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Disclaimer: CME certification for these activities has expired. All information is pertinent to the timeframe in which it was released.


Metabolic Syndrome and Type 2 Diabetes: New Paradigms of Treatment


GOAL
To provide physicians with the most recent information regarding the treatment of dyslipidemia in patients with type 2 diabetes.

TARGET AUDIENCE
This activity is designed for cardiologists and primary care physicians. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine takes responsibility for the content, quality, and scientific integrity of this CME activity. At the conclusion of this activity, participants should be able to:

  • Assess the clinical implications of the Veterans Affairs High-Density Lipo-protein Intervention Trial (VA-HIT) subgroup analysis and its impact on current treatment options
  • Discuss the pros and cons of fibrate monotherapy vs statin/fibrate combination therapy
  • Diagnose the metabolic syndrome and integrate new treatment options into clinical practice
  • Identify safety management issues related to combination therapy

ACCREDITATION STATEMENT
The Johns Hopkins University School of Medicine is accredited by the Accreditation Council for Continuing Medical Education to sponsor continuing medical education for physicians.

CREDIT DESIGNATION STATEMENT
The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 2 category 1 credits toward the AMA Physician's Recognition Award. Each physician should claim only those credits that he/she actually spent in the activity.

The estimated time to complete this educational activity: 2 hours.

Release date: April 15, 2003. Expiration date: April 15, 2005.

DISCLAIMER STATEMENT
The opinions and recommendations expressed by faculty and other experts whose input is included in this program are their own. This enduring material is produced for educational purposes only. Use of Johns Hopkins University School of Medicine name implies review of educational format design and approach. Please review the complete prescribing information of specific drugs or combinations of drugs, including indications, contraindications, warnings, and adverse effects, before administering pharmacologic therapy to patients.

This program is supported by an unrestricted educational grant from Abbott Laboratories.

Advanced Studies in Medicine (ISSN-1530-3004) is published by Galen Publishing, LLC, an HMG Company. P.O. Box 340, Somerville, NJ 08876. (908) 253-9001. Web site: www.galenpublishing.com. Copyright ©2001 by Galen Publishing, LLC. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. Bulk postage paid at Somerville, NJ Post Office and at additional mailing offices. Advanced Studies in Medicine is a registered trademark of The Healthcare Media Group, LLC. Printed on acid-free paper. BPA Membership applied for December 2000.

Full Disclosure Policy Affecting CME Activities:
As a sponsor accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of Johns Hopkins University School of Medicine to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer(s) of any commercial product(s) discussed in an educational presentation. The Program Director and Participating Faculty reported the following:

PROGRAM DIRECTOR

    Roger S. Blumenthal, MD, FACC, FCCP
    Associate Professor of Medicine
    Director, the Ciccarone Center for the Prevention of Heart Disease
    Johns Hopkins University School of Medicine
    Baltimore, Maryland
    • Dr Blumenthal reports receiving grant/research support and honoraria from Kos Pharmaceuticals Inc, Merck & Co Inc, Novartis Corporation, Pfizer Inc, and Wyeth.

PARTICIPATING FACULTY

    Michael H. Davidson, MD, FACC, FACP
    Associate Professor of Medicine
    Rush Medical College
    Director, Rush Preventive Cardiology Center
    Rush-Presbyterian-St. Lukes Medical Center
    Boston, Massachusetts
    • Dr Davidson reports receiving grant/research support from AstraZeneca Pharmaceuticals LP, Avant Immunotherapeutics, Bristol-Myers Squibb, Kos Pharmaceuticals Inc, Merck & Co Inc, Merck/Schering-Plough Pharmaceuticals, and Pfizer Inc; serving as a consultant to AstraZeneca Pharmaceuticals LP, Merck/Schering-Plough Pharmaceuticals, and Reliant Pharmaceuticals; serving on the speakers' bureau for AstraZeneca Pharmaceuticals LP, Kos Pharmaceuticals Inc, Merck & Co Inc, NovartisCorporation, and Pfizer Inc; and receiving honoraria from AstraZeneca Pharmaceuticals Inc, Kos Pharmaceuticals Inc, Merck & Co Inc, Merck/Schering-Plough Pharmaceuticals, Novartis Corporation, Pharmacia, and Wyeth.

