Course Overview
This section of the CME course presents physicians with the course
description and standards for enduring materials as set forth by the
Accreditation Council for Continuing Medical Education (ACCME) and
Washington Hospital Center. Complete the Overview by reviewing each of its
parts using the links below.
Statement of Need
Diabetes mellitus is the fifth leading cause of death in the United States, incurring $132 billion in direct and indirect costs in 2002.
1 Type 2 diabetes is the most common form of the disease, accounting for up to 95% of disease prevalence,
2 and is a serious, progressive disease that can have a significant impact on quality and length of life. If not adequately treated, diabetes can result in long-term complications, including heart disease, stroke, kidney failure, foot or leg amputation, blindness, and death.
3 Forecasts of disease trends predict that prevalence of type 2 diabetes will double by 2024.
3 However, with only about 4200 endocrinologists in the US,
4 the care and management of patients with diabetes falls to physicians, nurse practitioners, and physician assistants in primary care. Clearly, information regarding effective insulin therapy must be directed to physicians in this setting.
The goal of insulin therapy in diabetes treatment is to imitate the physiologic secretion of insulin in healthy patients in order to maintain blood glucose (BG) levels within targeted ranges. The Diabetes Control and Complications Trial (DCCT) provided conclusive evidence that strict glycemic control reduces the incidence and progression of neuropathy, nephropathy, and retinopathy in patients with type 1 diabetes mellitus.
5
The UK Prospective Diabetes Study (UKPDS)
6,7 is one of the pivotal studies upon which many of today’s standard treatment regimens for patients with type 2 diabetes are based. This multicenter, 10-year study followed 3867 newly diagnosed patients who were randomly assigned to conventional or intensive treatment. “Conventional” treatment was diet alone with the addition of oral antidiabetic drugs (OADs) only if hyperglycemic symptoms were present or fasting plasma glucose (FPG) was greater than 270 mg/dL (15 mmol/L). “Intensive” treatment included pharmacotherapy with a sulfonylurea, metformin in obese patients, or insulin. At 3 years, fewer than 55% of patients randomized to any single pharmacotherapeutic agent were able to maintain FPG concentrations less than 140 mg/dL (7.8 mmol/L). However, any monotherapy improved FPG levels compared with the diet-alone arm.
8 At 6 years, only 5% of patients in the sulfonylurea arm maintained FPG levels of less than 106 mg/dL (6 mmol/L).
8
In the UKPDS, as in the DCCT, targeted glucose control was associated with reduction in chronic microvascular symptoms of diabetes and with a trend toward reduction in cardiovascular events.
Both studies showed conclusively that intensive BG control is paramount in reducing morbidity associated with diabetes.
9 In general, current treatment approaches often react to the progressive nature of diabetes, treating the complications of hyperglycemia that are a result of micro- and macrovascular damage.
3 A proactive approach to treatment that emphasizes targeted BG control, preservation of ß-cell function, reduction in insulin resistance, and prevention of long-term complications is needed to optimize quality of life and life expectancy for the person with diabetes.
3
Insulin Therapy
Loss of ß-cell function in type 2 diabetes is progressive; therefore, insulin therapy will almost always be required over time. There is, however, an increasing awareness that adding insulin sooner rather than later in the disease state may confer an advantage in the treatment of type 2 diabetes. By describing disease progression and its complications at the time of initial diagnosis, the eventual need for patients to self-inject insulin may meet with fewer objections.
This continuing medical education (CME) activity focuses on the benefits, rationale, and strategies of initiating insulin therapy earlier than traditional regimens in the treatment protocol of patients with type 2 diabetes. Case studies are presented as a learning activity for physicians.
Course Overview
Despite the efficacy of insulin therapy in the management of diabetes, several obstacles exist from the perspective of both physician and patient as to its effective use early in the disease. Many of the obstacles result from patient fears and concerns about the perceived pain associated with multiple daily insulin injections, and from insufficient patient education about disease progression. Whether because they lack knowledge or have inadequate resources, physicians also have concerns with initiating insulin therapy. When insulin is initiated, it is often prescribed as one basal injection giving 24-hour coverage, a regimen that does not allow control of postprandial blood glucose—an important measure of control. When patients are provided with the appropriate resources and treatment options to achieve optimal glycemic control, the onset of potentially devastating complications frequently associated with uncontrolled diabetes can be averted or delayed.
This CME activity is an interactive course of study that includes 2 case studies. You will be presented with a realistic clinical scenario and will be asked to make selections among various therapeutic options. In many cases, there is not one correct answer but, rather, advantages and disadvantages to each selection. You are encouraged to review all the options to gain feedback on the benefits and limitations of each therapeutic intervention from the perspective of the case.
