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Type 2 diabetes mellitus (T2DM) is a major source of morbidity and mortality for millions of people throughout the world. Patients with T2DM are at risk for macrovascular complications, including coronary artery disease, stroke, and peripheral artery disease, as well as microvascular complications such as neuropathy, nephropathy, and retinopathy. Genetic susceptibility and phenotypic characteristics like obesity, lifestyle, and cultural factors impact an individual's risk of developing T2DM. People with impaired glucose tolerance or impaired fasting glucose are at high risk for progression to T2DM. These individuals with so-called prediabetes are typically asymptomatic and, therefore, may not be identified for many years. Targeted screening is recommended to identify those at high risk for T2DM in order to initiate early treatment. Lifestyle interventions aimed at weight reduction, healthy diet, and increased physical activity can prevent or delay the development of diabetes and its complications.

Educational Objectives
At the conclusion of this activity, participants should be better able to:

  • Identify risk factors for type 2 diabetes and related cardiovascular complications
  • Screen at-risk patients for type 2 diabetes according to recommended guidelines and using appropriate testing methods
  • Develop and implement evidence-based treatment strategies for patients with prediabetes

Target Audience These activities have been designed to meet the educational needs of primary care physicians and other health care professionals who are involved in the management of patients with type 2 diabetes.

Release Date: June 30, 2011
Expiration Date: June 29, 2013

Sponsored by SciMed

Supported by an independent educational grant from Merck

Accreditation Statement
SciMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation
SciMed designates this educational activity for a maximum of 3.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Disclosure and Resolution of Conflicts of Interest
SciMed requires all individuals who are involved with the development or delivery of content in any of its activities to disclose financial relationships they may have with commercial interests. Should SciMed determine that any of the disclosed relationships constitutes a conflict of interest, as defined by the ACCME, SciMed will act to resolve such a conflict.

When asked to report relevant financial relationships with commercial interests, faculty reported the following:

Lawrence Blonde, MD
Consultant
Amylin Pharmaceuticals, Inc.; AstraZeneca US; Boehringer Ingelheim Pharmaceuticals; Bristol-Myers Squibb; Daiichi Sankyo Co., LTD.; GlaxoSmithKline plc; Halozyme; Johnson & Johnson Services Inc; Mannkind Corporation; Merck & Co., Inc; Novo Nordisk Inc; Orexigen Therapeutics, Inc; Roche; Sanofi-Aventis U.S. LLC; Santarus, Inc; VeroScience, LLC.
Investigator
Boehringer Ingelheim Pharmaceuticals; Eli Lilly and Company; Johnson & Johnson Services Inc; Novo Nordisk Inc; Roche; Sanofi-Aventis U.S. LLC.
Speaker's Bureau
AstraZeneca US; Boehringer Ingelheim Pharmaceuticals; Bristol-Myers Squibb; Daiichi Sankyo Co., LTD.; Merck & Co., Inc; Novo Nordisk Inc; Santarus, Inc; VeroScience, LLC.
Other
Dr Blonde's late spouse's estate contains shares of Amylin Pharmaceuticals, Inc and Pfizer, Inc.
Edward Horton, MD
Consultant
Amylin Pharmaceuticals, Inc; Eli Lilly and Company; Merck & Co., Inc; Roche; Gilead; Medtronic, Inc.
Grant/Research Support
Amylin Pharmaceuticals, Inc; Eli Lilly and Company.
Chair/Member of Data Safety Monitoring Boards for studies sponsored by these companies Boehringer Ingelheim Pharmaceuticals; ChemoCentryx, Inc; GI Dynamics; MacroGenics, Inc; Takeda Pharmaceuticals North American, Inc; Theracos, Inc.
Frank Lavernia, MD
Speaker's Bureau
Abbott Laboratories.

The materials for this activity were peer reviewed by Scott Yager, MD, Private Practice, East Brunswick, NJ. Dr Yager has no relevant financial relationships to report.

The following planners and managers reported having a relevant financial relationship with a commercial interest:
Shari Fallet, DO - Pfizer (owns stock)

All other SciMed personnel involved in the development of content for this activity have no relevant financial relationships to report.

Instructions for Obtaining CME Credit
To obtain your CME Credit, please visit your Office in the Virtual Diabetes Institute or go to www.VirtualDiabetesInstitute.org

Disclaimer
The opinions or views expressed in this CME activity are those of the presenters and do not necessarily reflect the opinions or recommendations of SciMed or the commercial supporter. Participants should critically appraise the information presented and are encouraged to consult appropriate resources for information surrounding any product, device, or procedure mentions.

