patients with type 2 diabetes, yet the. best pathway to successful therapy remains cost-effective means of controlling diabetes, but …
THOMSON HEALTHCARE CLINICAL INSIGHTS IN
This educational activity is jointly sponsored by Thomson Professional Postgraduate Services, Secaucus, NJ, Thomson Advanced HealthMarket StrategiesTM, Secaucus, NJ, and AHC Media LLC and is conducted as part of the National Diabetes Education Initiative NDEI , sponsored by Thomson Professional Postgraduate Services, Secaucus, NJ Volume 6, Issue No 9 is an educational activity that offers both continuing medical education CME and continuing pharmacy education contact hours Participants who wish to receive the appropriate credit for this educational activity should do the following: 1 read this issue of the newsletter; 2 review the original articles discussed in their entirety; and 3 complete the post-test and registration/ evaluation form To receive the appropriate credit, participants must read this newsletter and complete the post-test and registration/evaluation form Participants should then return all forms to: Thomson Professional Postgraduate Services, PO Box 430, Montvale, NJ 07645-0430, or fax the completed materials to 1-888-251-5650 Participants must score 70 on the post-test to receive a statement of credit Upon successful
completion of the test, and submission of the registration/evaluation form, your statement of credit will be mailed within 6 to 8 weeks You will also receive a summary of the correct test answers and explanations Learning Objectives After studying the literature presented in the Clinical Insights in Diabetes series, participants will be able to: Identify patients with type 2 diabetes and the insulin resistance, or metabolic, syndrome Select the appropriate therapeutic regimen for patients with type 2 diabetes and the insulin resistance syndrome Summarize risk factors for cardiovascular disease in patients with type 2 diabetes and the insulin resistance syndrome Examine the overall clinical and economic issues, relative to payors, surrounding the management and treatment of various patient populations with type 2 diabetes
Diabetes
VOLUME 6, NUMBER 9
Management of Hyperglycemia in Type 2 Diabetes: A Consensus Statement From the ADA and EASD
umerous studies have been published on the management of hyperglycemia in patients with type 2 diabetes, yet the best pathway to successful therapy remains unclear To address this, the American Diabetes Association ADA and the European
Association for the Study of Diabetes EASD have developed a consensus approach to assist healthcare providers in choosing the most appropriate treatments Effective weight loss through increased physical activity and dietary control is the most cost-effective means of controlling diabetes, but the high rate of weight regain in patients limits the role of lifestyle intervention in long-term glycemic control Nevertheless, lifestyle therapy should be included, with rare exception, as a part of any diabetes management program Weightloss medications cannot be recommended as a primary diabetes treatment because of the high dropout rates, side effects, and low sustainability shown in studies of these agents The algorithm on page 2 is based on goals of achieving and maintaining glucose levels as close to the nondiabetic range as possible, initiating or changing therapy when the patients A1C level is 7, and changing interventions, if necessary, as rapidly as titration of medications allows Selection of antihyperglycemic agents is primarily based on their glucose-lowering efficacy Tolerability, safety, expense, and extraglycemic effects that may help reduce diabetic complications are also
considered Exenatide, glinides, pramlintide, and -glucosidase inhibitors are not included in this algorithm because of their lower overall efficacy in glycemic control, limited clinical data, and/or relative expense As the first step in treatment of new-onset type 2 diabetes, lifestyle intervention should be implemented by registered dietitians or other healthcare professionals However, due to the frequent failure of lifestyle intervention to
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Target Audience This educational activity is designed for medical directors, formulary directors, pharmacy directors, clinical pharmacists, VA/DoD pharmacists, outcomes specialists, and health economists 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 Thomson Professional Postgraduate Services , Secaucus, NJ, and Thomson Advanced HealthMarket StrategiesTM, Secaucus, NJ Thomson Professional Postgraduate Services is accredited by the ACCME to provide continuing medical education for physicians Thomson Professional Postgraduate Services designates this educational activity for a maximum of 1
