Annals for Educators - 21 February 2017

Darren B. Taichman

doi:10.7326/AFED201702210

Clinical Practice Points

Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline Update From the American College of Physicians

Twelve classes of FDA-approved drugs are available to treat type 2 diabetes mellitus (T2DM), creating a major challenge in determining the best approach to achieve and maintain the appropriate level of glycemic control, considering patient characteristics and preferences. These recommendations provide guidance to clinicians choosing oral therapy for their patients with T2DM.

Use this clinical guideline to:

Start a teaching session with a multiple-choice question. We've provided one below!
Ask your learners how many classes of drugs they can name for the treatment of T2DM. Do they know their mechanisms of action? Use the table in this guideline and the recent In the Clinic: Type 2 Diabetes to help.
How do your learners choose among available drugs when considering therapy for their patients?
The accompanying editorial notes the limitations in available evidence to guide the choice among agents to treat T2DM. Ask your learners what are comparative effectiveness studies. Why don't many of the available cardiovascular outcome trials provide the information required to choose among available therapies?
What concerns might limit the use of metformin? Is there reason to worry about renal function? Lactic acidosis? Use the accompanying editorial as well as a recent paper and its editorial addressing the safety of metformin to help guide your answers.
What variables would influence the treatments your learners would consider adding for a patient already receiving metformin who has unsatisfactory glycemic control?

Video Learning

Annals Consult Guys - Generation Gap: Stent to Stent

In this episode of the Annals consultative medicine talk show, Drs. Geno and Weitz (The Consult Guys) tackle how long dual antiplatelet therapy is required following placement of a coronary artery stent.

Use this video to:

Take a break with your learners to watch the short video.
Review the recommended approach to antiplatelet therapy following stent placement. What difference does it make whether the stent was placed in the setting of an acute coronary syndrome?
Answer the accompanying multiple-choice questions to review what you've learned, and be sure to enter your answer online to earn CME for yourself!
Invite an interventional cardiologist to discuss with your team how s/he chooses the type of stent to place.
Can your learners list physicians whose names have become verbs in common usage? Have them send in their answers to win a Consult Guys T-shirt!

History of Medicine

Battle of the Bulge: Aortic Aneurysm Management From Early Modernity to the Present

Over the past 500 years, clinicians have applied contemporary medical knowledge in an effort to understand, diagnose, and treat aortic aneurysms through highly innovative yet largely unsuccessful interventions that have culminated in modern surgical cures.

Use this paper to:

Start a teaching session with a multiple-choice question. We've provided one below.
Ask your learners what the risk factors are for aortic aneurysms. What previously was the most common cause? Use the information in DynaMed Plus: Thoracic Aortic Aneurysms and Abdominal Aortic Aneurysms (a benefit of your ACP membership) to help prepare a teaching session.
Ask if screening for aortic aneurysms is recommended. In whom? How?
How are thoracic aortic aneurysms classified? How should a patient with a thoracic aortic aneurysm be managed? Who requires surgery and when?
How should abdominal aortic aneurysms be monitored? Which require surgical intervention?

Improving Patient Care

Enhancing the Role of Internists in the Transition From Pediatric to Adult Health Care

The transition from adolescence to adulthood is replete with unique challenges that our current health system is ill-prepared to meet. The authors discuss the factors that make provision of quality health care to young adults challenging, particularly for individuals with established special health needs, as well as potential solutions for improvement.

Use this paper to:

Ask your learners if they have assumed the care of a young adult with a chronic condition. What are the challenges? Were the necessary medical records available? Had they discussed the patient's care with her or his prior physician(s)?
Invite a colleague from pediatrics or adolescent medicine to join a discussion on how to best plan for the transition of care from adolescent to adult medical office practices.
Ask your learners what the barriers are in your practice to achieving optimal transitions for these patients. Are there readily achievable changes that they could help implement to improve things?

The Scientific Basis of Guideline Recommendations on Sugar Intake. A Systematic Review

This systematic review examines the consistency and quality of 9 guidelines on dietary sugar intake.

Use this paper to:

Ask your learners what is known about the effect of sugar intake on metabolic outcomes. How would they propose to study this question in individual patients? What outcomes would they assess?
Recent laws have aimed at reducing dietary sugar intake (e.g., from sugar-sweetened beverages). On what basis would your learners expect such laws to be based? What studies would they propose to assess the impact of such laws?
How do your learners react to the findings of this review? Do they think it would matter if the evidence behind guidelines is not as strong as one would ideally like, provided most physicians believe that what the guideline recommends makes sense?
The accompanying editorial suggests that the authors of this review cannot be trusted because of their conflicts of interest. Should the presence of any conflict of interest within a field make the results of a study suspect? Are conflicts of interest only financial? Evaluate the conflict of interest declarations of the authors of the systematic review and those of the editorial.
If financial support is required to conduct research, how do your learners suggest that this potential conflict be managed by those seeking support in order to complete their studies? What influence should conflicts have on how readers evaluate the work?

