A patient-centered approach to managing patients with type 2 diabetes.

Despite the availability of a number of therapeutic options, management of type 2 diabetes (T2DM) and hyperglycemia remains suboptimal. Evidence shows that physicians are not adequately individualizing incretin-based therapies as there is lack of clear understanding of the similarities and differences between various incretin-based therapies. Additionally, sodium-dependent glucose co-transporter 2 (SGLT2) inhibitors, a very recent addition to the therapeutic armamentarium, are not adequately utilized in managing patients with T2DM due to a lack of awareness or an increased concern regarding their safety, efficacy, and the mechanism of action. Insulin therapy is also not initiated or intensified appropriately due to a lack of clear understanding on when to add and how to intensify them and, more importantly, due to fear of increasing the risk of hypoglycemia in patients. To address these gaps, in the first section of this educational activity, the expert faculty will review the current understanding of the risks associated with hypoglycemia-one of the main factors that limit the successful use of insulin therapy-and when to initiate insulin therapy, as well as the available data on the risk of hypoglycemia with emerging agents. The expert faculty will also provide practical strategies on how to minimize the risk of hypoglycemia in patients. In the second section, the expert faculty will highlight the differences between the various incretin-based therapies in addition to providing strategies for physicians to individualize their choice of incretin-based therapy. The expert faculty will also review the mechanism of action, safety, efficacy, and the appropriate place for this class of therapies in the treatment continuum. In the third section, the expert faculty will discuss the mechanism of action, safety, and efficacy of the currently available SGLT2 inhibitors as well as the appropriate use of these newer agents in T2DM management. This CME Multimedia Activity is also available through the Website of The American Journal of Medicine (www.amjmed.com). Click on the CME Multimedia Activity button in the navigation bar for full access. Or access: www.elseviercme.com/537.

Complexities in the pharmacologic management of osteoarthritis pain.

OBJECTIVE: To discuss challenges in the pharmacologic management of osteoarthritis (OA) pain. SCOPE: Literature searches through MEDLINE and Cochrane databases were used to identify relevant journal articles. The search was limited to articles published from January 1982 to January 2013. Additional references were obtained from articles extracted during the database search. FINDINGS: Pharmacologic management of OA is aimed at alleviating pain and reducing functional impairment. Limitations of the most commonly prescribed agents (non-steroidal anti-inflammatory drugs [NSAIDs], acetaminophen, and opioids) and conflicting practice guidelines have led to physician and patient dissatisfaction. OA management guidelines advocate the use of acetaminophen, NSAIDs, serotonin-norepinephrine reuptake inhibitors (SNRIs) and opioids; however, these agents are associated with serious adverse events (AEs) and, in some cases, efficacy concerns. Acetaminophen, particularly at higher dosages, may lead to acute liver failure and gastrointestinal (GI) bleeding. NSAIDs present a significant GI bleeding risk and are also associated with a variety of renal complications, myocardial infarction and other serious cardiovascular complications. SNRIs can cause AEs such as hepatotoxicity and drug/drug interactions that can lead to serotonin syndrome. Opioids exhibit abuse potential and tramadol may demonstrate limited efficacy. CONCLUSIONS: The safety and efficacy concerns associated with currently available OA treatment options establish a need to develop new treatment strategies. Disease-modifying agents and novel drug formulations are currently under investigation. As these new pharmacologic options evolve, their adoption may lower risk and improve clinical outcomes.

Restless legs syndrome: nonpharmacologic and pharmacologic treatments.

Treatment of restless legs syndrome (RLS) has as its goals alleviation of the primary symptoms of the disorder and establishment of normal sleep. Dopamine agonists are considered first-line treatment when daily treatment for primary RLS is indicated. Gabapentin and opioids may be of value for refractory cases. Initial treatment of secondary RLS should address the underlying cause.

Restless legs syndrome: demographics, presentation, and differential diagnosis.

Restless legs syndrome (RLS) is a sensorimotor disorder characterized by a distressing urge to move the legs and sometimes other parts of the body. Diagnosis is based on clinical features that may be easily remembered with the mnemonic URGE: Urge to move, Rest induced, Gets better with activity, and Evening and night accentuation. RLS is common, its prevalence increases with age, and women are more frequently affected. The course is chronic with often severe sleep disruption, including periodic leg movements. Differential diagnosis includes disorders of restlessness and leg discomfort. Primary RLS is familial and likely to be genetic. Important causes of secondary RLS are end-stage renal disease, pregnancy, and iron deficiency. Every patient should be checked for iron status with a serum ferritin measurement.

