Obstetrics/Gynecology

PCP submission

Diagnosed with diabetes a few months ago. Currently on metformin 1500 mg BID, previously on metformin 1500 mg BID and Farxiga (depak gliflozin) 5 mg. Stopped Farxiga upon discovering pregnanacy. A1C improved from 7.7 to 6.4 since diagnosis. Concerns about teratogenic effects of medications during pregnancy. Confirming DM2 treatment plan before patient has first appointment with OBGYN in 2 weeks.

Specialist response

As you indicate, management of DM in pregnancy can be quite different than outside pregnancy as many medications do not have demonstrated safety and others have demonstrated harm.

Unfortunately, the majority of her medications will need to be stopped as you have done. The metformin may be continued, but I suspect that it will be inadequate alone. It could be trialed as a single agent with intensive diet and exercise change, but she will likely need insulin therapy. I typically start with 0.7 units/kg daily in the first trimester, 0.8 units/kg daily in the second and 0.9 units/kg daily in the third. I divide the dose into 50% long acting (ie lantus) and the remainder divided into thirds given with short acting immediately prior to meals (ie humalog).

Goals for glucose on pregnancy as also very different. She will need to check her glucose 4 times daily and log all values. For her fasting in am, recommend < 90 ideally, although low 90s is ok. She should also check postprandial, either 1 or 2 hours. If checking 1 hr should be < 140 and for 2 hr checks should be < 120 mg/dL. After the initial start, insulin should be titrated to reach these goals. I typically see patients every 1-2 weeks throughout the pregnancy (weekly if rapid changes and every other weeks if more stable).

Weight gain goals for her during the entire pregnancy should be in the 15 lb range, the majority of which will be in the third trimester.

Until she is able to see a perinatologist/obstetrician, basic counseling would be that there is an increased risk of fetal anomalies with DM which worse the higher the periconceptional A1c, particularly the risk of congenital heart disease. She will need detailed fetal anatomy US in the mid-trimester as well as fetal echocardiogram.

There is definitely a lot to cover, but I hope this helps with things. Please let me know if there are any questions as these big changes can be really difficult for patients.