-code), family, medical and obstetric data   
- Concomitant medication 
- Weight (additional weight and height from booking visit to be obtained from medical 
records) 
- Continuous Glucose Monitoring implementation and education  
- Optional Vascular studies: blood pressure pulse wave velocity, central arterial 
pressure, augmentation index. 
- Blood pressure and pulse (if not consented for the vascular studies) 
- Optional faecal sample (can be produced at the participant’s home and shipped to 
hospital)  
- Collect 4-day food diary from participant 
- Study procedures-related adverse events 
- eCRF completion  
 
To coincide with the following hospital appointment: 
- CGM data download and collection of device. 
 
After birth (data to be collected from the medical notes): 
- Labour and birth data: onset of labour, genital tract trauma, post-partum 
haemorrhage, mode of birth.  

 
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- Neonatal data: Apgar scores: 5 min post-birth, gestational age at birth, gender, 
NICU/SCBU admission, morbidity, feeding method at birth and discharge, inpatient night, 
shoulder dystocia and manoeuvres required for delivery. 
- Neonatal anthropometry will be measured taken on day of delivery or as soon as 
feasible: birth weight and the following measurements in triplicate: 
a) With blank tapes (then checked measured these with a steel rule): head 
circumference, chest circumference, abdominal circumference, midarm circumference  
b) Skinfold thicknesses in triplicate: subscapular and triceps 
c) Crown rump length, crown foot length 
 
Visit name & approximate pregnancy week  
Baseline 
Follow up 2 
Labour 
26+0-35+6 
36+0 ± 1 b 
 
Patient information  
X 
 
 
Informed consent  
X 
 
 
Inclusion / exclusion criteria 
X 
 
 
Demographics  
X 
 
 
Medical and obstetric personal and family history  
X 
 
 
Adverse events 
 
X f 
 
Concomitant medication  
X 
X 
 
Weight  
 
X 
 
Blood pressure and pulse a 
 
X 
 
Optional faecal sample b  
 
X g 
 
GUARD MEC Blood samples after a breakfast b  
 
X h 
 
Continuous Glucose Monitoring c  
 
X 
 
Download CGM data & collect device 
 
 
X 
Optional vascular studies d  
 
X 
 
4-day food diary e 
 
X e 
 
Labour and birth data  
 
 
X i 
Neonatal anthropometry  
 
 
X j k 
Neonatal data  
 
 
X k l  
 
a - Blood pressure in triplicate and pulse only for woman who don’t consent to the vascular studies. Use non-
dominant arm. 
b - Research samples, for storage.  
c - CGM will be in place for 10 days after each study visit. Women to be trained to remove the device 
themselves and return it at their next visit or at labour. 
d - Vascular studies: blood pressure pulse wave velocity, central arterial pressure, augmentation index. 
e - Food diaries should be given to patients at baseline to be completed the 4 days prior to Follow up 2. This 
should occur prior to providing a faecal sample (if applicable). 
f – In Arms 3 & 4, study procedure-related adverse events will be collected from the day of the procedure until 
the CGM is disconnected.  
g -Faecal samples are optional and should be produced at approximately 36 weeks. If the woman is unable to 
give a faecal sample on the day, a stool sample collection kit may be provided and the sample collected by 
courier from the participant’s home. 
h - A hospital standardised breakfast will be provided. Four blood samples will be taken at the following 
timepoints: before breakfast, 15 minutes, 1 hour and 2 hours postprandially.  
i - Labour and birth data: onset of labour, genital tract trauma, post-partum haemorrhage, mode of birth, 
gestational age at delivery, NICU admission, morbidity, feeding at discharge. 
j - Neonatal anthropometry: birth weight and the following measurements in triplicate: 
 
With blank tapes (then checked measured these with a steel rule): head circumference, chest 
circumference, abdominal circumference, midarm circumference  
 
Skinfold thicknesses in triplicate: subscapular and triceps 
 
Crown rump length, crown foot length 
k - Neonatal assessments will be performed on the day of delivery, or as soon as feasible.   
l - Apgar scores: 5 min post-birth 
 

 
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19.6 Laboratory details  
 
Measurement of gut hormone release and gut hormone production over a 2.5-hour 
period will be performed at approximately 36 weeks: participants will attend the hospital 
fasted and will be given a standardised breakfast with pre-determined lipid and glucose 
content. Blood samples will be taken when fasting, 15 minutes, 1 hour and 2 hours after 
breakfast finish time. These fasting samples will be evaluated in place of Follow-up 2 
samples on the main GUARD participants.  
 