AMA PRA Category 1 CreditTM Physicians should only claim credit commensurate with the extent of their participation in the activity AHC Media LLC is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education This program, ACPE 381-999-06-052-H01, has been designated for 1 contact hour 01 CEU Each attendee should claim only those contact hours that he/she actually spent in the activity AMA PRA Category 1 Credit is a trademark of the American Medical Association This activity is supported by an unrestricted educational grant from Takeda Pharmaceuticals North America, Inc
Metformin therapy should be initiated at diagnosis with lifestyle therapy
achieve or maintain glycemic goals, concurrent metformin therapy should be initiated at diagnosis Metformin is recommended because of its efficacy in glycemic control 15 expected decrease in A1C, low level of long-term side effects short-term gastrointestinal side effects are common, absence of hypoglycemia or weight gain, relatively low cost, and high level of acceptance It should be titrated over 1 to 2 months to its maximally effective dose, as tolerated If glycemic goals are not achieved
or sustained with metformin within 2 to 3 months of its initiation, a second medication should be added Either insulin, a sulfonylurea, or a thiazolidinedione TZD is recommended, but there is no consensus as to which of the three should be used The synergy of drug combinations should be considered, as antihyperglycemic medications with different mechanisms of action will have the greatest synergy Metformin plus insulin and insulin plus a TZD are particularly effective in lowering glycemia, although the latter combination has a greater risk of fluid retention that should be monitored Adding a TZD to metformin has been shown to have modest additive effects in lowering A1C Advantages of insulin include greater expected A1C decrease 15 to 25, relatively low cost, and an improved lipid profile; disadvantages include injections, monitoring, hypoglycemia, and weight gain Sulfonylurea advantages include 15 expected A1C decrease and relatively low cost; disadvantages include weight gain and hypoglycemia, although usually not severe Thiazolidinedione advantages include expected A1C decrease of 05 to 14 and an improved lipid profile; disadvantages include fluid retention, weight gain, and
relatively higher cost For patients with A1C 85 or with symptoms secondary to hyperglycemia, basal insulin should be considered for its greater glycemia-lowering effect Continued
Reviewed by Charles Baumgart, MD, Presbyterian Healthcare Services; Dea Belazi, PharmD, MPH, PAHM, Independence Blue Cross; William J Cardarelli, RPh, Harvard Vanguard Medical Associates; Mayer A Davidson, MD, Charles R Drew University, Silvio E Inzucchi, MD, Yale University School of Medicine; Michael Neville, PharmD, Emory University; and NDEI Education Council Member David L Bronson, MD, FACP, The Cleveland Clinic Foundation In addition, this newsletter has been developed and prepared under the guidance of John R Clay, General Manager, Thomson Advanced HealthMarket StrategiesTM; Terry Fagan, managing editor, Thomson Professional Postgraduate Services; and Mark Palangio, medical writer, Thomson Professional Postgraduate Services
Management of Hyperglycemia in Type 2 Diabetes:
Dr Baumgart, Mr Cardarelli, Dr Davidson, Dr Neville, Dr Bronson, Mr Clay, Mr Fagan, and Mr Palangio have indicated no relevant financial relationships Dr Belazi has indicated the following relevant financial relationships:
Advisor, Eli Lilly and Company and Takeda Pharmaceuticals North America, Inc Dr Inzucchi has indicated the following relevant financial relationships: retained consultant, Takeda Pharmaceuticals North America, Inc; speakers bureau, GlaxoSmithKlline, Merck and Co, Inc, and Takeda Pharmaceuticals North America, Inc
CLINICAL INSIGHTS
IN DIABETES
A Consensus Statement From the ADA and EASD
Continued If the addition of a secondary medication does not achieve or sustain goal A1C, insulin therapy should be initiated or intensified If A1C is close to goal 80, a third oral agent may be considered instead of insulin; however, it may be more expensive and less effective than an insulin regimen If prandial rapid- or very-rapidacting insulin injections are initiated, insulin secretagogues such as glinides or sulfonylureas should be discontinued, or tapered and then discontinued, since they are not synergistic with administered insulin Patients presenting with severely uncontrolled diabetes with catabolism A1C 10, fasting plasma glucose levels 250 mg/dL, random glucose levels consistently 300 mg/dL, or the presence of ketonuria or diabetes with polydipsia, polyuria, and weight loss should
