Annals for Educators - 5 February 2019
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2019)

Web Exclusives5 February 2019Annals for Educators - 5 February 2019FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED201902050 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsFracture Risk After Initiation of Use of Canagliflozin. A Cohort StudyCanagliflozin, a sodium–glucose cotransporter-2 (SGLT2) inhibitor used for diabetes treatment, has been associated with decreased bone mineral density, potentially increasing risk for fracture. This analysis examined risk for nonvertebral fractures among new users of canagliflozin compared with a glucagon-like peptide-1 agonist.Use this paper to:Start a teaching session with a multiple-choice question. We've provided one below!Ask your learners how SGLT2 inhibitors decrease serum glucose levels. Where do these agents fit into treatment for diabetes? What are their potential adverse effects?Ask your learners what the advantages and disadvantages are of randomized trials and observational studies in evaluating a drug's efficacy and safety. Use the accompanying editorial to help frame your discussion. What comparison groups would your learners consider using when assessing risk for fractures associated with canagliflozin? What did the authors choose, and why? They explain in the “Study Cohort” section of the Methods.Ask what the purpose of propensity score matching is when evaluating observational data. In what way does this technique help to address potential confounding? Does it “mimic” a randomized trial? Look at Table 1 and ask your learners whether they think the matching worked.What are the limitations in what may be concluded from these data? The editorialists note concerns about the generalizability of the findings. Recommended Adult Immunization Schedule, United States, 2019This article provides immunization recommendations from the Advisory Committee on Immunization Practices (ACIP) for adults aged 19 years or older. The ACIP-recommended use of each vaccine is determined after in-depth reviews of vaccine-related data, including disease epidemiology and burden of disease, vaccine efficacy and effectiveness, vaccine safety, the quality of evidence, feasibility of program implementation, and economic analyses of immunization policy.Use this paper to:Ask your learners whether vaccination status is routinely reviewed in your outpatient practice. Who does this? How would you find out whether the system is working? How accessible is the information?Ask whether your learners check if their young adult patients have received human papillomavirus vaccination. What are the recommendations for females up to age 26 years and males up to age 21 years?What is the difference between the recombinant and live zoster vaccines? Which is recommended? To whom? How do patients access these vaccines?What is the appropriate timing of pneumococcal vaccination with PPSV23 and PCV13?Beyond the GuidelinesHow Would You Treat This Patient With Gallstone Pancreatitis? Grand Rounds Discussion From Beth Israel Deaconess Medical CenterAcute pancreatitis is a common reason for hospitalization. Here, 2 experts debate how they would apply an American Gastroenterological Association guideline addressing management of acute pancreatitis to a patient with recurrent episodes, focusing on initial management and timing of subsequent surgery.Use this feature to:Review the brief history of Mr. R and watch the video of his interview with your learners.Ask your learners what approach they take to fluid management and nutrition in patients with acute pancreatitis.Ask what imaging is appropriate. When and how does it assist in patient management?When do your learners recommend surgery be considered?Now, watch the video of the grand rounds discussion, or have your learners read the manuscript. Have the approaches they plan to take in the future changed?How would your learners answer Mr. R's concern that the delay in surgery might have caused permanent damage to his pancreas?Use the provided multiple-choice questions to introduce discussion topics, and log on to enter your answers and earn CME and MOC credit for yourself!In the Clinic: ContraceptionContraception counseling and provision are vital components of comprehensive health care. Unplanned pregnancy can be devastating to any woman but is particularly dangerous for those with chronic illness. Internal medicine providers are in a unique position to provide contraception, given that they often intersect with women at the moment of a new medical diagnosis or throughout care for a chronic problem. Are your learners prepared to engage in a shared decision-making approach to ensure that a chosen contraceptive method aligns with a patient's reproductive plans and medical