Lawrence Blonde, MD (Virtual Patient, Newsletter)
Director
Ochsner Diabetes Clinical Research Unit
Department of Endocrinology, Diabetes, and Metabolism
Associate Internal Medicine Residency Program Director
Ochsner Medical Center
New Orleans, LA

Edward S. Horton, MD (Presentations, Virtual Patient)
Professor of Medicine
Harvard Medical School
Vice President and Director of Clinical Research
Joslin Diabetes Center
Boston, MA

Frank Lavernia, MD (Virtual Patient)
Medical Director
North Broward Diabetes Center
North Broward Medical Center
Pompano Beach, FL

Type 2 diabetes mellitus (T2DM) is a complex metabolic disease characterized by progressive pancreatic islet cell dysfunction and insulin resistance in peripheral tissues, which leads to worsening hyperglycemia. Poor glycemic control is associated with an increased risk of microvascular complications, including retinopathy, neuropathy, and nephropathy, as well as morbidity and mortality from macrovascular complications. Early aggressive treatment aimed at improving glycemic control can slow the progression of disease and reduce the risk of long-term diabetes-associated complications. In addition to lifestyle modifications, pharmacotherapy is an essential component in the management of patients with T2DM. An expanded knowledge of the pathophysiology of the disease has enabled development of pharmacotherapeutic agents that target various pathogenic mechanisms. In addition, improved drug safety profiles reduce weight gain, hypoglycemia, and other medication-related adverse effects and provide options to improve patient outcomes.

Educational Objectives
At the conclusion of this activity, participants should be better able to:

  • Discuss the impact of early intervention in patients with type 2 diabetes
  • Explain how the various classes of antihyperglycemic medications impact the pathophysiologic defects of type 2 diabetes
  • Develop and implement evidence-based treatment strategies for achieving and maintaining glycemic control
  • Identify and reduce barriers to optimal care in patients with type 2 diabetes

Target Audience
These activities have been designed to meet the educational needs of primary care physicians and other health care professionals who are involved in the management of patients with type 2 diabetes.

Release Date: June 30, 2011
Expiration Date: June 29, 2013

Sponsored by SciMed

Supported by an independent educational grant from Merck

Accreditation Statement
SciMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation
SciMed designates this educational activity for a maximum of 3.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Disclosure and Resolution of Conflicts of Interest
SciMed requires all individuals who are involved with the development or delivery of content in any of its activities to disclose financial relationships they may have with commercial interests. Should SciMed determine that any of the disclosed relationships constitutes a conflict of interest, as defined by the ACCME, SciMed will act to resolve such a conflict.

When asked to report relevant financial relationships with commercial interests, faculty reported the following:

James R. Gavin III. MD, PhD
Consultant
AstraZeneca US; Amylin Pharmaceuticals, Inc; Bristol-Myers Squibb; Daiichi-Sankyo Co., LTD; Sanofi-Aventis U.S. LLC.
Speaker's Bureau
AstraZeneca US; Bristol-Myers Squibb; Sanofi-Aventis U.S. LLC.
Stockholder
Amylin Pharmaceuticals, Inc.
Edward S. Horton, MD
Consultant
Amylin Pharmaceuticals, Inc; Eli Lilly and Company; Merck & Co., Inc; Roche; Gilead; Medtronic, Inc.
Grant/Research Support
Amylin Pharmaceuticals, Inc; Eli Lilly and Company.
Chair/Member of Data Safety Monitoring Boards for studies sponsored by these companies Boehringer Ingelheim Pharmaceuticals; ChemoCentryx, Inc; GI Dynamics; MacroGenics, Inc; Takeda Pharmaceuticals North American, Inc; Theracos, Inc.
Louis Kuritzky, MD
Consultant
Eli Lilly and Company; Novartis; Sanofi-Aventis U.S. LLC; Takeda North America Pharmaceuticals.
Mark Stolar, MD
Advisory Board
Takeda North America Pharmaceuticals.
Speaker's Bureau
Amylin Pharmaceuticals, Inc.; Novo Nordisk Inc; Takeda North America Pharmaceuticals.

The materials for this activity were peer reviewed by Scott Yager, MD, Private Practice, East Brunswick, NJ. Dr Yager has no relevant financial relationships to report.

The following planners and managers reported having a relevant financial relationship with a commercial interest:
Shari Fallet, DO - Pfizer (owns stock)

All other SciMed personnel involved in the development of content for this activity have no relevant financial relationships to report.

James R. Gavin III, MD, PhD (Presentations, Newsletter)
CEO and Chief Medical Officer
Healing our Village, Inc.
Clinical Professor of Medicine
Emory University School of Medicine
Atlanta, Georgia

Edward S. Horton, MD (Virtual Patient)
Professor of Medicine
Harvard Medical School
Vice President and Director of Clinical Research
Joslin Diabetes Center
Boston, MA

Louis Kuritzky, MD (Virtual Patient)
Family Physician
Clinical Assistant Professor
Department of Community Health and Family Medicine
University of Florida
Gainesville, FL

Mark Stolar, MD (Virtual Patient)
Associate Professor, Clinical Medicine
Northwestern University Medical School
Attending Physician
Northwestern Memorial Hospital
Chicago, IL

Type 2 diabetes mellitus (T2DM) is a chronic, progressive disease characterized by worsening glycemic control over time. Decreased endogenous insulin production contributes to hyperglycemia, and chronic exposure to hyperglycemia increases the likelihood of developing diabetes-related microvascular, macrovascular, and neuropathic complications. Most patients with T2DM eventually will require the addition of insulin to their pharmacotherapeutic regimens to maintain glycemic control. The goal of insulin therapy is to provide exogenous insulin in a manner that mimics normal physiologic insulin secretion. Various formulations of insulin are available, which allow treatment regimens to be tailored to patients' needs. In most patients, management strategies are based on continuing most or all previous oral antihyperglycemic medications and adding insulin therapy. Many issues contribute to delays in starting insulin therapy. Often, patients are opposed to taking insulin and clinicians are hesitant to prescribe insulin. These barriers must be addressed to achieve a smooth transition to insulin therapy and therapeutic success.