The samples will be used to evaluate LFTs, lipid (total cholesterol, HDL-cholesterol, 
LDL-cholesterol, triglycerides, free fatty acids) and glucose metabolism (glucose, C-peptide, 
insulin, HbA1c) by either standard laboratory analysis or ELISA (for gut hormone secretion, 
insulin, C-peptide and free fatty acids). Individual bile acid analysis will also be performed 
using UPLC-MS/MS. Leftover serum and plasma samples will be stored at -80oC for 
subsequent analysis of incretins and metabolic markers.  
 
The table below details the volume of blood and the vacutainer required for collection 
at each time point. 
 
Time 
FO 
SST 
EDTA  
Fasting 
4 mL 
2 x 3.5 mL vacutainers (send to 
laboratory: 1 x liver function test 
and lipid profile, 1 x total bile 
acids) 
1 x 5 mL vacutainer for storage 
1 x 6 mL (1 x HbA1c, 
send to laboratory) 
1 x 6 mL storage 
0h15 
postprandial 
4 mL 
1 x 3.5 mL vacutainer (lipid 
profile – send to laboratory) 
1 x 5mL vacutainer for storage 
1 x 6 mL (storage) 
1h00 
postprandial 
4 mL 
1 x 3.5 mL vacutainer (lipid 
profile – send to laboratory) 
1 x 6mL vacutainer for storage 
1 x 6 mL (storage) 
2h00 
postprandial 
4 mL 
1 x 3.5 mL vacutainer (lipid 
profile – send to laboratory) 
1 x 6 mL vacutainer for storage 
1 x 6 mL (storage) 
Estimated total 
volume of blood 
collected: 
16 mL 
39.5 mL 
30 mL 
 
Samples collected for storage from SST vacutainers will be used to determine free 
fatty acids, bile acids, FGF19, C4 and other metabolic hormones of interest. Samples 
collected for storage from EDTA vacutainers will be used to determine HbA1c, GLP-1, 
insulin, C-peptide and other metabolic hormones of interest. 
 
In total, approximately 86 mL of blood will be collected for each participant in GUARD-
MEC.  
 
19.7 Reporting of Adverse Events 
 

 
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For participants of GUARD MEC who are not part of the main trial, only adverse events 
who are related to study procedures will be collected. This includes (but is not limited to) 
allergic reactions to food, fainting, reactions to the CGM device, reactions of the phlebotomy, 
etc.  
 
AE will be collected from the day of the study procedure at week 36, until the time the 
CGM device is disconnected, 10 days later. Severity will be assessed as mild, moderate 
and severe. 
 

