Annals for Educators - 6 October 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives6 October 2020Annals for Educators - 6 October 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202010060 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsSodium–Glucose Cotransporter-2 Inhibitors and the Risk for Diabetic Ketoacidosis. A Multicenter Cohort StudySodium–glucose cotransporter-2 (SGLT2) inhibitors, a newer class of diabetes medications, can reduce the risk for important cardiovascular outcomes in patients with type 2 diabetes at high cardiovascular risk. However, concerns have been raised about a possible increased risk for diabetic ketoacidosis (DKA). This large study assessed whether initiation of an SGLT2 inhibitor was associated with subsequent DKA.Use this study to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners to name risk factors for DKA.If there is an association between SGLT2 inhibitor use and DKA, what are possible explanations? How do SGLT2 inhibitors work? The authors provide potential explanations in the paper's discussion.Ask your learners how a cohort study works. Review the design of this one. Why did the authors study only patients who were new users of SGLT2 inhibitors? Why did they match patients to new users of a dipeptidyl peptidase-4 inhibitor? What is the purpose of the propensity score?What are the limitations to what may be concluded from this study? Should it alter clinical practice?Postmarketing Safety of Vaccines Approved by the U.S. Food and Drug Administration. A Cohort StudyVaccination has greatly reduced morbidity, disability, and death from numerous infectious diseases. However, concern about the safety of vaccines is partly responsible for declining rates of vaccination for preventable disease. This study used a national vaccine safety surveillance program to assess newly identified safety concerns related to all vaccines approved from 1996 to 2015.Use this study to:Ask your learners to list the vaccines recommended for children and adults by the Advisory Committee on Immunization Practices. Review the most recent recommendations. Have your learners ever seen a patient with one of the diseases against which these vaccines provide protection?How does vaccination work? Do your learners believe that vaccines are generally safe? Are there safety concerns? What are they?Have your learners encountered patients who resist or refuse recommended vaccines? What concerns do these patients have? How might the results of this study be useful when discussing such concerns with patients?Many parents report unfounded concerns about autism with MMR vaccination. Use a recent Annals for Educators alert to review this topic. Ask your learners how they would reply to a patient who is afraid of vaccination.What are valid safety concerns? In whom are certain vaccines contraindicated?How Hospital Stays Resemble Enhanced InterrogationReview of the Central Intelligence Agency's manual on enhanced interrogation techniques reveals disturbing analogies between the unintentional consequences of some hospital practices and those aimed at purposefully disorienting and dehumanizing prisoners.Use this essay to:Ask your learners what aspects of our hospital practices resemble prison. How does the loss of autonomy affect some patients? Does it explain why some are “noncooperative”?Can your learners think of ways to address some of the problems the authors note? Can we alter the schedule of certain tests? Can we do a better job of making sure patients understand what is about to happen to them, and why?Teach at the bedside! Ask patients on rounds what aspects of being in the hospital are bothersome. Are there little things that could be improved? Have blood draws, other tests, and blood pressure measurements been explained to them? Are there things your team can do to make the hospital stay better?In the Clinic: DeliriumDelirium is an acute confusional state that is common, costly, and associated with significant functional decline and distress. Are your learners prepared to prevent it when possible and to evaluate and manage patients with delirium?Use this review to:Ask your learners who is at risk for delirium. Can it be prevented? Should medications be used for prevention?How should a patient with an acute change in mental status be evaluated?Teach at the bedside! Demonstrate the use of the CAM tool (or the CAM-ICU in an intubated patient) with your team.Are all patients with delirium hyperactive and agitated? Why is this important to know?Should medications be used to treat patients with delirium? What should be done? Should restraints ever be used?Use the provided multiple-choice questions to introduce topics for discussion during a teaching session. And, be sure to log on and enter your responses to earn CME and MOC credit for yourself!Humanism and ProfessionalismOn Being a Doctor: Becoming a Real DoctorDr. Garris reflects on how becoming a “real doctor” does not involve a stamp on a diploma and how it comes at the most inconvenient and unexpected of times.Use this essay to:Listen to an audio recording, read by Dr. Virginia Hood. Consider whether just listening together is the best use of this powerful essay, or whether your