Educational Objectives
At the conclusion of this activity, participants should be better able to:

  • Review the pathophysiology of type 2 diabetes and its impact on disease progression
  • Develop and implement evidence-based treatment strategies for achieving and maintaining glycemic control in patients with advanced T2DM
  • Apply an evidence-based approach to monitor and manage complications in patients with T2DM

Target Audience
These activities have been designed to meet the educational needs of primary care physicians and other health care professionals who are involved in the management of patients with type 2 diabetes.

Release Date: August 31, 2011
Expiration Date: August 30, 2013

Sponsored by SciMed

Supported by an independent educational grant from Merck & Co., Inc.

Accreditation Statement
SciMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation
SciMed designates this educational activity for a maximum of 3.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Disclosure and Resolution of Conflicts of Interest
SciMed requires all individuals who are involved with the development or delivery of content in any of its activities to disclose financial relationships they may have with commercial interests. Should SciMed determine that any of the disclosed relationships constitutes a conflict of interest, as defined by the ACCME, SciMed will act to resolve such a conflict.

When asked to report relevant financial relationships with commercial interests, faculty reported the following:

Steven Edelman, MD (Presentations)
Speaker's Bureau
AstraZeneca; Merck & Co., Inc.; Boehringer Ingelheim Pharmaceuticals, Inc.; Bristol-Myers Squibb Company; sanofi-aventis
Mark Stolar, MD (Virtual Patient Visits)
Advisory Board
Takeda Pharmaceuticals North America, Inc.
Speaker's Bureau
Amylin Pharmaceuticals, Inc.; Novo Nordisk; Takeda Pharmaceuticals North America, Inc.
Jeffrey Unger, MD (Newsletter, Virtual Patient Visits)
Advisory Board
Abbott Laboratories; Allergan, Inc.; Amylin Pharmaceuticals, Inc.; Boehringer Ingelheim Pharmaceuticals, Inc.; Novo Nordisk; Roche; sanofi-aventis; Takeda Pharmaceuticals North America, Inc.
Research
Abbott Laboratories; Amylin Pharmaceuticals, Inc.; AstraZeneca; Daiichi Sankyo Co., Ltd.; Forest Pharmaceuticals, Inc.; GlaxoSmithKlein; F. Hoffman-La Roche Ltd; Intarcia Therapeutics, Inc.; Johnson & Johnson; MAP Pharmaceuticals, Inc.; Merck & Co., Inc.; Novo Nordisk; Otsuka America Pharmaceutical, Inc.; POZEN, Inc.; Pfizer Inc; Purdue Pharma L.P.; Roche; Sangamo BioSciences, Inc.; sanofi-aventis; Sepracor, Inc.; Takeda Pharmaceuticals North America, Inc.; TWi Pharmaceuticals, Inc.; Warner Chilcott plc; Wyeth Research; XOMA
Speaker's Bureau
Abbott Laboratories; Amylin Pharmaceuticals, Inc.; AstraZeneca; Boehringer Ingelheim Pharmaceuticals, Inc.; Bristol-Myers Squibb Company; Eli Lilly and Company; Roche
Charles Vega, MD (Virtual Patient Visits)
No financial relationships to disclose

The materials for this activity were peer reviewed by Scott Yager, MD, Private Practice, East Brunswick, New Jersey. Dr Yager has no relevant financial relationships to report.

The following planners and managers reported having a relevant financial relationship with a commercial interest:
Shari Fallet, DO - Pfizer Inc (owns stock)

All other SciMed personnel involved in the development of content for this activity have no relevant financial relationships to report.

Steven Edelman, MD
Professor of Medicine
University of California, San Diego
Veterans Affairs Medical Center
San Diego California

Mark Stolar, MD
Associate Professor, Clinical Medicine
Northwestern University Medical School
Attending Physician
Northwestern Memorial Hospital
Chicago, Illinois

Jeffrey R. Unger, MD
Associate Clinical Professor of Medicine, Family Medicine
Loma Linda University School of Medicine
Director of Metabolic Studies
Catalina Research Institute
Chino, California

Charles Vega, MD
Associate Clinical Professor, Family Medicine
Residency Program Director
Department of Family Medicine
University of California, Irvine
Irvine, California

Comorbid hypertension is common in patients with type 2 diabetes mellitus (T2DM) and is associated with an increased risk of diabetes-related complications, both microvascular and macrovascular. The relationship between effective treatment of hypertension and risk reduction in patients with T2DM has been well established. Increased emphasis is being placed on the need to control blood pressure in patients with T2DM. Yet despite the availability of compelling evidence from research studies, implementing effective management strategies in clinical practice remains a challenge. Lifestyle interventions, including dietary management, weight reduction, and increased physical activity, along with pharmacotherapy, are the cornerstones of treatment. Many patients will require multiple drugs to control blood pressure. Combining agents with distinct and complementary modes of action can address different pathophysiologic mechanisms and may lead to earlier achievement of blood pressure goals. In addition, treatment with certain antihypertensives may provide cardiovascular and renal protection beyond blood pressure control.