 
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20. References 
 
1. 
HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, Dyer AR, Trimble ER, 
Chaovarindr U, et al. Hyperglycemia and Adverse Pregnancy Outcomes. N Engl J Med 
2008;358:1991–2002.   
2. 
Black MH, Sacks DA, Xiang AH, Lawrence JM. Clinical Outcomes of Pregnancies 
Complicated by Mild Gestational Diabetes Mellitus Differ by Combinations of Abnormal Oral Glucose 
Tolerance Test Values. Diabetes Care 2010;33:2524–30.   
3. 
Tobias DK, Stuart JJ, Li S, Chavarro J, Rimm EB, Rich-Edwards J, et al. Association of 
History of Gestational Diabetes With Long-term Cardiovascular Disease Risk in a Large Prospective 
Cohort of US Women. JAMA Intern Med 2017;177:1735–42.   
4. 
Albareda M, Caballero A, Badell G, Piquer S, Ortiz A, de Leiva A, et al. Diabetes and 
abnormal glucose tolerance in women with previous gestational diabetes. Diabetes Care 
2003;26:1199–205.   
5. 
Lowe WL, Scholtens DM, Lowe LP, Kuang A, Nodzenski M, Talbot O, et al. Association of 
Gestational Diabetes With Maternal Disorders of Glucose Metabolism and Childhood Adiposity. 
JAMA 2018;320:1005.  
6. 
Ryckman K, Spracklen C, Smith C, Robinson J, Saftlas A. Maternal lipid levels during 
pregnancy and gestational diabetes: a systematic review and meta-analysis. BJOG 2015;122:643–
51.  
7. 
White SL, Pasupathy D, Sattar N, Nelson SM, Lawlor DA, Briley AL, et al. Metabolic profiling 
of gestational diabetes in obese women during pregnancy. Diabetologia 2017;60:1903–12.   
8. 
Anderson SG, Dunn WB, Banerjee M, Brown M, Broadhurst DI, Goodacre R, et al. Evidence 
That Multiple Defects in Lipid Regulation Occur before Hyperglycemia during the Prodrome of Type-
2 Diabetes. PLoS One 2014;9:e103217.   
9. 
Fasshauer M, Blüher M, Stumvoll M. Adipokines in gestational diabetes. Lancet Diabetes 
Endocrinol 2014;2:488–99.   
10. 
Banerjee M, Anderson SG, Malik RA, Austin CE, Cruickshank JK. Small artery function 2 
years postpartum in women with altered glycaemic distributions in their preceding pregnancy. Clin 
Sci 2012;122:53–61.   
11. 
O’Sullivan EP, Avalos G, O’Reilly M, Dennedy MC, Gaffney G, Dunne F, et al. Atlantic 
Diabetes in Pregnancy (DIP): the prevalence and outcomes of gestational diabetes mellitus using 
new diagnostic criteria. Diabetologia 2011;54:1670–5.   
12. 
Athukorala C, Crowther CA, Willson K, Australian Carbohydrate Intolerance Study in 
Pregnant Women (ACHOIS) Trial Group. Women with gestational diabetes mellitus in the ACHOIS 
trial: Risk factors for shoulder dystocia. Aust New Zeal J Obstet Gynaecol 2007;47:37–41.  
13. 
Schaefer-Graf UM, Graf K, Kulbacka I, Kjos SL, Dudenhausen J, Vetter K, et al. Maternal 
Lipids as Strong Determinants of Fetal Environment and Growth in Pregnancies With Gestational 
Diabetes Mellitus. Diabetes Care 2008;31:1858–63.   
14. 
Son GH, Kwon JY, Kim YH, Park YW. Maternal serum triglycerides as predictive factors for 
large-forgestational age newborns in women with gestational diabetes mellitus. Acta Obstet 
Gynecol Scand 2010;89:700–4.  

 
EudraCT Number 2019-002880-82, IRAS Number 1003208 
 
 
GUARD protocol V1.0 11Mar20 
Page 47 of 53 
 
 
 
15. 
Harmon KA, Gerard L, Jensen DR, Kealey EH, Hernandez TL, Reece MS, et al. Continuous 
Glucose Profiles in Obese and Normal-Weight Pregnant Women on a Controlled Diet: Metabolic 
determinants of fetal growth. Diabetes Care 2011;34:2198–204.   
16. 
Kawasaki M, Arata N, Miyazaki C, Mori R, Kikuchi T, Ogawa Y, et al. Obesity and abnormal 
glucose tolerance in offspring of diabetic mothers: A systematic review and meta-analysis. PLoS 
One 2018;13:e0190676.   
17. 
Leybovitz-Haleluya N, Wainstock T, Landau D, Sheiner E. Maternal gestational diabetes 
mellitus and the risk of subsequent pediatric cardiovascular diseases of the offspring: a population-
based cohort study with up to 18 years of follow up. Acta Diabetol 2018; doi: 10.1007/s00592-018-
1176-1.   
18. 
Sacco F, Calderone A, Castagnoli L, Cesareni G. The cell-autonomous mechanisms 
underlying the activity of metformin as an anticancer drug. Br J Cancer 2016;115:1451–6.   
19. 
Romero R, Erez O, Hüttemann M, Maymon E, Panaitescu B, Conde-Agudelo A, et al. 
Metformin, the aspirin of the 21st century: its role in gestational diabetes mellitus, prevention of 
preeclampsia and cancer, and the promotion of longevity. Am J Obstet Gynecol 2017;217:282–
302.  
20. 
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;358:2003–15.   
21. 
Rowan JA, Rush EC, Obolonkin V, Battin M, Wouldes T, Hague WM. Metformin in 
Gestational Diabetes: The Offspring Follow-Up (MiG TOFU): Body composition at 2 years of age. 
Diabetes Care 2011;34:2279– 84.  
22. 
Vanky E, Stridsklev S, Heimstad R, Romundstad P, Skogøy K, Kleggetveit O, et al. 
Metformin versus placebo from first trimester to delivery in polycystic ovary syndrome: a randomized, 
controlled multicenter study. J Clin Endocrinol Metab 2010;95:E448–55.  
23. 
Barbour LA, Scifres C, Valent AM, Friedman JE, Buchanan TA, Coustan D, et al. A 
cautionary response to SMFM statement: pharmacological treatment of gestational diabetes. Am J 
Obstet Gynecol 2018; doi:  
10.1016/j.ajog.2018.06.013.  
24. 
van Weelden W, Wekker V, de Wit L, Limpens J, Ijäs H, van Wassenaer-Leemhuis AG, et 
al. Long-Term Effects of Oral Antidiabetic Drugs During Pregnancy on Offspring: A Systematic 
Review and Metaanalysis of Follow-up Studies of RCTs. Diabetes Ther [Internet]. 2018 [cited 2018 
Sep 12]; Available from: http://www.ncbi.nlm.nih.gov/pubmed/30168045  
25. 
Martis R, Crowther CA, Shepherd E, Alsweiler J, Downie MR, Brown J. Treatments for 
women with gestational diabetes mellitus: an overview of Cochrane systematic reviews. Cochrane 
Database Syst Rev 2018;8:CD012327.   
26. 
Langer O, Conway DL, Berkus MD, Xenakis EM-J, Gonzales O. A Comparison of Glyburide 
and Insulin in Women with Gestational Diabetes Mellitus. N Engl J Med 2000;343:1134–8.   
27. 
Reynolds RM, Denison FC, Juszczak E, Bell JL, Penneycard J, Strachan MWJ, et al. 
Glibenclamide and metfoRmin versus stAndard care in gEstational diabeteS (GRACES): a feasibility 
open label randomised trial. BMC Pregnancy Childbirth 2017;17:316.   
28. 
Bonde L, Vilsbøll T, Nielsen T, Bagger JI, Svare JA, Holst JJ, et al. Reduced postprandial 
GLP-1 responses in women with gestational diabetes mellitus. Diabetes, Obes Metab 2013;15:713–
20.   
29. 
Koren O, Goodrich JK, Cullender TC, Spor A, Laitinen K, Bäckhed HK, et al. Host remodeling 
of the gut microbiome and metabolic changes during pregnancy. Cell 2012;150:470–80.   