Annals for Hospitalists

Annals for Hospitalists Inpatient Notes - Legislating Quality to Prevent Infection: A Primer for Hospitalists

This issue's Annals for Hospitalists alert includes a provocative essay that reviews how new regulations aimed at promoting payment for quality, rather than quantity, may lower costs without established evidence that they improve patient outcomes.

Use this article to:

Ask your learners how they would define a catheter-associated urinary tract infection and a catheter-associated central line–associated bloodstream infection. How do clinical definitions differ from those used in administrative databases?
Invite your hospital's compliance officer, chief medical officer, or someone from utilization review to discuss with your learners how penalties (or the threat of penalties) have altered activities at your institution. What “rules” have changed? Has behavior changed? Have infection rates changed? Invite someone from your infection control group to join the discussion.

MKSAP 17 Question 1

A 52-year-old woman presents for follow-up evaluation after being diagnosed with type 2 diabetes mellitus 6 weeks ago. Her initial hemoglobin A_1c level was 8.0%. Management at this time is with lifestyle modifications. She has worked closely with a diabetes educator and a nutritionist since her diagnosis. She has lost 3.2 kg (7 lb) by making changes to her diet and activity level. Review of her blood glucose log for the past 2 weeks shows preprandial blood glucose values in the 150 to 160 mg/dL (8.3-8.9 mmol/L) range and several 2-hour postprandial blood glucose values of 190 to 200 mg/dL (10.5-11.1 mmol/L). Her only other medical problem is hypertension for which she takes lisinopril.

On physical examination, blood pressure is 125/70 mm Hg and pulse rate is 74/min. BMI is 28. There is no evidence of diabetic retinopathy. She has normal monofilament and vibratory sensation in her extremities.

Except for her blood glucose parameters, basic laboratory studies obtained at the time of her initial diagnosis were normal.

In addition to continuing lifestyle modifications, which of the following is the most appropriate management for this patient's diabetes?

A. Initiate dapagliflozin

B. Initiate glipizide

C. Initiate metformin

D. Initiate sitagliptin

Correct Answer

C. Initiate metformin

Educational Objective

Manage early type 2 diabetes mellitus.

Critique

The most appropriate management for this patient is to initiate metformin. The patient is early in her diabetes disease course without evidence of microvascular disease. For otherwise healthy adults meeting these criteria, the American Diabetes Association recommends a hemoglobin A_1c level of less than 7.0%, preprandial glucose values of 70 to 130 mg/dL (3.9-7.2 mmol/L), and 1- to 2-hour postprandial glucose values of less than 180 mg/dL (10 mmol/L). Because the patient has not met these goals, a pharmacologic agent should be added at this time. Lifestyle recommendations consisting of increased physical activity, dietary modifications, and weight loss (if BMI is elevated) are the initial first step in treating diabetes. When lifestyle modifications fail to meet glycemic goals within 6 weeks, metformin is the recommended first-line therapy to be started in conjunction with continued lifestyle modifications. If glycemic goals are not met after 3 months of lifestyle modifications and metformin use, additional agents should be added to the regimen every 3 months until glucose goals are met.

Dapagliflozin, a sodium-glucose transporter-2 (SGLT-2) inhibitor, increases excretion of glucose through the kidney. It is a second-line agent that should be used after lifestyle modifications and metformin fail to reach glycemic goals.

The sulfonylurea glipizide stimulates insulin secretion from the pancreatic beta cells. This agent could improve the patient's postprandial hyperglycemia, but it may also induce weight gain in a patient actively working on weight loss. Glipizide is a second-line agent that should be used after lifestyle modifications and metformin fail to reach glycemic goals.

Sitagliptin, a dipeptidyl peptidase-4 (DPP-4) inhibitor, improves glycemic control by slowing gastric emptying and suppressing glucagon secretion. It is also considered a second-line agent that might be considered if lifestyle modifications and metformin fail to reach glycemic goals.

Key Point

For most patients with type 2 diabetes mellitus, lifestyle modifications and metformin therapy are the most appropriate initial treatments.

Bibliography

American Diabetes Association. (7) Approaches to glycemic treatment. In: Standards of Medical Care in Diabetes-2015. Diabetes Care. 2015 Jan;38 Suppl 1:S41-8.

MKSAP 17 Question 2

A 52-year-old woman is evaluated in the office during a routine visit. Her medical history is significant for type 2 diabetes mellitus and hypertension. Medications are aspirin, lisinopril, amlodipine, insulin glargine, insulin aspart, and rosuvastatin.

