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


Is There an Intrinsic Vascular Benefit to TZDs? Examining the Evidence


GOAL
To provide nurse practitioners, physician assistants, and nurses with up-to-date information on the treatment and management of patients with diabetes.

TARGET AUDIENCE
This activity is designed for nurse practitioners, physician assistants, and nurses. No prerequisites required.

LEARNING OBJECTIVES
The Johns Hopkins University School of Medicine and The Institute for Johns Hopkins Nursing take responsibility for the content, quality, and scientific integrity of this CE activity. At the conclusion of this activity, the participant should be able to:

  • Discuss the relationships between type 2 diabetes and cardiovascular disease.
  • Analyze data on the impact of current diabetes therapies on cardiovascular
    outcomes.
  • Evaluate clinical situations in which cardiovascular outcomes can be improved in the context of successful diabetes treatment.

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

The Institute for Johns Hopkins Nursing is accredited as a provider of continuing nursing education by the American Nurses' Credentialing Center's Commission on Accreditation.

CREDIT DESIGNATION STATEMENT
This program has been approved for 1.8 contact hours of continuing education by the American Academy of Nurse Practitioners. Program ID 0609348.

The Johns Hopkins University School of Medicine designates this educational activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

This 1.8 contact hour Education Activity (Provider Directed/Learner Paced) is provided by The Institute for Johns Hopkins Nursing (50 minutes of content = 1 contact hour). Claim only those contact hours actually spent in the activity.

The estimated time to complete this educational activity: 1.5 hours.

Release date: November 15, 2006. Expiration date: November 15, 2008.

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 The Johns Hopkins University School of Medicine, The Institute for Johns Hopkins Nursing, and the American Academy of Nurse Practitioners names 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 educational grant from Takeda Pharmaceuticals North America, Inc.

Full Disclosure Policy Affecting CME Activities:
As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is the policy of the 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

Sherita Hill Golden, MD, MHS  
Assistant Professor of Medicine and Epidemiology
Johns Hopkins University School of Medicine
Division of Endocrinology and Metabolism
Welch Center for Prevention, Epidemiology, and Clinical Research
Baltimore, Maryland
Dr Golden reports having no financial or advisory relationships with
corporate organizations related to this activity.

Thomas G. Bartol, NP, CDE
Family Nurse Practitioner
Richmond Area Health Center
Richmond, Maine
Adjunct Faculty
Husson College School of Nursing
Bangor, Maine
Mr Bartol reports receiving honoraria from Takeda Pharmaceuticals North America, Inc; and serving on the speakers' bureau for GlaxoSmithKline, Sanofi-Aventis, and Takeda Pharmaceuticals North America, Inc.

John B. Buse, MD, PhD, FACE
Associate Professor of Medicine
Director, Diabetes Care Center
Director, Endocrinology Clinics
Chief, Division of General Medicine and Clinical Epidemiology
University of North Carolina School of Medicine
Chapel Hill, North Carolina
Dr Buse reports receiving grants/research support from Amylin Pharmaceuticals, BD Research Laboratories, Bristol-Myers Squibb Company, Dexcom, Eli Lilly and Company, LipoScience, Novartis, Novo Nordisk, Pfizer Inc, Roche, and Transition Therapeutics; serving as a consultant for Amylin Pharmaceuticals, BD Research Laboratories, Bristol-Myers Squibb Company, Eli Lilly and Company, LipoScience, Insulet Corporation, Merck and Company, Roche, Sanofi-Aventis, and Wyeth; serving on the speakers' bureau for Amylin Pharmaceuticals, Eli Lilly and Company, Merck and Company, Novo Nordisk, and Sanofi-Aventis; and owning stock in Insulet Corporation.

Carol Hatch Wysham, MD, FACE, FACP
Assistant Clinical Professor of Medicine
University of Washington Medical School
Assistant Clinical Professor of Pharmacotherapy
Washington State University
Clinical Endocrinologist
Rockwood Clinic
Spokane, Washington
Dr Wysham reports receiving grants/ research support from Amylin Pharmaceuticals, AstraZeneca, Eli Lilly and Company, GlaxoSmithKline, and Sanofi-Aventis; serving as a consultant for Amylin Pharmaceuticals; receiving honoraria from Amylin Pharmaceuticals, Eli Lilly and Company, GlaxoSmithKline, and Sanofi-Aventis; and serving on the speakers' bureau for Amylin Pharmaceuticals, Eli Lilly and Company, GlaxoSmithKline, and Sanofi-Aventis.