be treated at the outset with insulin therapy and lifestyle intervention The authors concluded that interventions that achieve glucose levels close to nondiabetic range can substantially reduce the morbidity associated with long-term complications in patients with type 2 diabetes, and that currentday management has failed to achieve and maintain those levels
Nathan DM et al Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy A consensus statement from the American Diabetes Association and the European Association for the Study of Diabetes Diabetes Care 2006;29:1963-1972
Algorithm for the Metabolic Management of Type 2 Diabetes
Diagnosis
Lifestyle Intervention Metformin A1C 7 Add Sulfonylurea
Least expensive
No Add Basal Insulin
Most effective
Yes Add Glitazone
No hypoglycemia
No
A1C 7 Intensify Insulin
Yes
No Add Glitazone
A1C 7
Yes
No
A1C 7
Yes
Add Basal Insulin
Add Sulfonylurea A1C 7
No
A1C 7
Yes
No
Yes
Add Basal or Intensify Insulin
Intensive Insulin Metformin /- Glitazone
Check A1C every 3 months until 7 and then at least every 6 months Although three oral agents can be used,
initiation and intensification of insulin therapy is preferred based on effectiveness and expense Nathan DM et al Diabetes Care 2006;29:1963-1972
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CLINICAL INSIGHTS
IN DIABETES
COMMENTARY
SILVIO E INZUCCHI, MD Professor of Medicine at Yale University School of Medicine, New Haven, Connecticut
This consensus statement by some of the leading experts in the field presents a logical framework upon which practitioners can build rational antihyperglycemic strategies in patients with type 2 diabetes There are several important take-home messages herein First, the authors underscore the importance of metformin as the initial agent when diet and exercise alone have failed to adequately control blood glucose Second, combination therapy, when necessary, should be introduced early on in the course of the disease Third, the addition of insulin is the most effective intervention in those patients requiring more than 1-2 antihyperglycemic drugs Finally, oral therapies should generally be continued when basal insulin is initiated, but secretagogues have little role once mealtime insulin therapy is begun As clinicians, we can apply these recommendations in our practice, adapting them to our
patients individual characteristics, predispositions, and tolerances
Charles Baumgart, MD, Senior Medical Director, Presbyterian Healthcare Services
Diabetes management guidelines from the ADA have long been a gold standard for payors to use for educational and measurement purposes within their diabetes disease-management programs This consensus metabolic treatment algorithm is another helpful tool that emphasizes appropriate first-line treatment, a step-therapy approach to treatment, and the appropriateness of insulin early in the course of treatment Its interesting that the list of agents not addressed in the algorithm due to insufficient supportive evidence, or relative expense, includes several that have been part of a recent trend toward promoting noninsulin alternatives Therefore, this still leaves payors with the need to create coverage policies for these highly marketed agents and, ultimately, for newer agents, including dipeptidyl peptidase IV DPP4 inhibitors
Metabolic Syndrome No More Predictive of CV Mortality Than Its Individual Components
he presence of the metabolic syndrome identifies patients with risk factors for cardiovascular CV disease, but the question of
whether the syndrome predicts risk above and beyond its individual components has not been answered Sundström and colleagues addressed this question using a cohort of men examined at age 50 years and then at age 70 years, with a maximum of 327 years of follow-up median 298 years and an outcome of CV mortality The cohort was split into four baseline samples: two at 50 years of age the entire cohort [n2,322] and a primary preventive sample [n2,198], excluding people with diabetes, stroke, or a myocardial infarction at or before baseline and two at 70 years of age the entire cohort [n1,221] and a primary preventive sample [n872] All subjects at age 50 baseline were tested for fasting cholesterol, triglycerides TG, HDL cholesterol, smoking, hypertension, and homeostasis model assessment–insulin resistance; at age 70 baseline they were tested as above with the addition of an insulin sensitivity test using the euglycemic insulin clamp technique The National Cholesterol Education Program definition of metabolic syndrome was used: fasting glucose 110 mg/dL, blood pressure 130/85 mm Hg or treatment for hypertension, TG 150 mg/dL, HDL-C 40 mg/dL, and body 2 mass index 294 kg/m substituted