Educational Objectives
At the conclusion of this activity, participants should be better able to:

  • Describe the effect of blood pressure on cardiovascular risk in patients with T2DM
  • Discuss the interrelated pathophysiologic mechanisms involved in hypertension and T2DM
  • Assess the role and impact of antihypertensive therapy in patients with T2DM and comorbid hypertension
  • Develop and implement evidence-based treatment strategies for patients with T2DM and comorbid hypertension

Target Audience
This activity has been designed to meet the educational needs of primary care physicians and other health care professionals who are involved in the management of patients with type 2 diabetes.

Release Date: October 31, 2011
Expiration Date: October 30, 2013

Sponsored by SciMed

Supported by an independent educational grant from Merck & Co., Inc.

Accreditation Statement

SciMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation

SciMed designates this educational activity for a maximum of 3.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Disclosure and Resolution of Conflicts of Interest

SciMed requires all individuals who are involved with the development or delivery of content in any of its activities to disclose financial relationships they may have with commercial interests. Should SciMed determine that any of the disclosed relationships constitutes a conflict of interest, as defined by the ACCME, SciMed will act to resolve such a conflict.

When asked to report relevant financial relationships with commercial interests, faculty reported the following:

George Bakris, MD (Newsletter, Virtual Patient Visits)
Advisory Board
National Kidney Foundation, American Society of Hypertension
Consultant
Abbott Laboratories; CVRx, Inc.; Eli Lilly and Company; US Food and Drug Administration; Johnson & Johnson; Takeda Pharmaceuticals North America, Inc.
National Clinical Trial Principal Investigator Studies
Medtronic Inc.; Relapysa
Research
Forest Pharmaceuticals, Inc.; Novartis
Speakers Bureau
Novartis; Takeda Pharmaceuticals North America, Inc.
Brent M. Egan, MD (Presentations, Virtual Patient Visits)
Grant/Research Support
Daiichi Sankyo Co., Ltd
James R. Gavin III, MD, PhD (Virtual Patient Visits)
Consultant
AstraZeneca; Amylin Pharmaceuticals, Inc.; Bristol-Myers Squibb Company;
Daiichi Sankyo Co., Ltd; sanofi-aventis
Speakers Bureau
AstraZeneca; Bristol-Myers Squibb Company; sanofi-aventis
Stockholder
Amylin Pharmaceuticals, Inc.

The materials for this activity were peer reviewed by Scott Yager, MD, Private Practice, East Brunswick, New Jersey. Dr Yager has no relevant financial relationships to report.

The following planners and managers reported having a relevant financial relationship with a commercial interest: Shari Fallet, DO—Pfizer Inc (owns stock)

All other SciMed personnel involved in the development of content for this activity have no relevant financial relationships to report.

George Bakris, MD
Professor of Medicine
Section of Endocrinology, Diabetes and Metabolism
Director, Hypertension Unit
University of Chicago
Chicago, Illinois

Brent M. Egan, MD
Head, Hypertension Section
Division of General Internal Medicine
Medical University of South Carolina
Charleston, South Carolina

James R. Gavin III, MD, PhD
CEO and Chief Medical Officer
Healing Our Village, Inc.
Clinical Professor of Medicine
Emory University School of Medicine
Atlanta, Georgia

Patients with type 2 diabetes mellitus (T2DM) have an increased prevalence of lipid abnormalities, which contributes to a high risk of cardiovascular disease (CVD). Prevention of CVD in these patients involves a multifaceted approach that addresses all major risk factors, including dyslipidemia. Patients with T2DM typically present with high triglyceride levels, low levels of HDL cholesterol, and LDL-cholesterol particles that are smaller, denser, and more atherogenic. Lifestyle changes improve lipid profiles in patients with T2DM, but most patients require pharmacotherapy in addition to lifestyle modifications to achieve recommended lipid and lipoprotein targets. Statins are generally regarded as the cornerstone of dyslipidemia management in patients with T2DM. Statins are very effective in lowering serum LDL-cholesterol levels but are less effective in normalizing serum triglyceride or HDL-cholesterol levels. Other pharmacotherapeutic agents regulate serum lipids by different mechanisms. Combination therapy may offer benefits in patients with T2DM who typically present with combined hyperlipidemia.

Educational Objectives
At the conclusion of this activity, participants should be better able to:

  • Describe the effect of dyslipidemia on cardiovascular risk in patients with T2DM
  • Assess the role and impact of lipid-lowering therapy in patients with T2DM and comorbid dyslipidemia
  • Develop and implement evidence-based treatment strategies for lipid control in patients with T2DM and comorbid dyslipidemia

Target Audience
This activity has been designed to meet the educational needs of primary care physicians and other health care professionals who are involved in the management of patients with type 2 diabetes.

Release Date: December 22, 2011
Expiration Date: December 21, 2013

Sponsored by SciMed

Supported by an independent educational grant from Merck & Co., Inc.