Notice: The audience is advised that the articles in this CE activity contain no reference(s) to unlabeled or unapproved uses of drugs or devices.

Johns Hopkins Advanced Studies in Medicine provides disclosure information from contributing authors, lead presenters, and participating faculty. Johns Hopkins 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.

Is There an Intrinsic Vascular Benefit To TZDs? Examining The Evidence
Sherita Hill Golden, MD, MHS*

Type 2 diabetes is a progressive disease with significant mortality and morbidity from microvascular and macrovascular complications. Along with its increasing prevalence, which many have termed a "diabetes epidemic," the disease represents a growing public health burden and underscores the need for improved disease management and effective preventive intervention. However, as the faculty for the symposium featured in this issue of Johns Hopkins Advanced Studies in Medicine point out, both diabetes and its macrovascular complications develop over the course of years, providing nurse practitioners, physician assistants, and other healthcare professionals involved in primary care with opportunities to intervene and prevent or delay disease progression.

The symposium, "Is There an Intrinsic Vascular Benefit to TZDs? Examining the Evidence," explored the links between type 2 diabetes and cardiovascular disease and the impact of thiazolidinediones and other current diabetes therapies on macrovascular outcomes. It was held at the 2006 National Conference of the American Academy of Nurse Practitioners in Grapevine, Texas, on June 24, 2006, and featured a distinguished faculty of 2 endocrinologists and a nurse practitioner, all with expertise in the management of diabetes.

As the symposium presentations amply illustrate, diabetes is heralded by abnormalities in glucose, blood pressure, and lipids, all of which contribute to the development of cardiovascular disease. Therefore, early and continued attention to these abnormalities and other exacerbating risk factors, such as smoking and obesity, is crucial. So is patient counseling on the importance and benefits of lifestyle modification in preventing diabetes and cardiovascular disease.

Thomas G. Bartol, NP, CDE, begins with an overview of the evidence linking type 2 diabetes to cardiovascular disease. He explains the role of insulin resistance in the development of type 2 diabetes and how insulin resistance, impaired glucose tolerance, and diabetes promote atherosclerosis. He also reviews the changes in glucose and insulin levels that occur during the progression of normoglycemia to insulin resistance, glucose intolerance, and diabetes, and integrates the time course of these changes with the natural history of type 2 diabetes and the development of microvascular and macrovascular complications.

Carol Hatch Wysham, MD, FACE, FACP, a clinical endocrinologist, follows with a discussion of the impact of current diabetes therapies on macrovascular outcomes. Emphasizing that type 2 diabetes requires management of multiple risk factors, she reviews major studies demonstrating the benefits of lowering glucose and blood pressure and normalizing lipid levels. She also addresses the pharmacologic and nonpharmacologic management of other cardiovascular risk factors, including insulin resistance and its deleterious effects on glycemia, lipids, blood pressure, endothelial function and inflammation, coagulation, and fat distribution.

Mr Bartol continues with an analysis of 2 case studies provided by John B. Buse, MD, PhD, FACE, an endocrinologist and Vice President of the American Diabetes Association. The case studies, which were presented to the nurse practitioners attending the symposium and involved "show of hands" voting for the various treatment options, illustrate the power of motivation and lifestyle interventions in prediabetes and the need for multiple interventions and aggressive therapy in poorly controlled diabetes.

Highlights of the concluding question-and-answer session round out this issue of Johns Hopkins Advanced Studies in Medicine.

We hope the information presented in this monograph provides additional insight into the management of prediabetes and diabetes, and that it will ultimately lead to improved patient care and the prevention of diabetes and macrovascular complications.

*Assistant Professor of Medicine and Epidemiology, Johns Hopkins University School of Medicine, Division of Endocrinology and Metabolism, Welch Center for Prevention,
Epidemiology, and Clinical Research, Baltimore, Maryland.
Address correspondence to: Sherita Hill Golden, MD, MHS, Assistant Professor of Medicine and Epidemiology, Johns Hopkins University School of Medicine, Division of Endocrinology and Metabolism, Welch Center for Prevention, Epidemiology, and Clinical Research, 2024 East Monument Street, Suite 2-600, Baltimore, MD 21205.
E-mail: sahill@jhmi.edu.

The content in this monograph was developed with the assistance of a staff medical writer. Each author had final approval of his/her article and all its contents.





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.