for waist circumference measurement Two measures were used to test the hypothesis that the metabolic syndrome predicts CV mortality better than the sum of its parts:
T
The metabolic syndrome might be considered not as a strong biological entity but as a clinically handy summary measure of nontraditional CV risk factors
likelihood ratio tests and areas under receiveroperating characteristics curves C-statistics Likelihood ratio tests compared Cox proportional models including only the individual metabolic syndrome components with models also including the metabolic syndrome as a variable C-statistics were calculated for all metabolic syndrome components, and then the researchers compared C-statistics with and without the metabolic syndrome variable The metabolic syndrome was present in 178 of the cohort at 50 years of age 159 of the primary preventive sample and 232 of the cohort at 70 years of age 158 of the primary preventive sample During the followup to the baseline examination at age 50, 502 persons in the total cohort died from CV disease 83 per 1,000 person-years at risk [PYAR], and an additional 133 died during follow-up after the baseline examination at 70 years of age
127/1,000 PYAR Using likelihood ratio tests and comparisons of C-statistics, the metabolic syndrome did not predict CV mortality independently of its components at any age or in any sample The authors concluded that if these results are confirmed in other samples, the metabolic syndrome might be considered not as a strong biological entity but as a clinically handy summary measure of nontraditional CV risk factors
Sundström J et al Risk associated with the metabolic syndrome versus the sum of its individual components Diabetes Care 2006;29:1673-1674
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CLINICAL INSIGHTS
IN DIABETES
COMMENTARY
Charles Baumgart, MD, Senior Medical Director, Presbyterian Healthcare Services
D 
id we jump the gun in assigning an ICD-9 code to the metabolic syndrome? The authors conclusion seems to be supported by the data as well as other clinical studies–that the metabolic syndrome may not be seen so much as a biologic entity but rather a clinically handy summary measure of nontraditional CV risk factors Therefore, attempting to identify and label individuals as having this syndrome probably should not be the focus of payor disease-management efforts Increased visibility of these specific risk
factors, however, has clearly been a positive outcome of the remarkable amount of published information about this syndrome
Sibutramine Treatment Added to Behavioral Therapy Improves Metabolic Risk Factors in Obese Adolescents
pproximately 155 of US adolescents aged 12 to 19 years are defined as overweight 95th percentile for age- and gender-specific measures for body mass index [BMI] and the incidence of type 2 diabetes is increasing in this population Cardiovascular risk factors are also more prevalent compared with adolescents with BMI 85th percentile Comprehensive behavioral therapy has shown weight loss benefit in younger children, but adolescents in most studies typically remain overweight after such therapy Sibutramine, a norepinephrine and serotonin reuptake inhibitor, has been shown to assist in weight loss and weight maintenance and to improve metabolic variables in obese adults In a 12-month, double-blind, randomized study at 33 US outpatient clinics, Berkowitz and colleagues evaluated the effects of sibutramine treatment combined with behavioral therapy on weight loss in adolescents 12 to 16 years of age with a BMI at least 2 units more than the US weighted mean of the
95th percentile based on 2 age and sex, but not more than 44 kg/m In addition to behavioral therapy flexible lifestyle management therapy tailored to individual needs, the sibutramine group n368 received 10 mg of sibutramine daily, while the control group n130 received placebo The two groups were well balanced with no clinically significant differences at baseline At 6 months, participants who did not lose a minimum of 10 of baseline BMI were uptitrated to 15 mg of sibutramine or placebo Primary outcome was absolute change in BMI from baseline; secondary end points included percentage change in BMI, absolute change in waist circumference, and percentage and absolute changes in body weight and glycemic and lipid variables Overall completion rate was 76 in the sibutramine group vs 62 in the placebo group P0001, with 6 of the total sibutramine group n22 and 5 of the total placebo group n7 withdrawing due to adverse events Other causes for withdrawal from the study included lost to follow-up, withdrawal of consent, administrative reasons, and protocol deviation At 12 months, the absolute change in BMI from baseline with sibutramine plus behavior