Accreditation Statement

SciMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation

SciMed designates this educational activity for a maximum of 3.5 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Disclosure and Resolution of Conflicts of Interest

SciMed requires all individuals who are involved with the development or delivery of content in any of its activities to disclose financial relationships they may have with commercial interests. Should SciMed determine that any of the disclosed relationships constitutes a conflict of interest, as defined by the ACCME, SciMed will act to resolve such a conflict.

When asked to report relevant financial relationships with commercial interests, faculty reported the following:

Edward S. Horton, MD (Newsletter, Virtual Patient Visits)
Consultant
Amylin Pharmaceuticals, Inc.; Eli Lilly and Company; Merck & Co., Inc.; Roche; Gilead; Medtronic, Inc.
Grant/Research Support
Amylin Pharmaceuticals, Inc.; Eli Lilly and Company
Chair/Member of Data Safety Monitoring Boards for studies sponsored by these companies
Boehringer Ingelheim Pharmaceuticals, Inc.; ChemoCentryx, Inc.; GI Dynamics, Inc.; MacroGenics, Inc.; Takeda Pharmaceuticals North American, Inc.; Theracos, Inc.
Richard W. Nesto, MD (Presentations, Virtual Patient Visits)
Advisory Board
Genentech, Inc.; Merck & Co., Inc.; Roche
Mark Stolar, MD (Virtual Patient Visits)
Advisory Board
Takeda Pharmaceuticals North America, Inc.
Speaker's Bureau Amylin Pharmaceuticals, Inc.; Novo Nordisk; Takeda Pharmaceuticals North America, Inc.

The materials for this activity were peer reviewed by Scott Yager, MD, Private Practice, East Brunswick, New Jersey. Dr. Yager has no relevant financial relationships to report.

The following planners and managers reported having a relevant financial relationship with a commercial interest: Shari Fallet, DO-Pfizer Inc (owns stock)

All other SciMed personnel involved in the development of content for this activity have no relevant financial relationships to report.

Edward S. Horton, MD
Professor of Medicine
Harvard Medical School
Vice President of Research and Director of Clinical Research
Joslin Diabetes Center
Boston, Massachusetts

Richard W. Nesto, MD
Professor of Medicine
Tufts University School of Medicine
Executive Vice President
Chief Medical Officer
Chair, Department of Cardiovascular Medicine
Lahey Clinic Medical Center
Burlington, Massachusetts

Mark W. Stolar, MD
Associate Professor, Clinical Medicine
Northwestern University Medical School
Attending Physician
Northwestern Memorial Hospital
Chicago, Illinois

Recent reports that bariatric surgery normalizes glucose levels in patients with type 2 diabetes mellitus have prompted discussions of surgical options for treating hyperglycemia. It is known that the rising incidence of type 2 diabetes is fueled by the increasing number of obese adults, especially those with more severe obesity. It is also known that weight reduction resulting from lifestyle modifications or weight loss medication improves glycemic control and diabetic comorbidities, but is difficult to sustain.

The first evidence that bariatric surgery may improve or resolve type 2 diabetes emerged from early observational studies of patients who had undergone gastric restrictive surgery with or without malabsorptive procedures, such as bypass or biliopancreatic diversion. There is now evidence from three randomized clinical trials comparing medical therapy to bariatric surgery for patients with obesity that the surgical approach achieved diabetes remission (defined as the normalization of glucose without the use of antidiabetes medications) in more patients for as long as 2 years. Although there is insufficient data to consider bariatric surgery as a cure for type 2 diabetes, glucose levels may normalize for a period of time after successful weight loss surgery.

Patients with type 2 diabetes considering bariatric procedures should have a body mass index (BMI) ≥35 kg/m2, should have failed to maintain weight reduction using medical approaches, and must accept the potential health risks and the postsurgical requirements for behavioral and dietary modifications. These patients must also commit to lifelong monitoring and treatment of possible adverse health consequences of bariatric surgery, including the possible recurrence of type 2 diabetes.

EDUCATIONAL OBJECTIVES:

  • Understand the association between obesity and type 2 diabetes, including the benefits associated with weight reduction
  • Evaluate the clinical evidence showing that various bariatric procedures may normalize glucose levels without the use of antidiabetes medications
  • Discuss the concept of diabetes remission
  • Describe eligibility criteria for bariatric surgery in patients with type 2 diabetes
  • Develop a plan for monitoring patients after bariatric surgery

Target Audience
This activity is designed to meet the needs of primary care physicians and other health care professionals who are interested in the management of patients with diabetes.

Accreditation Statement
SciMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation
SciMed designates this educational activity for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their partcipation in the activity.

Release Date: April 30th, 2012
Expiration date: April 29th 2014

Disclosure and Resolution of Conflicts of Interest
SciMed requires all individuals who are involved with the development or delivery of content in any of its activities to disclose financial relationships they may have with commercial interests. Should SciMed determine that any of the disclosed relationships constitutes a conflict of interest, as defined by the ACCME, SciMed will act to resolve such a conflict.

When asked to report relevant financial relationships with commercial interests, faculty reported the following:

James R. Gavin III. MD, PhD
AstraZeneca US (Speaker's Bureau, Consultant); Amylin Pharmaceuticals, Inc (Consultant, Stakeholder); Bristol-Myers Squibb (Speaker's Bureau, Consultant); Daiichi-Sankyo Co., LTD (Consultant); Sanofi-Aventis U.S. LLC ( Speaker's Bureau, Consultant)

All SciMed personnel involved in the development of content for this activity have no relevant financial relationships to report.

