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Volume 10, Number 5 May 2007 - NDEI.org

Professional Postgraduate Services ®Release Date: June 2007Valid Until: October 2007SponsorThis educational activity is a component of theNational Diabetes Education Initiative ® (NDEI ® ),sponsored by Professional PostgraduateServices ® (PPS), Secaucus, NJ.Clinicians who wish to receive CME credit forthis educational activity should do the following:(1) read the current issue; and (2) complete thepost-test and evaluation form included to concludethis CME activity. You may also complete thepost-test and evaluation form on our website,www.ndei.org. To apply for CME credit, returnthe completed post-test and evaluation form to:Professional Postgraduate Services ®CME Dept. T196150 Meadowlands ParkwaySecaucus, NJ 07094-1505You may also fax the completed materials to1 (201) 430-1441. If you have any questions,please call 1 (800) 606-6106 Ext. 6139.Applicants will receive a certificate of participationfrom PPS by return mail within 6 to 8 weeks of thedate of receipt of the completed evaluation formand post-test. Online applicants will automaticallyreceive their CME credit certificate upon completionof the online post-test and evaluation form.Target AudienceThis educational activity is designed for primarycare physicians, internal medicine specialists,endocrinologists, diabetologists, cardiologists,and other healthcare professionals involved inthe care and management of patients withtype 2 diabetes, insulin resistance, and cardiovasculardisease.Learning ObjectivesWith information from the latest evidence-basedstudies, participants should be able to:• Identify patients with insulin resistance, type2 diabetes, and/or cardiovascular disease• Select the most appropriate therapeuticregimen for patients with type 2 diabetesand its macrovascular and microvascularcomplications• Identify risk factors for cardiovascular diseasein patients with type 2 diabetes and selectan appropriate therapeutic regimenAccreditationProfessional Postgraduate Services ®is accredited by the Accreditation Councilfor Continuing Medical Education to providecontinuing medical education for physicians.Professional Postgraduate Services ®designates this educational activity for amaximum of .75 AMA PRA Category 1 Credit.Physicians should only claim credit commensuratewith the extent of their participation in theactivity.GrantorThis CME activity is supported by an educationalgrant from Takeda Pharmaceuticals NorthAmerica, Inc.Off-Label DisclosureSome of the drug treatments discussed in thisissue may note uses not approved by the Foodand Drug Administration. Articles containing suchuses will be noted at the end of the article.Additional PPS Staff DisclosuresMs. Fontan, MPA is Professional PostgraduateServices’ Program Manager for the NDEIClinical Insights ® in Diabetes program. She hasindicated no relevant financial relationships.Ms. Terry is Professional Postgraduate Services’CME Program Manager. She has indicated norelevant financial relationships.CLINICAL INSIGHTS ®INDiabetesSILVIO E. INZUCCHI, MD,* CO-EDITOR-IN-CHIEF; THOMAS A. BUCHANAN, MD, † REVIEWER;TERRENCE F. FAGAN, ‡ MANAGING EDITOR; MARK A. PALANGIO, § WRITERAddition of Exenatide to Thiazolidinedione TherapyImproves Glycemic Control and Reduces Body Weight inPatients With Type 2 DiabetesExenatide, the first in a new class of antihyperglycemicagents called incretinmimetics, is approved for treating type 2diabetes in combination with metformin, asulfonylurea, metformin plus a sulfonylurea, ora thiazolidinedione (TZD). However, there arefew data regarding the efficacy of combiningexenatide with a TZD. The combination couldbe effective because exenatide and TZDs exertcomplementary actions that target β-celldysfunction and insulin resistance—the primarypathophysiologic defects in hyperglycemia oftype 2 diabetes.Zinman and colleagues tested the effects ofthis combination in patients with type 2 diabetes.Conducted at 49 sites in Canada, Spain, andthe United States, this randomized, double-blindtrial involved 233 patients with type 2 diabetesthat was suboptimally controlled with TZDtreatment. Patients were randomized to receiveeither exenatide (10 µg; twice-daily subcutaneousabdominal injections) (n=121) or placebo(n=112) added to a TZD (with or without metformin)for 16 weeks. Patients were required tobe on stable doses of a TZD (rosiglitazone≥4 mg/d or pioglitazone ≥30 mg/d). The mean ±standard error (SE) baseline glycated hemoglobin(A1C) level was 7.9% ± 0.1%. The primary outcomewas change from baseline in A1C level.Other outcomes included fasting serum glucoselevel, body weight, self-monitored blood glucoselevel, and adverse events.After 16 weeks, A1C levels decreased by amean (± SE) of 0.89% (± 0.09%) in the exenatidegroup but increased by mean of 0.09% (± 0.10%)in the placebo group. The mean between-groupdifference in A1C levels was –0.98% (95% confidenceinterval [CI], –1.21% to –0.74%; P