A
At 12 months, the absolute change
in BMI from baseline with sibutramine plus behavior therapy was 2 -31 kg/m vs 2 -03 kg/m for placebo plus behavior therapy
therapy was -31 kg/m vs -03 kg/m for placebo plus behavior therapy, a mean between-group 2 difference of -29 kg/m 95 confidence interval [CI], -35 to -22; P0001 by linear mixed-effects model at all study points However, BMI plateaued in the sibutramine group after 8 months As for secondary outcomes, the sibutramine group experienced greater weight loss, with a mean between-group difference from baseline for body weight of -84 kg 95 CI, -97 to -72; P0001 by linear mixed-effects model starting at week 2 At month 12, a BMI reduction of 5 or 10 occurred in 698 and 456 of the sibutramine group, respectively, vs 215 and 63 of placebo recipients The sibutramine group also showed significant improvement vs placebo at 12 months for HDL-C, fasting triglycerides, and insulin levels, as well as insulin sensitivity P0001 for each comparison Rates of growth and Tanner scores did not differ significantly between groups There was a statistically significant increase in the sibutramine group in systolic and diastolic blood pressure, as well as pulse rates Tachycardia was the
only statistically significant adverse effect that occurred more frequently with sibutramine recipients than with the placebo group 125 vs 62, 63 percentage points difference [CI, 10 to 117]; P0049, but it did not lead to increased withdrawal compared with placebo Study limitations included short duration and the percentage in both cohorts 24 for sibutramine and 38 for placebo that did not complete follow-up, although the authors noted the completion rate was high compared with sibutramine studies of similar duration in adults The authors concluded that a regimen of sibutramine combined with behavioral therapy reduced BMI, body weight, and metabolic risk factors in obese adolescents better than behavioral modification alone
2
2
Berkowitz RI et al Effects of sibutramine treatment in obese adolescents: a randomized trial Ann Intern Med 2006;145:81-90
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CLINICAL INSIGHTS
IN DIABETES
COMMENTARY
Charles Baumgart, MD, Senior Medical Director, Presbyterian Healthcare Services
The rising prevalence of obesity in children, and especially adolescents, is certainly an issue that payors are taking seriously This study supports medication therapy as a treatment option that can produce
some degree of result However, the caveat remains that without the behavioral therapy component of this study, the results are likely to be dismal with medication alone Payors will continue to be selective in coverage decisions for these medications to ensure they are used in a setting that creates true benefit
Chronic Diseases Contribute to Rising Healthcare Expenditures Among Medicare Beneficiaries
edicare spending has drastically risen in recent years and is projected to nearly triple by 2030 As such, policymakers are investigating new strategies to slow the rapid growth of Medicare healthcare costs Thorpe and Howard recently examined trends in Medicare beneficiaries annual healthcare spending and the relationship between spending and disease prevalence Data for this study were drawn from the 1987 National Medical Expenditures Survey, the 2002 Medical Expenditure Panel Survey, and the National Health and Nutrition Examination Survey NHANES III for 19881994 and NHANES for 19992002 Their analysis revealed that the top 10 conditions among Medicare beneficiaries accounted for 662 of the spending growth between 1987 and 2002 The 3 conditions associated with metabolic syndrome
hypertension, diabetes, hyperlipidemia collectively accounted for 161 of the rise in healthcare spending Because the age-adjusted prevalence of treated heart disease was stable over time 270 in 1987 vs 278 in 2002, most of the spending increase was attributed to increased spending per treated case However, because age-adjusted prevalences of other disorders rose substantially, increases in spending were also due to growth in the number of treated cases For example, the treated prevalence of mental disorders increased from 79 in 1987 to 190 in 2002 During this same timeframe, treatment prevalence for hyperlipidemia increased from 26 to 222, whereas for diabetes, it increased from 114 to 175 The number of medical conditions treated per Medicare beneficiary also increased substantially over time The percentage of beneficiaries
