Annals for Educators - 4 February 2020
Authors: Darren B. Taichman
Journal: Annals of Internal Medicine (2020)

Web Exclusives4 February 2020Annals for Educators - 4 February 2020FREEDarren B. Taichman, MD, PhDDarren B. Taichman, MD, PhDSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/AWED202002040 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Clinical Practice PointsAnnals On Call - SGLT2 Inhibitors: The Good, the Bad, and the UglyAssessing the Risk for Gout With Sodium–Glucose Cotransporter-2 Inhibitors in Patients With Type 2 Diabetes. A Population-Based Cohort StudySodium–glucose cotransporter-2 (SGLT2) inhibitors block the reabsorption of glucose in the kidneys, resulting in glucosuria and increased excretion of uric acid. In this lively podcast, the benefits and potential risks of these drugs are discussed. The research study assesses the association between SGLT2 inhibitor use and risk for gout.Use this study and the podcast to:Start a teaching session with multiple-choice questions. We've provided 2 below!Ask your learners to listen to the podcast before a teaching session.Ask how SGLT2 inhibitors work. What benefits have been shown? What are the potential side effects?The discussants address the importance of examining our diabetic patients' feet. Do your learners do this? Ask each to recall the last 5 patients with diabetes they saw. Did they examine their feet? If not, why not? How can we do better? How might our practice be set up to ensure this happens?What is Fournier gangrene? Who is at risk? What do the discussants suggest is important in reducing the risk?How might SGLT2 inhibitors reduce risk for gout? What are the limitations of this observational study? The authors address these in the discussion.Where should SGLT2 inhibitors fit into the management of type 2 diabetes?Log on to claim CME and MOC credit related to the podcast. Nifedipine-Induced Shock in Pregnancy With Aortic StenosisThis case report describes the presentation and management of a patient who was 18 weeks pregnant and developed hypotension after a procedure.Use this report to:Ask your learners what the immediate concerns are in the evaluation of a pregnant woman with hypotension. What diagnoses should be considered?How should hypotension be managed during pregnancy?Read the case presentation to your learners. Stop after the first paragraph of the report, and show the initial ECG. How would your learners proceed?What caused hypotension? Why?How was this patient managed? Finish reading the case report. What are the take-home lessons?Beyond the GuidelinesCaring for the Transgender Patient. Grand Rounds Discussion From Beth Israel Deaconess Medical CenterTransgender patients experience discrimination and may not have access to medical professionals who can provide competent care. In addition to primary medical and preventive health care, transgender patients need access to gender-affirming interventions, including hormone therapy and surgeries. Here, 2 expert clinicians debate whether psychological evaluation is warranted when gender-affirming hormone therapy or surgery is considered, the potential risks and benefits of estrogen therapy, and the primary care practitioner's role in the care of the transgender population.Use this feature to:Watch a video of Ms. F providing her history.Discuss the recommendation from the 2017 Endocrine Society guideline that mental health professionals be involved in gender-affirming therapy. Do your learners agree with this recommendation?Watch or read the presentations by the 2 grand rounds discussants. In what ways do they agree or disagree about the need for mental health evaluation and treatment? Have your learners changed their views?What are the potential risks and benefits of estrogen therapy in a transgender woman?When should transgender patients be referred to a specialist? Who provides this care at your center? Invite a specialist to join your discussion.Log on and answer the brief CME/MOC questions to claim credit for yourself!In the Clinic: Urinary Incontinence in WomenIt is estimated that 17.1% of women aged 20 years or older in the United States have moderate to severe urinary incontinence (UI). Globally, prevalence increases with age, and up to 30% to 40% of older women report UI. UI may lead to social isolation and psychological distress and increases risk for falls and fractures. Are your learners paying attention to this problem and prepared to help their patients?Use this review to:Ask your learners what the risk factors for UI are. Are any modifiable?What are the potential causes of UI, and how are they evaluated?What is the difference between stress and urge UI? What about mixed UI? Incontinence associated with urine retention?What examination should be performed? Is testing needed for a diagnosis?What are the potential complications?How is treatment approached? How effective are interventions? When should pharmacologic therapies be considered, and what are their side effects?What education do patients