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Dr. Caldarella: I’m Felice Caldarella. I’m an endocrinologist in Clinton, New Jersey. I’ve been in practice now for just about 13 years at Hunterdon Medical Center which is in Hunterdon County with about a 100,000 people in the county, taking care of people with diabetes, thyroid disease and just having lots of fun. I also do a weight loss program as part of the Center for Advanced Weight Loss, so I do that for about 40% of my time is helping people lose weight with medical means, with meal replacement programs and medications. One part of my practice I get to start medications to help people control diabetes and another part of my practice I help them lose weight to help control their diabetes. Doing a little bit of both is exciting.
Joy Pape: That’s great. So, you’re on the board here at AACE and here we are at AACE 2016 in Orlando, Florida. So, you chaired a symposium. Can you tell us about that?
Dr. Caldarella: So, this is AACE’s 25th annual meeting, so we’re back in Orlando. It’s been a great meeting so far. My symposium was about endocrine diseases in pregnancy. We had three speakers. We had Dr. Hennessy talk about thyroid disease, Dr. Merck from the NAH speak to us about adrenal insufficiency and congenital adrenal hyperplasia, and we also had Dr. Jovanovic from California talk to us about diabetes in pregnancy. It was a dynamic program, well-received by the audience. A lot of take-home points, a lot of practical management skills, and how to use insulin, the doses, the protocol to follow to make diabetes management in pregnancy straight-forward, non-anxiety provoking. We wanted our audience to go back into the office on Tuesday, Monday’s Memorial Day, so not Monday but Tuesday, and when they get that phone call from the obstetrician, not to panic, not to go crazy, what am I going to do, but just to be able to comfortably take care of that patient, most often reassuring that pregnant patient that they’re fine. And that they’re going to have a healthy baby and a healthy pregnancy. So, it was really exciting to pass that information along to our attendees.
Joy Pape: Are there some quick take-home tips that you can share with our audience about what they can do when they get that call? Or when they get someone referred to them? What would you tell a person on the first visit? And something to help us work with women who are pregnant and have diabetes?
Dr. Caldarella: First, reassure the patient, most often it’s going to be ok that with proper management and care that things tend to go fine. We understand what happens in pregnancy. It’s not a big black box, there are predictable physiological changes that occur in pregnancy that yes, they change during the pregnancy. So, the first trimester is different from the second trimester which is different from the third trimester and now we see that delivery is different than all three combined. But it’s predictable, we understand it. So, we could anticipate what’s going to happen as clinicians. So, for diabetes probably the biggest point is, if you have diabetes, you need to control your diabetes first. That’s really the key to a healthy pregnancy, if someone has either Type 1 or Type 2, is having controlled diabetes prior to the start of their pregnancy. So, working with your endocrinologist and with your gynecologist to make sure that you’re healthy before getting pregnant.
Joy Pape: And for how long should you be working on getting tight management prior to getting pregnant.
Dr. Caldarella: Yeah, well you want it prior to conception, so for how long? I encourage my patients for at least 6 weeks prior and then I give them the red light to give me a call when you’re pregnant. And it takes a lot of work and it’s the work that will be continued during the pregnancy so: proper diet, meeting with the nutritionist, understanding what a proper diet is, meeting with the diabetes educator, knowing injections and blood sugar testing, sick day rules, when to call the doctor, meeting with your gynecologist, making sure you’re healthy, your labs are fine, you’re not anemic, you’re on the proper vitamin regimen, you’re taking your prenatals, you’re on the folic acid, meeting with your endocrinologist, make sure your insulins are proper for pregnancy, so any insulins that aren’t safe for pregnancy, you’ve been taken off of them, your blood sugars are controlled, so fasting sugars less than 90, one-hour blood sugars less than 120, which is pretty aggressive in getting used to that. So, it’s different than what we would recommend for most patients who aren’t pregnant. Testing your blood sugars, pre/post-meal, bedtime, 3 AM, lots of back and forth with your endocrinologist. So, it’s a lot of work, but at the end, when you have a healthy baby, it’s really quite worth it. It’s certainly worth it for the mom, but as an endocrinologist that’s taken care of patients during pregnancy, it’s the most rewarding thing to see, when you see a healthy baby. Then, the most exciting thing for me is when they come back to me with the second pregnancy, that they trust me the second time around. For the first time around, they don’t know, but the second time around when they come back to me and they’re pregnant again and they trust me to help them, that’s rewarding. That’s exciting. I’m making a big difference in their lives with the health of their baby. So, it’s really quite exciting.
Joy Pape: Do you recommend continuous glucose monitoring during pregnancy?
Dr. Caldarella: If patients are using it already, continue it, if they’re not, I think it’s just one more tool. It’s a tool and if you’re not paying attention to it, it’s not a helpful tool. If you are paying attention to it, then it’s going to help you. So, I don’t think it’s absolutely a must. Again, it’s probably part of that conversation that you’re having with your doctor when you are getting ready to want to start a family. So, it’s part of that conversation. Should we introduce CGM if you haven’t been on it already? I think it’s just one more tool. So, I don’t think it’s a must. I’ve treated plenty of women without CGM during pregnancy and they’ve done just fine. And the same with. And the same with insulin pumps. I think we put a lot into the technology and the technology makes people’s lives easier and more flexible but you could still get to the same place with old-fashioned injections.