 
EudraCT Number 2019-002880-82, IRAS Number 1003208 
 
 
GUARD protocol V1.0 11Mar20 
Page 48 of 53 
 
 
 
30. 
Crusell MKW, Hansen TH, Nielsen T, Allin KH, Rühlemann MC, Damm P, et al. Gestational 
diabetes is associated with change in the gut microbiota composition in third trimester of pregnancy 
and postpartum. Microbiome 2018;6:89.   
31. 
Collado MC, Isolauri E, Laitinen K, Salminen S. Distinct composition of gut microbiota during 
pregnancy in overweight and normal-weight women. Am J Clin Nutr 2008;88:894–9.   
32. 
Forslund K, Hildebrand F, Nielsen T, Falony G, Le Chatelier E, Sunagawa S, et al. 
Disentangling type 2 diabetes and metformin treatment signatures in the human gut microbiota. 
Nature 2015;528:262–6.   
33. 
Gao Z, Yin J, Zhang J, Ward RE, Martin RJ, Lefevre M, et al. Butyrate Improves Insulin 
Sensitivity and Increases Energy Expenditure in Mice. Diabetes 2009;58:1509–17.   
34. 
Wikström Shemer E, Marschall HU, Ludvigsson JF, Stephansson O. Intrahepatic cholestasis 
of pregnancy and associated adverse pregnancy and fetal outcomes: a 12-year population-based 
cohort study. BJOG 2013;120:717–23.   
35. 
Martineau MG, Raker C, Dixon PH, Chambers J, Machirori M, King NM, et al. The metabolic 
profile of intrahepatic cholestasis of pregnancy is associated with impaired glucose tolerance, 
dyslipidemia, and increased fetal growth. Diabetes Care 2015;38:243–8.   
36. 
Kreymann B, Ghatei MA, Williams G, Bloom SR. Glucagon-like peptide-1 7-36: a 
physiological incretin in man. Lancet 1987;330:1300–4.   
37. 
Maruyama T, Miyamoto Y, Nakamura T, Tamai Y, Okada H, Sugiyama E, et al. Identification 
of membrane-type receptor for bile acids (M-BAR). Biochem Biophys Res Commun 
2002;298:714–9.   
38. 
Shima KR, Ota T, Kato K-I, Takeshita Y, Misu H, Kaneko S, et al. Ursodeoxycholic acid 
potentiates dipeptidyl peptidase-4 inhibitor sitagliptin by enhancing glucagon-like peptide-1 secretion 
in patients with type 2 diabetes and chronic liver disease: a pilot randomized controlled and add-on 
study. BMJ Open Diabetes Res Care 2018;6:e000469.   
39. 
Sánchez-García A, Sahebkar A, Simental-Mendía M, Simental-Mendía LE. Effect of 
ursodeoxycholic acid on glycemic markers: A systematic review and meta-analysis of clinical trials. 
Pharmacol Res 2018;135:144–9.  
40. 
Foghsgaard S, Andreasen C, Vedtofte L, Andersen ES, Bahne E, Strandberg C, et al. 
Nonalcoholic Fatty Liver Disease Is Prevalent in Women With Prior Gestational Diabetes Mellitus 
and Independently Associated With Insulin Resistance and Waist Circumference. Diabetes Care 
2017;40:109–16.  
41. 
Murphy HR, Rayman G, Duffield K, Lewis KS, Kelly S, Johal B, et al. Changes in the 
Glycemic Profiles of Women With Type 1 and Type 2 Diabetes During Pregnancy. Diabetes Care 
2007;30:2785–91.  
42. 
Danne T, Nimri R, Battelino T, Bergenstal RM, Close KL, DeVries JH, et al. International 
Consensus on Use of Continuous Glucose Monitoring. Diabetes Care 2017;40:1631–40.  
43. 
HAPO Study Cooperative Research Group, Metzger BE, Lowe LP, Dyer AR, Trimble ER, 
Chaovarindr U, et al. Hyperglycemia and Adverse Pregnancy Outcomes. N Engl J Med 
2008;358:1991–2002.   
44. 
Méndez-Sánchez N, González V, Chávez-Tapia N, Ramos MH, Uribe M. Weight reduction 
and ursodeoxycholic acid in subjects with nonalcoholic fatty liver disease. A double-blind, placebo-
controlled trial. Ann Hepatol 2004;3:108–12.   
45. 
Chappell LC, Gurung V, Seed PT, Chambers J, Williamson C, Thornton JG. Ursodeoxycholic 
acid versus placebo, and early term delivery versus expectant management, in women with 
intrahepatic cholestasis of pregnancy: semifactorial randomised clinical trial. BMJ 2012;344:e3799.  