needs?Use this paper to:Ask your learners whether they inquire about contraceptive needs. Do they consider how a patient's chronic illnesses might affect the safety of pregnancy or the choice of contraceptive method?What long-acting, reversible contraceptive methods are available? In whom should they be considered, and what are their relative advantages and disadvantages?What forms of emergency contraception are available?What risks are associated with combined oral contraceptives? What about with other forms of contraception?What conditions increase the risk for complications in pregnancy?Use the provided multiple-choice questions to introduce discussion topics, and log on to enter your answers and earn CME and MOC credit for yourself!Teaching Medical StudentsAvoiding Pitfalls While Implementing New Guidelines on Student DocumentationThe federal regulation regarding student documentation in the medical record was recently changed to allow the teaching physician to verify in the medical record any student documentation of evaluation and management services rather than redocumenting the work. This change will alter how students and teaching physicians interact and may have unintended consequences. This article describes some that should be avoided.Use this essay to:Consider whether your teaching program has discussed the role medical students are now expected to play in chart documentation.Are teaching physicians aware of expectations? Should this be discussed among the educators at your institution?What have they been told about the responsibility to review what students write? How might the value of students' chart notes as teaching tools be maximized? Do you and your colleagues share the authors' concerns about unintended consequences?Are your own progress notes models you wish medical students to emulate? Do they communicate your thoughts about a patient's condition and the rationale for management plans to others, or are they only aimed at fulfilling billing requirements?Ask your learners what they see as the goals of patient progress notes. What makes a useful note and a not so useful (or even useless) note?Humanism and ProfessionalismAnnals Graphic Medicine – The Med StudentAnnals Graphic Medicine – The Tale of a Wannabe SuperheroAnnals Graphic Medicine – Team DoctorAnnals Graphic Medicine – What It Is LikeThe graphic medicine pieces drawn by medical students in this issue show the vulnerability that they face during medical school.Use these works to:Plan a teaching session with the medical students on your service, focusing on their experiences in discovering what medicine is all about.Can they relate to what the students portrayed in these cartoons?Have they felt disillusioned by what they have seen? In awe? Both?How did their expectations differ from the reality they have experienced thus far?Use the accompanying editorial to help plan your discussion. On Being a Doctor: A Thousand BlessingsDr. Weinberg recalls the surprise of his trainee at the thanks expressed by a patient.Use this essay to:Listen to an audio recording, read by Dr. Michael LaCombe. Ask your learners if there are patients for whom they feel they do very little or nothing.Why do such patients return for follow-up?Do your learners believe they make a difference for such patients? In what way?Have your learners been thanked by their patients or families in special ways? Did it make them uncomfortable? Did it make them proud?Does our profession's culture make it difficult to admit if we long for such expressions of gratitude from patients? Why is it important to embrace such experiences? Does it also help the patient?MKSAP 17 QuestionA 52-year-old man is evaluated in the emergency department after experiencing the onset of nausea, vomiting, and abdominal pain 12 hours ago. According to his wife, the patient had undergone an elective cholecystectomy 5 days prior for biliary colic, had an uncomplicated postoperative course, and was discharged home 3 days ago. Over the last 2 to 3 hours, he has become progressively confused and sleepy. The patient has well-controlled type 2 diabetes mellitus that was diagnosed 6 years ago and is complicated by peripheral neuropathy. Results of laboratory studies from 4 weeks ago revealed hemoglobin A1c level of 7.1%; serum creatinine level of 0.9 mg/dl (79.6 µmol/L), and negative urine microalbumin/creatinine ratio. His last visit with his primary care provider was 6 weeks ago, and his last retinal examination was 6 months ago. In addition to type 2 diabetes mellitus, medical history is significant for hypertension, dyslipidemia, and cholelithiasis. Family history is notable for type 2 diabetes in his mother. Medications are atorvastatin, canagliflozin, glipizide, liraglutide, losartan, and metformin.On physical