M
When analyzing total healthcare spending incurred by Medicare beneficiaries with 3 or more conditions, this percentage rose to 929 in 2002
affected with 5 or more conditions was 310 in 1987, which accounted for 522 of total healthcare spending In 2002, 502 had 5 conditions, which accounted for 763 of total spending When analyzing total healthcare spending
incurred by Medicare beneficiaries with 3 or more conditions, this percentage rose to 929 in 2002 This spending growth was traced to both a rise in true disease prevalence and changes in clinical treatment thresholds These trends were directly related to increased obesity among Medicare beneficiaries Between 1987 and 2002, the prevalence of obesity doubled from 117 to 225, while the percent of obesity-related spending nearly tripled 94 to 248 According to NHANES data for 1999 through 2002, almost half 478 of Medicare beneficiaries met the clinical criteria for metabolic syndrome Using the metabolic syndrome as a case study, it was noted that the share of patients treated with medications significantly increased by 115 in less than 10 years P005 Based on these findings, the authors questioned the appropriateness of Medicares current payment methods for complex medical management They also note that because Medicare operates under a fee-for-service model, it may complicate the adoption of chronic care treatment models
Thorpe KE, Howard DH The rise in spending among Medicare beneficiaries: the role of chronic disease prevalence and changes in treatment intensity Health Aff Millwood
2006;22:w378-w388; 101377/hlthaff25w378
COMMENTARY
Charles Baumgart, MD, Senior Medical Director, Presbyterian Healthcare Services
The authors of this study point out the important cost impact of the growing prevalence of illness and comorbidities in the Medicare population, particularly obesity Payors involved in Medicare Advantage certainly have seen the value of chronic care or disease-management programs in this population to help improve quality outcomes and reduce cost trends An interesting aspect of this study is the component of cost increase related to changing clinical treatment thresholds The potential cost effectiveness of these treatments was not factored into this study, nor was there a measure of outcomes such as major medical events or mortality We hope that were investing some of these dollars to get a long-term return in areas that include improved life expectancy
CLINICAL INSIGHTS
IN DIABETES
COMING IN ISSUE N0 10: High-dose atorvastatin and reduced stroke risk: results from the SPARCL trial; diabetes and mortality risk in patients with acute coronary syndrome; increased mortality in midlife adults who are overweight or obese NDEI MISSION STATEMENT
The
National Diabetes Education Initiative NDEI is a multicomponent educational program on type 2 diabetes designed for endocrinologists, diabetologists, cardiologists, primary care physicians, and other healthcare professionals involved in the care and management of patients with type 2 diabetes and insulin resistance NDEI programs address issues concerning insulin resistance and type 2 diabetes, from the epidemiology and pathophysiology of the disease and its associated complications to the therapeutic options for treatment and prevention
If you have any questions or comments for our faculty regarding the contents of this newsletter, please provide them in the space below After completion, please fax this page to 201 430-1248 Thank you QUESTION/COMMENT:
You have received this fax because we believe it may be of interest to you If you have received this fax in error and/or would like to have you fax number removed from our database, please call our toll free number 800 311-0217 and enter PIN 7589 Copyright 2006 Thomson Professional Postgraduate Services All rights reserved
Clinical Insights in Diabetes Post-Test
Issue No 9, 2006
1 Which one of the following is not an ADA
