Exclusive Interview from AACE Orlando
Steve Freed: How much should we be concerned with when it comes to gestational diabetes?
Dr. Jovanovic: Actually gestational diabetes — and that’s where the ADA, AACE and the international congresses have all been fighting about how you make the diagnosis — quite frankly, probably 50% of all pregnant women have some form of glucose intolerance. So we should be universal screening, [but] the ADA doesn’t do universal screening. They say there are risk factors for which you would give the drink in the middle of the pregnancy. We really need to do universal screenings for all pregnant women, get a sugar drink and have their blood-sugar measured after the drink and the cut off has to be very low, as you hear a blood sugar greater than 120 [it] increases the risk of fat baby. So really I’ve been yelling for years that we needed to give a 50 gram drink, a one hour test and anybody with a one hour test greater than 120 we label as hyperglycemia in pregnancy; who cares about the word gestational? And we end up making the blood sugars below 120. So you see if you don’t use the word gestational it’s not a problem, you just make the blood sugars normal. And in fact a great friend of mine who helped write the guidelines, obliterated the word “gestational” diabetes, and it’s now called hyperglycemia in pregnancy. So now you’ve got a new term.
Steve Freed: Well we’ve seen some changes when it comes to the numbers over the… very recently obviously. What are your feelings, do you think the numbers make more sense?
Dr. Jovanovic: The glucose tolerance test has always been a problem because obstetricians worry that you see the two-step test makes a prevalence of gestational diabetes of about 9%. If you do the one-step test, my way, the prevalence of gestational diabetes goes up to 18%. Now that doubles the number of women who have hyperglycemia in pregnancy. And obstetricians think that’s going to abuse health care costs, it’s going to take up too much time. But I always say, you know it’s easier to teach two women than one. If you’re going to teach somebody and go to the effort of teaching well, isn’t it nice to have two people in the room, not one. So it doesn’t increase the cost if you double the number of women with the diagnosis of hyperglycemia in pregnancy. The controversy’s always been, well the obstetricians don’t want too many people labeled and the endocrinologists want to take care of everybody. So we’re still split, and it’s been that way since I’ve been in the practice of medicine.
Steve Freed: Coming up is the ADA, and everybody’s waiting for the news of the artificial pancreas. There’s a recent study that was just done. I had a chance to talk to Dr. Bode and how exactly will it affect pregnancy and diabetes for the gestational diabetic?
Dr. Jovanovic: Well first of all I wouldn’t use an artificial pancreas on a woman with gestational diabetes, because it’s a teachable moment for that woman to learn how to take care of herself and prevent type 2 diabetes in the future. So to use an artificial pancreas on her it really is a waste of resources. In addition there’s always the concern about where do you put the needles, because as her tummy stretches and grows, she doesn’t have a lot of real estate, Bruce Bode likes to call it real estate, to put the needle and make sure one device is talking to the other. The other concern is the continuous glucose monitor isn’t accurate enough in blood sugars less than 70; now a normal blood sugar in a pregnant woman is 55 to 120. So if you don’t know if your blood sugar is 55 or 70 with a glucose sensor, you have no way to keep blood sugars in normal range. So the glucose sensor is very difficult to use and keep good control on pregnancy just because it isn’t accurate in the low ranges. So now you hear my thoughts on using an artificial pancreas in pregnancy. I think the truth is as long as a woman is checking her blood sugars herself and making sure her insulin pump is working and not stopping, because if it stops she’s not going to get insulin at all and that’s more dangerous than anything you can ever think of in pregnancy, that she has to work even harder if she wears an artificial pancreas than if she just takes multiple injections.
Steve Freed: So what is your feeling about pregnancy for any type 1s and using insulin pumps?
Dr. Jovanovic: I think they can continue to use their insulin pump, they have to realize they have to go to a physician who knows how to increase the basal and bolus during pregnancy for the algorithms, not just stay on the same basal all the time. You have to know that you have to take a kiss of a long-acting insulin every night. And the reason is if the pump stops on the artificial pancreas, you only have 4 hours to go into ketoacidosis. So she has to realize she’s getting her insulin through a pump and it could malfunction, she has to have available syringes, pens, insulin in a refrigerator to take over while she’s waiting for her pump or her device to be returned to her. So she truly… it’s really harder to be on a continuous glucose sensor and a continuous glucose pump and to think that you can put the right algorithms in there for pregnancy and nobody’s written them. So you can’t use the non-pregnant algorithm by Bruce Bode and think it applies to pregnant women. So you’d have to make it specific, which would mean another go through the FDA. The FDA really needs to improve everything on pregnancy including devices.