The materials for this activity were peer reviewed by Scott Yager, MD, Private Practice, East Brunswick, NJ. Dr Yager has no relevant financial relationships to report.

Instructions for Obtaining CME Credit
To obtain your CME Credit, please visit your office in the Virtual Diabetes Institute or go to www.VirtualDiabetesInstitute.org

Disclaimer
The opinions or views expressed in this CME activity are those of the presenters and do not necessarily reflect the opinions or recommendations of SciMed or the commercial supporter. Participants should critically appraise the information presented and are encouraged to consult appropriate resources for information surrounding any product, device, or procedure mentions.

James R. Gavin III, MD, PhD
Clinical Professor of Medicine
Emory University School of Medicine
CEO and Chief Medical Officer
Healing our Village, Inc.
Fayetteville, Georgia

Sleep-disordered breathing, most commonly obstructive sleep apnea (OSA), occurs to some degree in more than 75% of patients with type 2 diabetes, most of whom are undiagnosed. Prompt diagnosis and treatment is especially important because OSA exacerbates insulin resistance, increases hyperglycemia, makes weight loss more difficult, and increases blood pressure. Therefore, all physicians who care for patients with type 2 diabetes should recognize the classic OSA symptoms-witnessed apnea during sleep, loud snoring, and excessive daytime sleepiness or fatigue-and confirm suspected OSA by ordering a sleep study for high-risk patients. Successful treatment of OSA by lifestyle modification as necessary to promote weight loss and by the use of continuous positive airway pressure (CPAP) therapy reduces sleepiness and fatigue, improves quality of life, and reduces blood pressure. Although the effects of CPAP on glycemic control have yet to be proven in large randomized studies, reducing OSA symptoms may help increase activity level, promote weight loss, and make it easier for patients with type 2 diabetes to achieve their glycemic targets.

EDUCATIONAL OBJECTIVES

  • Raise awareness of the occurrence of sleep apnea in people with type 2 diabetes
  • Describe the effects of sleep apnea on glucose regulation
  • Outline the evaluation of patients with obstructive sleep apnea
  • Discuss the benefits of treating obstructive sleep apnea in patients with type 2 diabetes

Target Audience
This activity is designed to meet the needs of primary care physicians and other health care professionals who are interested in the management of patients with diabetes.

Accreditation Statement
SciMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation
SciMed designates this educational activity for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Release Date: June 30th 2012
Expiration date: June 29th 2014

Disclosure and Resolution of Conflicts of Interest
SciMed requires all individuals who are involved with the development or delivery of content in any of its activities to disclose financial relationships they may have with commercial interests. Should SciMed determine that any of the disclosed relationships constitutes a conflict of interest, as defined by the ACCME, SciMed will act to resolve such a conflict.

When asked to report relevant financial relationships with commercial interests, faculty reported the following:

Mark Stolar, MD
Advisory Board
Takeda Pharmaceuticals North America, Inc.
Speaker's Bureau
Amylin Pharmaceuticals, Inc.; Novo Nordisk; Takeda Pharmaceuticals North America, Inc.

All SciMed personnel involved in the development of content for this activity have no relevant financial relationships to report.

The materials for this activity were peer reviewed by Scott Yager, MD, Private Practice, East Brunswick, NJ. Dr Yager has no relevant financial relationships to report.

Instructions for Obtaining CME Credit

To obtain your CME Credit, please visit your office in the Virtual Diabetes Institute or go to www.VirtualDiabetesInstitute.org

Disclaimer
The opinions or views expressed in this CME activity are those of the presenters and do not necessarily reflect the opinions or recommendations of SciMed or the commercial supporter. Participants should critically appraise the information presented and are encouraged to consult appropriate resources for information surrounding any product, device, or procedure mentions.

Mark Stolar, MD
Associate Professor, Clinical Medicine
Northwestern University Feinberg School of Medicine

Attending Physician
Northwestern Memorial Hospital
Chicago, Illinois

The 2012 update of the American Diabetes Association and the European Association for the Study of Diabetes (ADA/EASD) guidelines for treating hyperglycemia in patients with type 2 diabetes highlights the need to individualize glycemic goals. As revealed in recent clinical trials, intensive therapy aimed at normalizing glucose levels may not be safe and effective for limiting diabetic complications in all patients with type 2 diabetes.

Based on the results of clinical trials, the ADA recommends a target hemoglobin A1c (A1C) of <7%, whereas the American Association of Clinical Endocrinologists (AACE) recommends A1C ≤6.5% if that goal can be safely maintained. Both associations propose individualizing A1C targets based on each patient's needs and preferences as well as his or her clinical status. More stringent targets of normal or near-normal glucose levels are recommended for patients with a short duration of diabetes, no significant cardiovascular disease, and a long life expectancy. Less stringent A1C targets ranging from 7% to 8% are suggested for patients with a history of severe hypoglycemia, long-standing diabetes, advanced diabetic complications, extensive comorbidities, or limited life expectancy.