Learning Objectives
Upon completion of this monograph, physicians should be able to:
- Identify the contribution of fasting and postprandial blood glucose on parameters used to monitor control (fasting blood glucose plus postprandial glucose equates with A1C)
- Describe the rationale for earlier initiation of physiologic insulin in the management of patients with type 2 diabetes
- Describe insulin therapy treatment options currently available for the management of newly diagnosed patients with type 2 diabetes
Target Audience
This CME activity is designed for healthcare professionals who treat patients with diabetes, including internists, family practitioners, and other primary care providers.
Sponsors
This educational activity is jointly sponsored by Washington Hospital Center, MedStar Diabetes Institute at Washington Hospital Center, and MedStar Research Institute.
Washington Hospital Center
Washington Hospital Center is a 907-bed, not-for-profit teaching hospital noted for its clinical expertise, innovative medical technology, and patient-centered care. Since 1958, it has set the standard for adult tertiary care in the Washington, DC, metropolitan area, providing the area’s premier specialty services. Its nationally acclaimed programs include Washington Heart, Endocrinology and Metabolism, Washington Cancer Institute, The Burn Center, MedStar shock/trauma and medical transport services, women’s services, transplantation services, and Washington National Eye Center.
Contact information: On the Web at:
www.whcenter.org, or phone (202) 877-8201.
MedStar Diabetes Institute at Washington Hospital Center
The MedStar Diabetes Institute at Washington Hospital Center provides a cohesive approach to management for the patient with diabetes mellitus through all levels of care. The MedStar Diabetes Institute at Washington Hospital Center is a program of the MedStar Health System and a cooperative effort of the Washington Hospital Center, Visiting Nurse Association of Washington, DC, and the MedStar Research Institute. The MedStar Diabetes Institute is dedicated to excellence in clinical care, diabetes education, and diabetes research. Its comprehensive outpatient services provide state-of-the-art care for the patient with diabetes. The American Diabetes Association, in accordance with the National Standards of Diabetes Self-Management Education Program, has awarded recognition to the institute’s Diabetes Self-Management Education Program. Call the Diabetes Team at the MedStar Diabetes Institute at (202) 877-7777. On the Web at:
www.whcenter.org.
MedStar Research Institute
MedStar Research Institute coordinates research for the Washington Hospital Center, National Rehabilitation Hospital, Georgetown University Hospital Center, and the entire MedStar System in Washington, DC, and Baltimore, MD. The MedStar Research Institute supports a wide range of research programs designed to develop and implement innovative and effective strategies for clinical care and healthcare delivery for patients in the community.
Specialized research areas include atherosclerosis, cancer, cardiology, cardiac surgery, diabetes, critical care, gene therapy. nephrology, nutrition, rehabilitation medicine, transplantation, and women’s health. For more information about MedStar Research Institute, call (202) 877-2383. On the Web at:
www.whcenter.org.
CME Accreditation
This activity has been planned and implemented in accordance with the Essential Areas and Policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Washington Hospital Center, MedStar Research Institute and Clinical Connexion. Washington Hospital Center is accredited by the ACCME to provide continuing medical education for physicians.
Credit Designation
The Washington Hospital Center designates this educational activity for a maximum of 1.0 credit toward the AMA Physician’s Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.
Conflict of Interest Disclosure
As a sponsor accredited by the ACCME, it is the policy of Washington Hospital Center to require that everyone who is in a position to control the content of an educational activity disclose all relevant financial relationships with any commercial interest prior to the educational activity. The ACCME considers relationships of the person involved in the CME activity to include financial relationships of a spouse or partner.
Faculty who refuse to disclose relevant financial relationships will be disqualified from being a planning committee member, a teacher, or an author of CME, and cannot have control of, or responsibility for, the development, management, presentation, or evaluation of a CME activity. For an individual with no relevant financial relationship(s), the participants must be informed that no relevant financial relationship(s) exist.
All faculty are also required to disclose any discussions of unlabeled/unapproved uses of drugs or devices.
Term of Approval
| Release date: | October 2004 |
| Expiration date: | October 2006 |
| Estimated time for completion: | 1 hour |
Method of Participation
This activity should take approximately 1 hour to complete. The participant should, in order, read the learning objectives and symposium presentation summaries, answer the posttest questions, and complete the evaluation. The evaluation provides each participant with the opportunity to comment on the quality of the instructional process, the perception of enhanced professional effectiveness, and the perception of commercial bias. To receive category 1 AMA PRA credit for this activity, participants should complete the posttest and follow the instructions for submission. Credit will be granted through October 2006.
Content copyright 2004
All rights reserved.
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