CLINICAL INSIGHTS ®IN DIABETESNEW On-Demand CMEInteractive Case Studyat www.ndei.org:‘‘A 54-Year-Old Taxi DriverWho Presents for Reassessmentof His Type 2 Diabetes andNew Dyspnea on Exertion’’.For primary care physicians andother healthcare professionalsinvolved in the care of patientswith type 2 diabetes.Earn .75 AMA PRA Category1 Credit--Free.Addition of Exenatide to Thiazolidinedione TherapyImproves Glycemic Control and Reduces Body Weight inPatients With Type 2 DiabetesContinuedplacebo group. Significantly more patients inthe exenatide group than in the placebo groupexperienced nausea (40% vs 15%) and vomiting(13% vs 1%). The incidence of treatmentemergentedema was similar in the exenatideand placebo groups (6% vs 8%). The overall incidenceof hypoglycemia, defined as symptoms ora self-monitored glucose

CLINICAL INSIGHTS ®IN DIABETESDisparities in Insulin Resistance and Risk Factors forType 2 Diabetes and Cardiovascular Disease inModerately Obese IndividualsContinuedtertile 3 were also significantly different fromthose in tertile 2. There were no significant differencesbetween the groups with regard tototal and low-density lipoprotein cholesterolconcentrations.Risk factors for developing type 2 diabetesor CVD assessed in this study included hypertension,hypertriglyceridemia (≥150 mg/dL), low HDLcholesterol (men,