Individualized glycemic goals, determined in partnership with the patient, are essential for the successful management of hyperglycemia in people with type 2 diabetes. Glycemic goals for each individual must evolve to meet each patient's changing health status, age, and personal circumstances.

Educational Objectives
After completing this activity, the participant should be better able to:

  • Review the clinical evidence supporting individualized glycemic goals for patients with type 2 diabetes
  • Identify the patient characteristics that permit treatment to attain normal or near normal glucose levels
  • Discuss the clinical conditions that necessitate less stringent A1C targets
  • Explore the role of the patient in setting glycemic goals

Target Audience
This activity has been designed to meet the educational needs of primary care physicians and other health care providers involved in the management of patients with type 2 diabetes.

Accreditation Statement
SciMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation
SciMed designates this educational activity for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in this activity.

Release Date: August 31, 2012
Expiration Date: August 30, 2014

Disclosure and Resolution of Conflicts of Interest
SciMed requires all individuals who are involved with the development or delivery of content in any of its activities to disclose any financial relationships they may have with commercial interests. Should SciMed determine that any of the disclosed relationships constitute a conflict of interest, as defined by the ACCME, SciMed will act to resolve such a conflict.

When asked to report relevant financial relationships with commercial interests, faculty reported the following:

Mark Stolar, MD
Advisory Board
Takeda Pharmaceuticals North America, Inc.
Speakers Bureau
Amylin Pharmaceuticals, Inc.; Novo Nordisk; Takeda Pharmaceuticals North America, Inc.

SciMed personnel involved in the development of content for this activity have no relevant financial relationships to report.

The materials for this activity were peer reviewed by Scott Yager, MD, Private Practice, East Brunswick, NJ. Dr. Yager has no relevant financial relationships to report.

Instructions for obtaining CME Credit
To obtain your CME Credit, please visit your office in the Virtual Diabetes Institute or go to www.VirtualDiabetesInstitute.org.

Mark Stolar, MD
Associate Professor, Clinical Medicine
Northwestern University Feinberg School of Medicine

Attending Physician
Northwestern Memorial Hospital
Chicago, Illinois

Recent updates to clinical guidelines for the treatment of hyperglycemia in type 2 diabetes provide direction on individualizing currently available therapies to a patient's clinical needs, and begin the transition away from step care. The present program highlights recommendations of the American Diabetes Association with the European Association for the Study of Diabetes (ADA/EASD) and the American Association of Clinical Endocrinologists with the American College of Endocrinology (AACE/ACE) for customized treatment plans for patients with type 2 diabetes.

Although we have no clinical markers that can consistently predict an individual's response to a specific treatment, therapy can be chosen based on each patient's clinical status, safety concerns, and preferences. Customization begins with individualized lifestyle modifications and education on diabetes, as well as psychosocial interventions to address diabetes-related distress. Recognition of a patient's specific barriers to successful implementation of lifestyle changes is a fundamental component of successful disease management. Emphasizing this need for individualized treatment, valuable time is often lost, both in the office and in the disease course, waiting for nonpharmacologic success to occur.

Initial pharmacotherapy strategies--monotherapy, combination therapy, or insulin--may be individualized based on the patient's baseline hemoglobin A1c (A1C) level, with combination therapy as the encouraged treatment when A1C is above 7.5% and with initial insulin as the encouraged treatment when A1C is above 9.0%. In addition, medications should be chosen by considering each drug's efficacy, safety, tolerability, and cost and matching those considerations to a patient's needs, age, comorbid conditions, and safety risks. Finally, the guidelines also recommend appropriate ways to intensify therapy, as needed, to achieve and maintain each individual's target A1C as type 2 diabetes progresses.

This program outlines key features of the most recent ADA/EASD and AACE/ACE guidelines that provide a foundation for building effective treatment strategies for patients with type 2 diabetes.

EDUCATIONAL OBJECTIVES
After participating in this activity, participants should be better able to:

  • Individualize the treatment strategy for each of their patients with type 2 diabetes
  • Recognize the need to customize lifestyle modifications, diabetes education and psychosocial interventions for their patients with type 2 diabetes
  • Initiate pharmacotherapy with drugs that meet the needs and preferences of the patient, while necessarily considering glucose-lowering efficacy, tolerability, safety, and cost
  • Address recurrent or persistent hyperglycemia using a personalized plan to intensify therapy

TARGET AUDIENCE
This activity has been designed to meet the educational needs of primary care physicians and other health care providers involved in the management of patients with type 2 diabetes.

ACCREDITATION STATEMENT
SciMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

CREDIT DESIGNATION
SciMed designates this educational activity for a maximum of 0.50 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in this activity.

Release Date: October 31, 2012
Expiration Date: October 30, 2014

Disclosure and Resolution of Conflicts of Interest
SciMed requires all individuals who are involved with the development or delivery of content in any of its activities to disclose any financial relationships they may have with commercial interests. Should SciMed determine that any of the disclosed relationships constitute a conflict of interest, as defined by the ACCME, SciMed will act to resolve such a conflict. When asked to report relevant financial relationships with commercial interests, faculty reported the following:

Mark Stolar, MD
Advisory Board:
Takeda Pharmaceuticals North America, Inc.
Speakers Bureau:
Amylin Pharmaceuticals, Inc.; Novo Nordisk; Takeda Pharmaceuticals North America, Inc.