On physical examination, the patient is afebrile, blood pressure is 128/80 mm Hg, pulse rate is 73/min, and respiration rate is 18/min. BMI is 24. The lungs are clear to auscultation, and no cardiac murmurs are heard. Abdominal examination reveals a pulsatile mass in the epigastrium.

An infrarenal abdominal aortic aneurysm with maximum diameter of 5.7 cm is noted on abdominal ultrasound.

Which of the following is the most appropriate management of this patient's abdominal aortic aneurysm?

A. Refer for aneurysm repair

B. Repeat abdominal ultrasonography in 6 months

C. Repeat abdominal ultrasonography in 12 months

D. Switch amlodipine to propranolol

Correct Answer

A. Refer for aneurysm repair

Educational Objective

Manage abdominal aortic aneurysm with referral for repair.

Critique

The most appropriate management is to refer this patient for abdominal aortic aneurysm (AAA) repair. AAA is a common and potentially life-threatening condition, and management of detected aneurysms is based on size or rate of expansion. Elective repair to prevent rupture in asymptomatic patients is optimal management in those meeting criteria for intervention. Once an aneurysm reaches 5.5 cm in men and 5.0 cm in women, repair is generally warranted. Repair may be performed by an open approach or an endovascular approach, if the anatomy of the aneurysm is amenable; the mode of therapy should be decided by the surgeon, the internist, and the patient after a comprehensive discussion of risks and long-term benefits. Randomized trials show that endovascular aneurysm repair (EVAR) is associated with lower perioperative morbidity and mortality compared with open AAA repair, but EVAR does not completely eliminate the future risk of AAA rupture. Open repair is associated with higher perioperative morbidity and mortality than EVAR, but it provides a more definitive repair.

The optimal surveillance schedule for patients once an AAA has been identified has not been clearly defined. Annual surveillance is recommended, but larger aneurysms expand faster than small ones and may require more frequent surveillance. Aneurysm diameter is the most important factor predisposing to rupture, with risk increasing markedly at aneurysm diameters greater than 5.5 cm. For asymptomatic patients, the risk of AAA rupture generally exceeds the risk associated with elective AAA repair when aneurysm diameter exceeds 5.0 cm in a woman and 5.5 cm in a man. This patient's AAA is 5.7 cm in diameter; therefore, she should be referred for repair, rather than continuing surveillance.

Although controlling risk factors for cardiovascular disease is essential in patients with AAA, there is little compelling evidence for treating hypertension in these patients with a specific agent, including β-blockers, to prevent aneurysm expansion. As this patient's blood pressure is well controlled, no change in antihypertensive therapy is indicated.

Key Point

An abdominal aortic aneurysm larger than 5.5 cm in men and 5.0 cm in women is an indication for referral for repair.

Bibliography

Buck DB, van Herwaarden JA, Schermerhorn ML, Moll FL. Endovascular treatment of abdominal aortic aneurysms. Nat Rev Cardiol. 2014 Feb;11(2):112-23. Erratum in: Nat Rev Cardiol. 2014 Feb;11(2):i.

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Web Exclusives |21 February 2017

Annals for Educators - 21 February 2017 Free

Clinical Practice Points

Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline Update From the American College of Physicians

Video Learning

Annals Consult Guys - Generation Gap: Stent to Stent

History of Medicine

Battle of the Bulge: Aortic Aneurysm Management From Early Modernity to the Present

Improving Patient Care

Enhancing the Role of Internists in the Transition From Pediatric to Adult Health Care

The Scientific Basis of Guideline Recommendations on Sugar Intake. A Systematic Review

Annals for Hospitalists

Annals for Hospitalists Inpatient Notes - Legislating Quality to Prevent Infection: A Primer for Hospitalists

MKSAP 17 Question 1

MKSAP 17 Question 2

This feature is available only to Registered Users

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Web Exclusives |21 February 2017

Annals for Educators - 21 February 2017 Free

Clinical Practice Points

Oral Pharmacologic Treatment of Type 2 Diabetes Mellitus: A Clinical Practice Guideline Update From the American College of Physicians

Video Learning

Annals Consult Guys - Generation Gap: Stent to Stent

History of Medicine

Battle of the Bulge: Aortic Aneurysm Management From Early Modernity to the Present

Improving Patient Care

Enhancing the Role of Internists in the Transition From Pediatric to Adult Health Care

The Scientific Basis of Guideline Recommendations on Sugar Intake. A Systematic Review

Annals for Hospitalists

Annals for Hospitalists Inpatient Notes - Legislating Quality to Prevent Infection: A Primer for Hospitalists

MKSAP 17 Question 1

MKSAP 17 Question 2

This feature is available only to Registered Users

0 Comments

Related Articles

Journal Club

Related Point of Care

Related Topics

PubMed Articles

Content

Information For

Services

Awards and Cover

Other Resources

Follow Annals On

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