    Frank M. Sacks, MD
    Associate Professor of Medicine
    Harvard Medical School
    Brigham and Women's Hospital
    Associate Professor of Nutrition
    Harvard School of Public Health
    Boston, Massachusetts
    • Dr Sacks reports serving as a consultant to Abbott Laboratories, Bristol-Myers Squibb, Fournier Pharmaceuticals, Genzyme Pharma-ceuticals, and Kos Pharmaceuticals Inc; and receiving honoraria from Abbott Laboratories, Bristol-Myers Squibb, Fournier Pharmaceuticals, Genzyme Pharmaceuticals, Kos Pharmaceuticals Inc, and Sankyo Pharma Inc.

Notice:
In accordance with the ACCME Standards for Commercial Support, the audience is advised that one or more articles in this continuing medical education activity may contain reference(s) to unlabeled or unapproved uses of drugs or devices.

Faculty have indicated that they have not referenced unlabeled/unapproved uses of drugs or devices.

Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Advanced Studies in Medicine does not provide disclosure information from authors of abstracts and poster presentations. The reader shall be advised that these contributors may or may not maintain financial relationships with pharmaceutical companies.

Cardiovascular disease (CVD) is the leading cause of death in people with diabetes. As such, not only is the management of blood glucose in patients with diabetes essential, but also the management of cardiovascular risk. Patients with diabetes have a 2- to 4-fold higher risk of myocardial infarction and stroke, and are 3 to 4 times more likely to die from CVD than individuals without diabetes.1 This reality has prompted the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) to identify diabetes as a coronary heart disease risk equivalent, calling for more intense treatment strategies for this population.

Yet perhaps less recognized among clinicians is the need to manage cardiovascular risk in prediabetic patients—those who have above-normal blood glucose levels but do not meet the diagnostic criteria for diabetes. It is estimated that at least 16 million Americans have prediabetes, in addition to the 17 million with diabetes.2 Not only are those with prediabetes at risk of progressing to the more serious disease state of diabetes, but they are also at risk for cardiovascular disease3 as a result of the dyslipidemia typically associated with insulin resistance (ie, high triglyceride levels and low high-density lipoprotein cholesterol [HDL-C]). Also at risk are patients with the metabolic syndrome, a constellation of major risk factors that includes not only insulin resistance and its associated dyslipidemia, but also abdominal obesity, elevated blood pressure, and prothrombotic and proinflammatory states. The NCEP ATP III has established the metabolic syndrome as a secondary target of risk-reduction therapy.

Many of the CVD prevention randomized trials have reported the benefits of lipid-lowering therapy in type 2 diabetes, but the medical literature contains few reports about lipid management in patients with insulin resistance and/or the metabolic syndrome. This issue of Advanced Studies in Medicine offers a review of the existing medical literature on this topic, along with findings from the most recent and largest analysis to date on this topic: The Subgroup Analysis from the Department of Veterans Affairs High-Density Lipoprotein Intervention Trial (VA-HIT). Frank M. Sacks, MD, offers a cogent discussion of the clinical implications of this recent report, calling for a more aggressive approach within this population. Michael H. Davidson, MD, comments on the safety and efficacy of combination therapy designed to reduce the elevated triglycerides and raise the low HDL-C levels that are characteristic of patients with insulin resistance and/or the metabolic syndrome. Two case studies provide information on monotherapy and combination therapy as alternative approaches to clinical management.

The review article, Dyslipidemia, Prediabetes, and Type 2 Diabetes: Clinical Implications of the VA-HIT Subanalysis, and case studies that follow, address current concepts and some of the key issues involved in the diagnosis and treatment of dyslipidemia in patients with diabetes, prediabetes, and the metabolic syndrome. The information also provides insights into ATP III and the implications of recent analyses on clinical practice.

REFERENCES
1. Haffner SM, Lehto S, Ronnemaa T, et al. Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction. N Engl J Med. 1998;339:229-234.
2. American Diabetes Association. Basic diabetes information. Available at: http://www.diabetes.org/main/info/diabetesinfo.jsp]. Accessed January 14, 2003.
3. Haffner SM, Mykkanen L, Festa A, Burke JP, Stern MP. Insulin-resistant prediabetic subjects have more atherogenic risk factors than insulin-sensitive prediabetic subjects: implications for preventing coronary heart disease during the prediabetic state. Circulation. 2000;101:975-980.

*Associate Professor of Medicine, Director, the Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Johns Hopkins University School of Medicine, Baltimore, Maryland.





Johns Hopkins Advanced Studies in Medicine (ISSN-1558-0334), is published by Galen Publishing, LLC, d/b/a ASiM, PO Box 340, Somerville, NJ 08876. (908) 253-9001. Copyright ©2012 by Galen Publishing. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, without first obtaining permission from the publisher. ASiM is a registered trademark of The Healthcare Media Group, LLC.