 
EudraCT Number 2019-002880-82, IRAS Number 1003208 
 
 
GUARD protocol V1.0 11Mar20 
Page 49 of 53 
 
 
 
46. 
Webster LM, Myers JE, Nelson-Piercy C, Mills C, Watt-Coote I, Khalil A, et al. Longitudinal 
changes in vascular function parameters in pregnant women with chronic hypertension and 
association with adverse outcome: a cohort study. Ultrasound Obstet Gynecol 2018; doi: 
10.1002/uog.19021.   
47. 
Ben-Shlomo Y, Spears M, Boustred C, May M, Anderson SG, Benjamin EJ, et al. Aortic 
Pulse Wave Velocity Improves Cardiovascular Event Prediction. J Am Coll Cardiol 2014;63:636–
46.  
48. 
Vlachopoulos C, Aznaouridis K, O’Rourke MF, Safar ME, Baou K, Stefanadis C. Prediction 
of cardiovascular events and all-cause mortality with central haemodynamics: a systematic review 
and meta-analysis. Eur Heart J 2010;31:1865–71.   
49. 
Cruickshank K, Riste L, Anderson SG, Wright JS, Dunn G, Gosling RG. Aortic pulse-wave 
velocity and its relationship to mortality in diabetes and glucose intolerance: an integrated index of 
vascular function? Circulation 2002;106:2085–90.   
50. 
Ozcan U, Yilmaz E, Ozcan L, Furuhashi M, Vaillancourt E, Smith RO, et al. Chemical 
chaperones reduce ER stress and restore glucose homeostasis in a mouse model of type 2 diabetes. 
Science 2006;313:1137– 40.  
51. 
Gardosi J, Francis A, Williams M, Hugh O, Loi S. Customised Centile Calculator GROW 
v8.0.1, 2018. Gestation Network www.gestation.net. 
52. 
White IR, Horton NJ, Carpenter J, Pocock SJ (2011).  Strategy for intention to treat analysis 
in randomised trials with missing outcome data.  BMJ 2011;342:d40 doi: 10.1136/bmj.d40. 
53. 
Geller NL, Pocock SJ. Interim analyses in randomized clinical trials: ramifications and 
guidelines for practitioners. Biometrics 1987; 43:213-23. 
54. 
Jones B, Jarvis P, Lewis JA, Ebbutt AF. Trials to assess equivalence: the importance of 
rigorous methods. BMJ 1996; 313: 36-39. 
55. 
Pharmacol Res. 2018 Sep;135:144-149. doi: 10.1016/j.phrs.2018.08.008. Epub 2018 Aug 9. 
Effect of ursodeoxycholic acid on glycemic markers: A systematic review and meta-analysis of 
clinical trials. Sánchez-García A1, Sahebkar A2, Simental-Mendía M3, Simental-Mendía LE4. 
56. 
Chappell LC, Bell J, Smith A, Linsell L, Juszczak E, Dixon PH, Chambers J, Hunter R, Dorling 
J, Williamson C*, Thornton JG* Ursodeoxycholic acid versus placebo in women with intrahepatic 
cholestasis of pregnancy (PITCHES): a randomised controlled trial. Lancet May 2019. doi: 
10.1016/S0140-6736(19)31270-X. PMID: 3137839 
 