SciMed personnel involved in the development of content for this activity have no relevant financial relationships to report.

The materials for this activity were peer reviewed by Scott Yager, MD, Private Practice, East Brunswick, New Jersey. Dr. Yager has no relevant financial relationships to report.

INSTRUCTIONS FOR OBTAINING CME CREDIT
To obtain your CME Credit, please visit your office in the Virtual Diabetes Institute or go to www.VirtualDiabetesInstitute.org.

DISCLAIMER
The opinions or views expressed in this CME activity are those of the presenters and do not necessarily reflect the opinions or recommendations of SciMed or the commercial supporter(s). Participants should critically appraise the information presented and are encouraged to consult appropriate resources for information surrounding any product, device, or procedure mentioned.

Mark Stolar, MD
Associate Professor, Clinical Medicine
Northwestern University Feinberg School of Medicine

Attending Physician
Northwestern Memorial Hospital
Chicago, Illinois

Combinations of antidiabetes agents are often used to help patients with type 2 diabetes achieve and maintain individualized glycemic targets. This activity reviews the rationale for optimizing antidiabetes treatment by combining drugs that address different defects associated with type 2 diabetes. Coadministration of agents with complementary pharmacological action provides greater glycemic control while reducing the risk of some unacceptable side effects.

In addition, this newsletter summarizes guidelines for identifying patients with type 2 diabetes who may benefit from the use of combinations of noninsulin agents or insulin with a noninsulin antidiabetes drug as initial treatment or as replacement for suboptimal monotherapy. The decision to use combination therapy and the selection of the component medications are driven by the patient's level of glycemic control as well as the expected therapeutic benefits and risks.

A recent addition to treatment guidelines is the recommendation for initial combination therapy when a single agent is unlikely to attain glycemic targets in patients with higher hemoglobin A1C (A1C) levels. The results of clinical trials that support the approved use of initial combination therapy demonstrate that initial combination therapy helps more patients achieve glycemic targets at lower doses than does monotherapy with either of the component agents.

Complex treatment regimens may be simplified by the use of fixed-dose combination (FDC) products that contain 2 oral antidiabetes drugs in 1 pill. Studies have shown that patients taking FDCs of antidiabetes drugs have better adherence to medication, are more likely to reach glycemic goals, are more satisfied with diabetes treatment, and incur lower direct medical costs. To help initiate the use of FDC products as initial or replacement therapy in appropriate patients, dosing recommendations for FDC products are summarized.

Finally, the first polypharmacy FDC product containing an antidiabetes agent and a statin was recently approved for use in patients with type 2 diabetes and dyslipidemia. An overview of the appropriate use of this product is provided.

EDUCATIONAL OBJECTIVES
After participating in this activity, participants should be better able to:

  • Select appropriate combinations of antidiabetes agents based on complementary mechanisms of action
  • Individualize combination pharmacotherapy as initial therapy or as replacement treatment in patients with inadequate glycemic control
  • Initiate fixed-dose combination products or combinations of separate oral or injectable antidiabetes agents as needed to reach individualized glycemic goals and satisfy the patientís medical and personal needs and preferences
  • Understand the appropriate use of a fixed-dose polypharmacy product in patients with type 2 diabetes and dyslipidemia

TARGET AUDIENCE
This activity has been designed to meet the educational needs of primary care physicians and other health care providers involved in the management of patients with type 2 diabetes.

ACCREDITATION STATEMENT
SciMed is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

CREDIT DESIGNATION SciMed designates this educational activity for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in this activity.

Release Date: December 31, 2012 Expiration Date: December 30, 2014

DISCLOSURE AND RESOLUTION OF CONFLICTS OF INTEREST
SciMed requires all individuals who are involved with the development or delivery of content in any of its activities to disclose any financial relationships they may have with commercial interests. Should SciMed determine that any of the disclosed relationships constitute a conflict of interest, as defined by the ACCME, SciMed will act to resolve such a conflict.

When asked to report relevant financial relationships with commercial interests, faculty reported the following:

Mark Stolar, MD
Advisory Board: Takeda Pharmaceuticals North America, Inc.
Speakers Bureau: Amylin Pharmaceuticals, Inc.; Novo Nordisk;
Takeda Pharmaceuticals North America, Inc.

SciMed personnel involved in the development of content for this activity have no relevant financial relationships to report.

The materials for this activity were peer reviewed by Scott Yager, MD, Private Practice, East Brunswick, New Jersey. Dr. Yager has no relevant financial relationships to report.

Instructions for obtaining CME Credit
To obtain your CME Credit, please visit your office in the Virtual Diabetes Institute or go to www.VirtualDiabetesInstitute.org.

Disclaimer
The opinions or views expressed in this CME activity are those of the presenters and do not necessarily reflect the opinions or recommendations of SciMed or the commercial supporter(s). Participants should critically appraise the information presented and are encouraged to consult appropriate resources for information surrounding any product, device, or procedure mentioned.

Mark Stolar, MD
Associate Professor, Clinical Medicine
Northwestern University Feinberg School of Medicine

Attending Physician
Northwestern Memorial Hospital
Chicago, Illinois