require? Who should provide it?Use the provided multiple-choice questions to introduce topics during a teaching session, and log on to enter your answers for CME/MOC credit.Humanism and ProfessionalismOn Being a Doctor: Last Call to WisdomDr. Loge reflects on what four decades of practice, and his patient, have taught him.Use this essay to:Listen to an audio recording, read by the On Being a Doctor editor, Dr. Michael LaCombe. Ask your learners whether Dr. Loge's visit to Hal is medical or social.What might be found on physical examination that would alter care? Why does Dr. Loge feel the exam is important even if it does not alter Hal's management?What do your learners hope to feel years from now when they retire from medical practice? Do they anticipate that their practice of medicine will have included the kinds of relationships Dr. Loge describes with his patients?MKSAP 18 Question 1A 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. MKSAP 18 Question 2A 52-year-old woman is evaluated in the office for management of type 2 diabetes mellitus. She has lost 3.2 kg (7 lb) by changing her diet and activity level. Her other medical problems include hypertension, hyperlipidemia, and chronic stable angina. Current medications are aspirin, metformin, valsartan, metoprolol, atorvastatin, and as-needed sublingual nitroglycerin.On physical examination, blood pressure is 125/70 mm Hg and pulse rate is 74/min. BMI is 28. There is no evidence of diabetic retinopathy. The remainder of the physical examination is normal.The most recent hemoglobin A1c level, obtained last week, is 8%.Which of the following should be added to control hyperglycemia and lower her risk of a major atherosclerotic cardiovascular disease event?A. Basal insulinB. EmpagliflozinC. GlipizideD. RosiglitazoneCorrect AnswerB. EmpagliflozinEducational ObjectiveManage cardiovascular risk in a patient with diabetes mellitus by adjusting glycemic-control medications.CritiqueEmpagliflozin should be added to lower this patient's risk of a major atherosclerotic cardiovascular disease (ASCVD) event. The use of sodium-glucose cotransporter-2 (SGLT2) inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists in patients with type 2 diabetes mellitus has been shown to reduce rates of acute myocardial infarction, stroke, and cardiovascular death. For patients with type 2 diabetes and clinical ASCVD, SGLT2 inhibitors may reduce hospitalization for heart failure. These benefits seem to be unrelated to their glucose-lowering effects. Based on strong evidence, the American Diabetes Association recommends an SGLT2 inhibitor (typically empagliflozin) or a GLP-1 receptor agonist (typically liraglutide) as part of a glycemic control regimen in patients with type 2 diabetes and clinical ASCVD. Weaker evidence supports the use of an SGLT2 inhibitor in patients with ASCVD with heart failure or at high risk of heart failure.Insulin therapy should be strongly considered in the setting of symptomatic hyperglycemia or markedly elevated hemoglobin A1c (greater than 8.5% to 9%) at the time of diagnosis or when lifestyle modifications and/or noninsulin therapies fail to achieve glycemic goals. Tight glycemic control reduces microvascular complications; however, it does not reduce the risk for myocardial infarction. This patient does not have an indication for insulin therapy.Weight gain is likely with the use of insulin, sulfonylureas, thiazolidinediones, and meglitinides. The risk of hypoglycemia must be considered with the selection of any therapeutic agent, particularly when it is combined with insulin secretagogues or insulin. Glipizide would be a poor choice for a patient attempting to lose weight and would not decrease her risk for a major ASCVD event.Initial studies suggested thiazolidinediones, specifically rosiglitazone, were associated with an elevated risk for cardiovascular events, although a subsequent clinical trial demonstrated no elevated risk for myocardial infarction or death. Consequently, the FDA has removed the restriction on rosiglitazone use in patients with type 2 diabetes and CAD. Rosiglitazone does not reduce the risk of major ASCVD events and may result in weight gain.Key PointThe American Diabetes Association recommends a sodium-glucose cotransporter-2 inhibitor or a glucagon-like peptide-1 receptor agonist as part of a glycemic control regimen in patients with type 2 diabetes mellitus and clinical atherosclerotic cardiovascular disease.BibliographyAmerican Diabetes Association. 10. Cardiovascular Disease and Risk Management: Standards of Medical Care in Diabetes-2019. Diabetes Care. 2019;42:S103-S123. doi:10.2337/dc19-S010Do 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 4 February 2020Volume 172, Issue 3Page: ED3KeywordsAtherosclerotic cardiovascular diseaseFood and Drug AdministrationGlucoseHeart failureHypotensionInsulinKidneysStatinsType 2 diabetesWeight gain ePublished: 4 February 2020 Issue Published: 4 February 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...