Joy Pape: What about people who have gestational diabetes or even Type 2 diabetes? What about orals, do you use any oral agents?
Dr. Caldarella: I love insulin. Insulin works each and every time. Oral agents work most of the time, so you have to be on the lookout for when it doesn’t work. And that just doesn’t make me feel comfortable, because then you’re playing catch-up to making up for the time you lost when the patient was out of control and realizing they were out of control. So, I’m a believer in insulin for any type of diabetes during pregnancy. So, if you are not controlled for the gestational diabetes. If you’re not controlling with medical nutritional therapy with the help of your dietitian. And they are key, they are just as important as the physician, and your educator, helping to manage that person’s diabetes, I start on insulin.
Joy Pape: Anything else exciting you want to tell us about the symposium? About thyroid disease?
Dr. Caldarella: Thyroid disease. So earlier today we heard about the genetics of thyroid disease and being able to personalize the care of patients with thyroid cancer and understanding which thyroid nodules we need to pay attention to and which we don’t. So, I think the personalization is really wonderful, using genetic material from the nodule. I think that’s pretty exciting to reassure the patient that you’re going to be OK. Or maybe tell the patient this is something we really have to pay attention to and be more watchful. And so the patient understands. So, it relieves anxiety for some so we know what we are dealing with in terms of cancer. I think in thyroid we are ready for that. We do that for other cancers, like breast cancer, we do receptor marking. We choose medications based on genetic material of the cancer and we’re just starting that with thyroid cancer. So, I’m pretty excited about that.
Joy Pape: And what about thyroid and pregnancy?
Dr. Caldarella: Thyroid and pregnancy? Again, there’s physiological changes that happen in pregnancy with the thyroid hormone levels. Most of the time it’s just normal for pregnancy. Unfortunately, the lab doesn’t know that the patient is pregnant. I don’t want to call them a patient, because patient isn’t a disease, pregnancy is just a normal condition, and I think we sometimes forget that. As clinicians and physicians who are used to treating disease, that when we have a pregnant person in our office, they are just a healthy person who’s pregnant. It’s not a disease. Thyroid levels change in pregnancy. And that’s normal. Changes that are not going to have any effect on the baby or the mom, and they are just normal. That’s where you can really reassure the mom. In terms of treatment, treatments again are predictable. So, we know how the medications work and what their response is. Again, I think as endocrinologists, taking care of those patients with thyroid disease, it’s actually lots of fun. You get to see your results. You’re not waiting three or four years to avoid a complication, but you see it in 6-9 months, you see a healthy baby. So, it’s really reassuring. It’s pretty rewarding when you are taking care of a pregnant woman during the course of their pregnancy.
Joy Pape: So, with that, there’s a lot of people, OBGYNs, a lot of PCPs, who see people who are pregnant and have thyroid disease. Do you think these people should be referred to an endocrinologist?
Dr. Caldarella: I think so, because we are the experts in hormone levels and hormone disorders, and what’s normal and what’s not. I think an endocrinologist is best able to sort that out. Someone who isn’t would just get confused. A confused physician is not good for a healthy patient. It’s going to cause a lot of stress and anxiety in the patient. If someone has preexisting thyroid disease, check them with the endocrinologist. The endocrinologist would talk to you walk you through what’s going to happen: step A, step B, step C, what to expect. And you’ll have a healthier pregnancy and a pregnancy where it’s going to reduce a lot of stress on the patient’s part. Absolutely I think an endocrinologist should be involved in any thyroid patient during their pregnancy.
Joy Pape: So, from the last few days you’ve been here, what would you say is the most exciting thing you’ve learned and experienced here at the convention?
Dr. Caldarella: I would say experience wise, just interacting with my colleagues. It’s great to be in one place talking to other endocrinologists, what’s going on in their town, be it patient management, be it interaction with their health care systems. There’s a lot of change afoot with health care payment models changing and how are they reacting to that. I think it’s just talking and getting to know your colleagues. That’s what I find most exciting about coming to this type of meeting where you are interacting with other clinicians.
Joy Pape: When you get home, is there going to be one thing that you change in your practice? From being here these last few days? And what would that be?
Dr. Caldarella: I attended an obesity conference earlier in this session. I think continuing to work with my patients and helping them lose weight. To not lose weight to reduce the pounds, but lose weight to help reduce their diabetes risk if they have pre-diabetes, help them better manage their diabetes if they have diabetes, or hypertension or sleep apnea, if they have obstructive sleep apnea. Those conditions, to really help improve health. I think all physicians should really look at risk factors and the disease burden from things that can be preventable. Like weight, like smoking, so all of those lifestyle management issues that we should be spending a lot more time focusing on.
Joy Pape: But I think that you do, you say this is what you’ve been specializing in. What’s going to be different? It could be something specifically in obesity management? What’s going to be different from being here?
Dr. Caldarella: Let me think. It’s been hard.
Joy Pape: And what about next year. You’re on the board, tell us about what to expect next year?
Dr. Caldarella: So, next year we’re going to be in Austin. Nice environ, exciting, fresh town, where we’re going to hopefully just continue what we’ve been doing, which is providing education to our members, learning about and updating clinical medicine, learning new hot science that’s going to be translated into clinical medicine. So, it’s probably going to be more of the same, just a great exciting meeting.
Joy Pape: So, Austin is going to be awesome.
Dr. Caldarella: Awesome, yes.