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Sugar is not the only thing that will raise sugar
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A 36-year-old black female was referred to me by a young obstetrician for gestational diabetes. The patient is at 12 weeks gestation with twins. She has been experiencing polydipsia and polyuria, as well as dyspnea on exertion for the past two weeks. She was diagnosed with gestational diabetes a few days prior to seeing me based on a three hour oral glucose tolerance test with 100 g and had blood glucose levels of 106, 208, 190 and 161 mg/dL at baseline, one, two and three hours. Her obstetrician is also concerned about the patient’s weight loss — from 222 to 220 lb over the past four weeks.
She has a past medical history of hepatitis B, anxiety, depression, hyperlipidemia, hypertension and a mild stroke. The patient started monitoring her blood glucose levels a few days ago. Fasting range: 99 to 115 mg/dL; random range 110 to 170 mg/dL.
Her family history included diabetes in her sister and hypertension in her father, mother, and sister. She reported that she quit using tobacco about four weeks ago after a 12.5 pack-year smoking history.
The patient is very upset during the office visit and crying, because she is concerned that her pregnancy will have a similar outcome to the last one: she had a large child three years ago (weight over 9 lb) with complications at birth and subsequent cerebral palsy. The patient had never been screened for gestational diabetes before this pregnancy.
 Ronald Tamler |
The obstetrician had prescribed NPH 10 U at night; however, the patient is “scared of needles.” She stated that she has a sedentary lifestyle, but is proud that she has “cut out all sugar” from soft drinks and her diet.
Physical exam is remarkable for an anxious, tearful woman at 12 weeks gestation. BP is 128/72 mmHg, pulse 72 BPM, height 5’ 4”, weight 220 lb, BMI is 37.76 and she has trace ankle edema. Exam was otherwise unremarkable.
What is the best thing to do for this patient?
- Send her home with the NPH 10 U at bedtime each day and have her follow up with her obstetrician in six weeks.
- Start the patient on an insulin pump with lispro in your office.
- Prescribe glyburide 10 mg/metformin 1,000 mg by mouth twice daily.
- Ask detailed questions about dietary habits and have the patient see a nutritionist as soon as possible.
- Prescribe glargine 15 U daily and glulisine with meals.
CASE DISCUSSION
The answer is D.
This patient not only has gestational diabetes, but she also has a history of obstetric complications that is very likely related to gestational diabetes in a previous pregnancy. It is therefore understandable that she is emotional during the visit, and her case underlines the importance of controlling blood glucose levels during pregnancy.
While this patient still may require pharmacotherapy, the most important step is dietary education. It turned out in this case that the patient had never received proper input on her diet. She had not been aware that starches will raise blood glucose levels. A food log when seeing the nutritionist the very next day demonstrated that she was eating 12 servings of Doritos per day, as well as a bagel, fast food fries and a large bowl of pasta. Meanwhile, the patient pointed out that Doritos “do not contain sugar.” This intervention alone improved blood glucose levels significantly.
Glargine and glulisine both carry category C classifications for pregnancy and are not agents of first choice in this population at this time.
Insulin pumps are great tools to control blood glucose levels quickly and efficiently, but the patient should first learn the basics of counting carbohydrates, which clearly has not happened here.
Glyburide in low doses has been used by obstetricians in women who refused to be treated with insulin. However, titration is less precise than insulin, leading to hypoglycemia or insufficient glycemic control. There have recently been several publications on metformin use during pregnancy, one of which was published in the New England Journal of Medicine. The use of oral antidiabetic agents during pregnancy remains controversial, and initiating the maximum dose is certainly not the best way to go in this case.
Finally, simply sending the patient away with NPH at night does not address her postprandial hyperglycemia, and the follow-up in six weeks is too far off.
In summary, patients with gestational diabetes require close monitoring and a low threshold for pharmacotherapy. However, rigorous dietary assessment and education are the foundation of treatment.
Ronald Tamler, MD, PhD, MBA, is an Assistant Professor in the Division of Endocrinology at Mount Sinai School of Medicine, NY.