CLINICAL INSIGHTS ®IN DIABETESClinical Insights ® in Diabetes Post-Test May 20071) A 16-week study that combined exenatide or placebo with thiazolidinedione (TZD) treatment inpatients with type 2 diabetes resulted in all but 1 of the following:a. An A1C level of ≤7% achieved by significantly more patients treated with exenatide thanwith placebob. Self-monitored blood glucose measurements significantly lower throughout the day in theexenatide group than in the placebo groupc. Discontinuation of treatment because of adverse events that occurred equally betweenthe 2 groupsd. Patients in the exenatide group recorded weight loss of ~1.5 kg on average, compared with noweight change in the placebo group2) In a study of obese patients stratified in tertiles based on mean steady state plasma glucoseconcentrations, which risk factor was not significantly lower in patients in tertile 1 (81 mg/dL)compared with tertile 3 (247 mg/dL)?a. Low-density lipoprotein cholesterol concentrationsb. Systolic and diastolic blood pressurec. Triglyceride concentrationsd. Prevalent impaired glucose tolerance3) A comparison of metabolic risk and body mass index in 4 ethnic groups in a Canadian study showedthat, compared with patients of European descent with a BMI of 30 kg/m 2 , the collective cut pointfor obesity based on glucose and lipid factors for South Asians, Chinese, and Aboriginals isa. Equivalentb. Lower by approximately 6 kg/m 2 (ie, 24 kg/m 2 )c. Lower by approximately 2 kg/m 2 (ie, 28 kg/m 2 )d. Higher by approximately 3 kg/m 2 (ie, 33 kg/m 2 )ANSWER KEYNDEI MISSION STATEMENTThe National Diabetes EducationInitiative ® (NDEI ® ) is a multicomponenteducational program on type 2 diabetesdesigned for endocrinologists, diabetologists,cardiologists, primary carephysicians, and other healthcareprofessionals involved in the care andmanagement of patients with type 2diabetes and insulin resistance. NDEIprograms address issues concerninginsulin resistance and type 2 diabetes,from the epidemiology and pathophysiologyof the disease and its associatedcomplications to the therapeuticoptions for treatment and prevention.1. c. Discontinuation of treatment because of adverse events that occurred equally between the 2 groups.Adverse events caused discontinuation of treatment in 16% of patients in the exenatide group comparedwith 2% in the placebo group.2. a. Low-density lipoprotein cholesterol concentrations. Although the most insulin resistant tertile of patientsshowed significantly greater risk in almost all metabolic categories, there were no significant differencesbetween the groups in LDL-C or total cholesterol concentrations.3. b. Lower by approximately 6 kg/m 2 (ie, 24 kg/m 2 ). Compared with a BMI cut point of 30 kg/m 2 in theEuropean group, similar glucose and lipid factor distribution for metabolic risk was found in considerablylower BMI cut points in the South Asian, Chinese, and Aboriginal groups in the study.For more information about upcoming NDEI CME and CE activities, visit us at www.ndei.org or call1 (800) 606-6106, ext. 6139. Visit www.ppscme.org for information on other CME or CE activities.Clinical Insights ® in Diabetes is co-edited by NDEI faculty members Mayer B. Davidson, MD, and Silvio E. Inzucchi, MD.You have received this email because we believe it may be of interest to you. If you would likeyour name to be removed from the Clinical Insights ® newsletter email list, please click on thefollowing link www.pps-sso.com.National Diabetes Education Initiative, NDEI,and Clinical Insights are trademarks usedherein under license.Copyright © 2007 Professional PostgraduateServices ® . All rights reserved.If you have any colleagues who are not receiving this free, CME e-newsletter via email, please fillin their information on the lines below and fax this page back to us at 1 (800) 471-7716 and we willadd them to our subscriber list.Name: (Please print) Specialty: Email Address: EM-T196-2-PHYCME-05074

CLINICAL INSIGHTS ®IN DIABETESCME Activity Evaluation/Registration FormActivity Code: T196-2Issue Date: May 2007CME Credit Availability: October 2007Participants who wish to obtain CME credit for this activity, please complete the contact information below,sign this form, and fax it with the completed post-test to 1 (201) 430-1441 or mail to: ProfessionalPostgraduate Services ® , CME Dept. T196, 150 Meadowlands Parkway, Secaucus, NJ 07094-1505. You maydownload previous issues of Clinical Insights ® in Diabetes e-newsletters by visiting us online atwww.ndei.org.I have completed this activity as designed: ________________________________________________________________________________(signature)PLEASE PRINT CLEARLY:Name:Address:City:Phone:Email Address: State: ZIP Code: - - Fax: - - Professional Classification: MD DO PharmD RN NPOther ____________________________________________________________________Specialty: Endocrinology Cardiology Internal medicine Family medicineOther _________________________________________________________________________________________1. The activity met the stated objectives in such a way that I am better able to:StronglyDisagree Disagree AgreeStronglyAgreea. Identify patients with insulin resistance, type 2 diabetes, and/orcardiovascular disease1 2 3 4 5 6b. Select the most appropriate therapeutic regimen for patients with type 2diabetes and its macrovascular and microvascular complications1 2 3 4 5 6c. Identify risk factors for cardiovascular disease in patients with type 2 diabetesand select an appropriate therapeutic regimen1 2 3 4 5 62. Overall, the activity was presented in a fair-balanced manner. Yes No** If you checked “No,” please explain.3. Overall, the activity was free from commercial bias. Yes No** If you checked “No,” please explain.4. In reflecting on your practice, what type of impact will this educational activity have?This program has validated my practice in the treatment of type 2 diabetes and its cardiovascular complications.Need more information before making a change.(Please specify what information you would require.)5. What is the largest challenge or unmet educational need in your practice?6. What other clinical issues are you and your colleagues challenged by that could be addressed in a CME activity? (Please specify.)Thank you for your participation.5

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