recommended treatment for type 2 diabetes? a Metformin plus a sulfonylurea agent b Metformin as initial treatment c Metformin plus a sulfonylurea agent plus a glitazone d Diet and exercise alone as initial treatment e Insulin plus metformin Which one of the following statements is true? a The metabolic syndrome predicts CVD risk over and beyond the sum of its component parts b The metabolic syndrome may serve as a summary measure of CVD risk c The results of this study suggest that the metabolic syndrome is a strong biological entity d The prevalence of the metabolic syndrome is similar in men 50 years of age and those 70 years of age e Subsequent CVD death rates are similar in men studied at 50 years of age and those re-studied at 70 years of age Which one of the following is not true? Compared to the group receiving placebo: a There was a progressive decrease in BMI throughout the 12-month period in adolescents receiving sibutramine b Fasting triglycerides, HDL-C, insulin levels, and HOMA scores all improved in the sibutramine group c Systolic and diastolic blood pressures and pulse rates all significantly increased in the sibutramine group d Tachycardia occurred significantly
more often in the sibutramine group e Rates of growth and Tanner scores were no different between the sibutramine and placebo groups The presence of 5 medical conditions among Medicare beneficiaries accounted for approximately what percentage of total healthcare spending in 2002? a 10 b 25 c 50 d 75 e 90
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Post-Test Answer Sheet Please complete and fax along with the evaluation/registration form on the next page 1 2 3 4 a a a a b b b b c c c c d d d d e e e e 6
CLINICAL INSIGHTS
IN DIABETES
Activity Code: F201-09 Valid Until: February 28, 2007
CME/CE Activity Evaluation/Registration Form
To obtain the appropriate credit, please complete the post-test and contact information, sign this form, and fax both pages to 1-888-251-5650 You can also mail the completed forms to Thomson Professional Postgraduate Services , PO Box 430, Montvale, NJ 07645-0430 To receive past issues of this newsletter, please contact Thomson Advanced HealthMarket StrategiesTM at 201 271-6000 I have participated in this activity as designed and am claiming ____ AMA PRA Category 1 CreditsTM maximum 10 _____________________ Signature I have participated in this activity as designed and am claiming
____ continuing pharmacy education contact hours maximum 10 [010 CEU] Signature Name: _____________________________________________________ Address: _________________________________________________________ City: _____________________________________________________ State: _________________________ Zip Code: _________________________ Phone: _________________________________________________________ Fax: _________________________________________________________ Email Address: ________________________________________________________________________________________________________________ Professional Classification: MD Other PharmD RPh __________________________________________________________________________
Overall Program
1 The activity met the stated objectives in such a way that I am better able to: a Identify patients with type 2 diabetes and the insulin resistance, or metabolic, syndrome b Select the appropriate therapeutic regimen for patients with type 2 diabetes and the insulin resistance syndrome c Summarize risk factors for cardiovascular disease in patients with type 2 diabetes and the insulin resistance syndrome d Examine the overall clinical and economic issues,
relative to payors, surrounding the management and treatment of various patient populations with type 2 diabetes 2 Overall, the activity was current and clinically relevant If you checked No, please explain
Strongly Disagree Disagree Agree Strongly Agree
1 1 1
2 2 2
3 3 3
4 4 4
5 5 5
6 6 6
1 Yes
2
3
4 No
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3 Overall, the activity was presented in a fair-balanced manner If you checked No, please explain
Yes
No
4 What topics should be dealt with in more detail? Check all that apply Algorithms for treating type 2 diabetes The metabolic syndrome and cardiovascular mortality
Sibutramine and weight loss in obese adolescents
Healthcare expenditures among the Medicare population
5 What questions do you still have regarding this activity? 6 What information not presented should be included in future activities? 7 What is the most important thing you learned from this activity? 8 Why did you participate in this activity? Check all that apply Amount of CME/CE credit Convenience Content of the issues Quality of the faculty Format Other:
9 What other clinical issues are you and your colleagues challenged by that could be addressed in a CME/CE activity? Please be as
specific as possible Thank you for your participation CME activity F201-09 ACPE381-999-06-052-H01
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Source:ndei.org