examination, temperature is 37.4 °C (99.3 °F), blood pressure is 92/50 mm Hg, pulse rate is 108/min, and respiration rate is 24/min. BMI is 28. The patient is lethargic and arousable to painful stimuli but not to voice. Cardiac examination is notable for tachycardia. Respirations are shallow and rapid. His neurologic examination is without focal abnormalities. The remainder of his examination is normal.Laboratory studies:Hematocrit48%Hemoglobin14.3 g/dL (143 g/L)Leukocyte count12,000 /µL (12 x 109/L)Bicarbonate12 mEq/L (12 mmol/L)PO295 mmHg (12.6 kPa)PCO228 mmHg (3.7 kPa)Blood urea nitrogen60 mg/dL (21.4 mmol/L)Creatinine1.4 mg/dL (123.8 mmol/L)Sodium142 mEq/L (142 mmol/L)Potassium5.0 mEq/L (5.0 mmol/L)Chloride110 mEq/L (110 mmol/L)Lactate1.0 mEq/L (1.0 mmol/L)Glucose240 mg/dL (13.3 mmol/L)UrinalysisNormalArterial pH is 7.2. Noncontrast head CT scan and chest radiograph are normal.According to a recent U.S. Food and Drug Administration Drug Safety Communication, which of the following medications used in the treatment of type 2 diabetes may have contributed to the development of the patient's acute medical condition?A. CanagliflozinB. GlipizideC. LiraglutideD. MetforminCorrect AnswerA. CanagliflozinEducational ObjectiveDiagnose diabetic ketoacidosis resulting from treatment with a sodium-glucose transporter-2 (SGLT2) inhibitor.CritiqueIn May 2015, the U.S. Food and Drug Administration (FDA) issued a warning that treatment with sodium-glucose transporter-2 (SGLT2) inhibitors, which include canagliflozin, dapagliflozin, and empagliflozin, may increase the risk of diabetic ketoacidosis (DKA) in patients with diabetes mellitus. These oral type 2 diabetes medications lower plasma glucose levels by inhibiting SGLT2 in the proximal tubules of the kidneys, thus reducing the reabsorption of filtered glucose. The FDA Adverse Event Reporting System database identified 20 cases of DKA in patients treated with SGLT2 inhibitors from March 2013 to June 2014. Additional cases have since been reported. The FDA encourages patients taking SGLT2 inhibitors to immediately seek medical attention in the setting of possible symptoms of DKA, including nausea, vomiting, abdominal pain, confusion, lethargy, and difficulty breathing.Mechanistically, SGLT2 inhibitors may mediate DKA through hyperglucagonemia, elevated ketoacids, and volume depletion. DKA has been described both in patients with type 2 diabetes who were taking SGLT2 inhibitors and in patients with type 1 diabetes who were prescribed these medications off-label. In most reported cases, the patients were euglycemic or had mild hyperglycemia during the episode. Several case reports have described DKA occurring in patients with type 2 diabetes in the postoperative setting. Others have associated DKA with low caloric intake, carbohydrate restriction, concurrent illness (influenza), or recent discontinuation of insulin. Some cases did not have a clear inciting factor.Glipizide is a sulfonylurea medication that is used in the treatment of type 2 diabetes. Liraglutide is a glucagon-like peptide 1 (GLP-1) agonist that lowers plasma glucose by augmenting glucose-dependent insulin secretion, inhibiting glucagon secretion, slowing gastric emptying, and increasing satiety. Neither sulfonylureas nor GLP-1 agonists have been linked to an increased likelihood of developing DKA. Metformin is a biguanide medication that lowers plasma glucose levels primarily by decreasing hepatic glucose production and secondarily by increasing insulin sensitivity. Metformin is indicated as first-line therapy in the treatment of type 2 diabetes in the absence of contraindications. Treatment with metformin has been associated with the development of lactic acidosis, most commonly in the setting of concurrent sepsis, acute or progressive kidney injury, and/or decompensated heart failure. However, this patient's lactate level is normal, ruling out lactic acidosis.This content was last updated in January 2017.Key PointTreatment of type 2 diabetes mellitus with sodium-glucose transporter-2 (SGLT2) inhibitors, which include canagliflozin, dapagliflozin, and empagliflozin, may increase the risk of diabetic ketoacidosis.Bibliography FDA Drug Safety Communication: FDA revises labels of SGLT2 inhibitors for diabetes to include warnings about too much acid in the blood and serious urinary tract infections. Published December 4, 2015. Accessed September 1, 2016. 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 5 February 2019Volume 170, Issue 3Page: ED3KeywordsContraceptivesDrug safetyFemale contraceptionFood and Drug AdministrationGlucosePregnancySafetySurgeryType 2 diabetesVaccines ePublished: 5 February 2019 Issue Published: 5 February 2019 Copyright & PermissionsCopyright © 2019 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...