learners would value a discussion.Is being a “real doctor” a fund of knowledge, an attitude, something decided by others about us, or something else altogether?Ask your learners to consider whether they have become “real doctors” and, if so, when. How did they know? How will they know? Be careful not to put any of your learners on the spot with an expectation that they share; some may not be comfortable doing so.Do you recall moments that made you realize you are a “real doctor”? Care to share them with your team?MKSAP 18 QuestionA 66-year-old man recently diagnosed with type 2 diabetes mellitus is evaluated in the emergency department for nausea, vomiting, and fatigue. He was diagnosed with type 2 diabetes 18 months ago. In the past month metformin was discontinued due to severe diarrhea, and glipizide and empagliflozin were initiated. In addition to type 2 diabetes, medical history is significant for coronary artery disease, hypertension, and dyslipidemia. Medications are aspirin, lisinopril, metoprolol, atorvastatin, glipizide, and empagliflozin.On physical examination, temperature is normal, blood pressure is 90/60 mm Hg, pulse rate is 120/min, and respiration rate is 22/min. Dry mucous membranes are noted. There is diffuse abdominal tenderness to palpation without guarding. Other than tachycardia, the remainder of the examination is normal.Laboratory studies:Sodium133 mEq/L (133 mmol/L)Bicarbonate10 mEq/L (10 mmol/L)Glucose150 mg/dL (8.3 mmol/L)Anion gap17 mEq/L (17 mmol/L)β-HydroxybutyrateElevatedWhich of the following is most likely responsible for the patient's findings?A. AtorvastatinB. Discontinuation of metforminC. EmpagliflozinD. GlipizideE. LisinoprilCorrect AnswerC. EmpagliflozinEducational ObjectiveDiagnose diabetic ketoacidosis associated with a sodium-glucose cotransporter 2 (SGLT2) inhibitor.CritiqueSodium-glucose cotransporter 2 (SGLT2) inhibitors (canagliflozin, dapagliflozin, and empagliflozin) improve glycemia by increasing excretion of glucose by the kidney. SGLT2 is expressed in the proximal tubule and mediates reabsorption of approximately 90% of the filtered glucose load. SGLT2 inhibitors promote excretion of glucose by the kidneys and thereby modestly lower elevated blood glucose levels in patients with type 2 diabetes. Euglycemic diabetic ketoacidosis has been reported in patients with type 2 diabetes taking SGLT2 inhibitors. Because of this, the FDA issued a Drug Safety Communication that warns of an increased risk of diabetic ketoacidosis with uncharacteristically mild to moderate glucose elevations (euglycemic diabetic ketoacidosis) associated with the use of all the approved SGLT2 inhibitors. SGLT2 inhibitors should be discontinued in patients who develop acidosis on these agents.Statins may cause myopathy and liver aminotransferase elevations and are associated with an increased risk of diabetes and, possibly, cognitive dysfunction. The incidence of these adverse effects ranges from 1% to 10%, but permanent disability related to statin intolerance is rare. Statin therapy is not associated with ketoacidosis.According to labeling guidelines, initiation of metformin therapy is not recommended if the estimated glomerular filtration rate (eGFR) is between 30 and 45 mL/min/1.73 m2 and is contraindicated if the eGFR is less than 30 mL/min/1.73 m2 due to the risk of lactic acidosis. Metformin should be used cautiously in patients with heart failure or hepatic impairment. The discontinuation of metformin is not associated with the development of lactic acidosis or ketoacidosis.Glipizide is a sulfonylurea. Sulfonylurea agents work by stimulating insulin secretion. Sulfonylurea agents are associated with weight gain, and they can cause hypoglycemia. They are not, however, associated with the development of ketoacidosis in patients with type 2 diabetes.A common adverse effect of ACE inhibitors is a dry, nonproductive cough. Other common adverse effects include hyperkalemia and, occasionally, worsening kidney function. ACE inhibitors can cause life-threatening angioedema but not ketoacidosis.Key PointAn increased risk of diabetic ketoacidosis with mild to moderate glucose elevations has been associated with the use of all the approved sodium-glucose transporter-2 (SGLT2) inhibitors (canagliflozin, dapagliflozin, and empagliflozin).BibliographyFDA Drug Safety Communication. FDA warns that SGLT2 inhibitors for diabetes may result in a serious condition of too much acid in the blood. May 15, 2015. Accessed March 1, 2018. Do you like reading Annals for Educators? Receive it direct to your inbox. Sign up for the Annals for Educators alert today. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: From the Editors of Annals of Internal Medicine and Education Guest Editor, Gretchen Diemer, MD, FACP, Associate Dean of Graduate Medical Education and Affiliations, Thomas Jefferson University. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 6 October 2020Volume 173, Issue 7Page: ED7KeywordsCohort studiesDeliriumEstimated glomerular filtration rateFood and Drug AdministrationGlucoseKidneysSafetyStatinsType 2 diabetesVaccines ePublished: 6 October 2020 Issue Published: 6 October 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...