57. 
Flynn et al. Dietary patterns in obese pregnant women; influence of a behavioral intervention 
of diet and physical activity in the UPBEAT randomized controlled trial. International Journal of 
Behavioral Nutrition and Physical Activity (2016) 13:124 
58. 
 
 
 
 
 
 

 
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21. Appendixes 
 
Appendix 1 - Studies of gut metabolites show conversion of UDCA to lithocholic 
acid (LCA), a potent TGR5 ligand.  
 
Our data suggest that UDCA treatment causes enrichment with bile salt hydrolase-
encoding bacteria of the Bacteroidetes phylum (Figure 1A). These deconjugate intestinal 
bile acids, enabling their modification to the secondary bile acids; in particular UDCA is 
converted to lithocholic acid (LCA). Of relevance to this application, secondary bile acids 
have greater affinity for the bile acid receptor TGR5 (also known as G protein bile acid 
receptor, GPBAR1), with LCA having the highest affinity37. Activation of TGR5 in the 
intestine stimulates the release of GLP-1. Our pilot data also reveal increased 
concentrations of LCA in the faeces of UDCA treated women (Figure 1B). 
 
  
Figure 1. UDCA treatment alters the gut microbiota in ICP women. A. The ratio of Bacteroidetes 
to Firmicutes is increased with UDCA treatment of ICP, determined by 16S rRNA sequencing of 
the faecal microbiota. B. Secondary bile acids (LCA: lithocholic acid and UDCA) are significantly 
elevated in the faeces of women with ICP who were taking UDCA. C. The dyslipidaemia of 
cholestatic pregnancy is attenuated for cholesterol and low density lipoprotein (LDL) cholesterol 
with UDCA treatment. Groups compared with 2-way ANOVA and Tukey’s multiple comparisons 
tests, *P<0.05, **P<0.01, ***P<0.001, ****P<0.0001. 
 
 
Appendix 2 - UDCA treatment improves ICP-associated maternal and fetal 
dyslipidaemia   
  
(Figure 2A). Importantly, we also show that maternal UDCA treatment is associated 
with improvements in neonatal dyslipidaemia (Figure 2B).   
 
 
 
 
 
 

 
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Figure 2. Impact of maternal UDCA treatment on fetal lipid profiles of women with ICP. A. Maternal 
serum lipid profile of cholesterol, HDL-Cholesterol (HDL), LDL-Cholesterol (LDL), and triglycerides 
in normal pregnancy, untreated ICP pregnancy, and UDCA-treated ICP pregnancy. Fetal lipid 
profiles from mothers who had a normal pregnancy, ICP, or ICP treated with UDCA, of B. 
Cholesterol, C. free fatty acids (FFA) and D. triglycerides (TG). Samples were measured from 
umbilical cord serum in female and male fetuses of women with ICP. Error bars represent standard 
error of the mean (SEM). Data were analysed by multiple measures of ANOVA followed by Neuman 
Keul’s post-hoc testing. *P<0.05, n=8-10.  
 
 
 
A 
B 
C 
D 
Fetal Serum 
Maternal Serum 

 
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22. Record of protocol amendments 
 
Amendment type, number 
and date 
Summary of changes 
 
 
 
 

 
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23. Signatures 
 
 
 
 
______________________________________  
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Chief Investigator 
 
 
 
 
Date 
Print name 
 
 
 
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Statistician (if applicable) 
 
 
 
Date 
Print name 
 
 
 
 
 
______________________________________  
_________________________ 
Principal Investigator (if applicable)  
 
Date 
Print name