Exclusive Interview from AACE Orlando
Steve Freed: And pregnancy also, treating type 2 diabetes… obviously you can’t test it on pregnant women. The ADA has said that’s it’s ok to take certain oral medications. What is your feeling about that?
Dr. Jovanovic: You can’t. You can’t, you can’t. Glyburide crosses the placenta, metformin crosses the placenta, and so what are [you] going to do? Make the kid get, you know, have hyperinsulinemia because glyburide’s crossing the placenta. Who knows what metformin does to an unborn baby and metformin is associated with preeclampsia in a large population of mothers. And hypertension’s a worse disease than diabetes. So your only choice is insulin, the ADA is wrong to use glyburide.
Steve Freed: So that’s something that physicians certainly, OBGYNs obviously, should be aware of.
Dr. Jovanovic: Not only that but they think if you’re taking glyburide then they don’t have to measure your blood sugar. It takes away the urgency of taking good care of the mother. A pill sounds easy and it is, but it also takes away all of the checking, what do you do after the meal. Glyburide is way too long-acting, it doesn’t treat the postprandial. So if you take glyburide twice a day, how are you going to treat the one hour after breakfast? How are you going to that unless you get up at 3 o’clock in the morning so the glyburide peaks exactly when you’re eating breakfast? It’s impossible to design a normal glycemia protocol using pills.
Steve Freed: Plus, but they say it’s not dangerous for the baby?
Dr. Jovanovic: The “they” is four cases in the New England Journal of Medicine by Oded Langer. There are four cases in the New England Journal of Medicine, in the fine print where you’ll see the babies had hypoglycemia. It’s in really teeny tiny print.
Steve Freed: That’s interesting, you had mentioned that a woman has to decide whether she wants to eat the carbs or take the insulin? So how do you present that? Where do you weigh in on that? What are your personal feelings? And where should… what should the person be aware of in making that decision?
Dr. Jovanovic: Actually, I don’t care as long as their blood sugars are normal. We do point of care A1C every week in the clinic. The A1C normal is less than 5.1%. So we measure the A1C every single week. As long as the A1C is normal in the point of care machine, the women get to leave clinic. If the A1C is elevated then they have to wait for me, hours and hours and hours. So the nurses do the finger stick A1C, we have clinic about an hour after lunch so what we know what their blood sugar is approximately an hour after lunch. If their blood sugar is less than 120 and their A1C is less than 5.3% I don’t care what they’re doing. But usually what you do is because they’re waiting so long for me, they’re in the waiting room, is that they tell each other, “Ask the doc for insulin, ask the doc for insulin, if you get insulin you get to eat anything you want. Ask the doc for insulin.” So, come pouring out of the waiting room they say, “I want some too, I want some too.”
Steve Freed: So as long as their blood sugars are normal you don’t have an issue with carbohydrate even?
Dr. Jovanovic: Absolutely not.
Steve Freed: But is it harder to maintain your blood sugars if you’re eating carbohydrate?
Dr. Jovanovic: It is, because a quick-acting carbohydrate, there isn’t an insulin that’s fast enough to be able to blunt the first that really quick simple carbohydrate. I mean if you eat something sweet it’s going to get into your blood stream in 15 minutes. Not even inhaled insulin will be able to get into the blood stream that fast, and inhaled insulin is not approved in pregnancy. The truth is you need to eat more complex carbohydrates, so that you have an opportunity for the insulin to be able to hit the blood sugar so that it doesn’t go above 120.
Steve Freed: And how important is weight with pregnancy, how does that affect the baby?
Dr. Jovanovic: It doesn’t as long as the blood sugar is normal. If the woman eats a lot and she takes a lot of insulin, she’s going to get fat. And that’s the only thing I tell her, I say you know you can eat all the tortillas or all the rice or all the carbo you want, keep your blood sugars normal with a ton of insulin, you’re just going to get fat. So that’s enough for them to say, well gee maybe I’ll make the decision not to eat so much, so I don’t have to take so much insulin. But you know they’re happy, they’re happy when they’re eating.