Building cultural competency for improved diabetes care: Introduction and Overview.

Diabetes affects about 7% of the US population with more than 90% of cases being type 2 diabetes mellitus. In 2005, this translated into nearly 21 million Americans with diabetes. Whereas Americans from all ethnic and cultural groups are affected, minority populations are disproportionately affected. In fact, diabetes prevalence is 2 to 6 times higher among Latino Americans, African Americans, Native Americans (American Indians and Native Alaskans), and Asian Americans than among white Americans. The National Institutes of Health reports that American Indians and Native Alaskans are 2.2 times more likely to have the disease than are non-Hispanic whites. Furthermore, studies using glycosylated hemoglobin (A1C) as a marker have shown that Latino Americans, African Americans, and Asian Americans have poorer control of their diabetes. In a study by Brown and colleagues, mean A1C levels were higher among Latino Americans, African Americans, and Asian Americans/Pacific Islanders than among white Americans.

Building cultural competency for improved diabetes care: Latino Americans and diabetes.

The incidence of type 2 diabetes (T2DM) has reached epidemic proportions in the Latino American community, contributing to substantial morbidity, mortality, and health care costs. In fact, 2.5 million Latino Americans are affected by T2DM. Compared with the general population, Latino Americans suffer a higher burden of disease: 14% of Latino Americans have T2DM compared with 12% of African Americans and 7% of non-Hispanic whites. Further, using glycosylated hemoglobin (A1C) as a marker indicates that Latino Americans have poorer disease control; higher rates of complications, including diabetic retinopathy, nephropathy, and amputations; and increased mortality. According to a recent survey, Mexican Americans are less likely to achieve glycemic control than are non-Hispanic whites. Peripheral vascular disease is 80% more common among Mexican Americans than among whites with diabetes, and mortality rates due to diabetes are twice as high among Mexican Americans and Puerto Ricans as among non-Hispanic whites. Despite greater understanding of the etiology of T2DM and the development of novel treatment strategies, T2DM is on the rise among Latino American populations. While the prevalence of T2DM is projected to increase in the general population by 44% by 2020, it is projected to increase by 107% in the Latino American population. Latino American children born today have a 50% chance of developing T2DM in their lifetime. These startling statistics underscore the need for the health care community to focus on the prevention and treatment of T2DM among Latino Americans, and, indeed, research has shown that effective communication directly affects physician-patient interaction and subsequent outcomes.

Pregnant smokers who quit, pregnant smokers who don't: does history of problem behavior make a difference?

More than half of women who smoke in the USA continue to do so while pregnant. While socioeconomic and demographic factors that distinguish pregnancy quitters from persistent smokers have been identified, less is known about behavioral factors that are associated with persistent smoking. Because smoking during pregnancy is not only an individual, but also a maternal behavior, it may have different behavioral correlates than women's smoking has in general. We propose a conceptual framework in which smoking during pregnancy is viewed as a maternal problem behavior. We explore this conceptualization by examining whether persistent smoking during pregnancy is associated with a pattern of psychosocial risk- and health-compromising behaviors in multiple domains, with pilot data from a small clinic-based sample. Data are presented for 96 predominantly Caucasian, working-class pregnant women recruited from prenatal clinics in the USA. Smoking during pregnancy was measured repeatedly by self-report and biochemical assay. Participants were non-smokers (37%), pregnancy quitters (17%), and persistent smokers (46%). These groups were compared in terms of their history of problem behavior in three domains: interpersonal difficulties, problems in adaptive functioning and problematic health behaviors. With few exceptions, smokers were more likely to have problematic relationships, poorer adaptive functioning and to engage in problematic health behaviors, than both pregnancy quitters and non-smokers. This pattern of problem behavior may interfere with the effectiveness of standard public health prenatal cessation interventions for a sub-group of women. Examining pregnancy smoking as part of a broader matrix of problem behavior may help to identify pregnant women most at risk for persistent smoking and inform the development of targeted interventions.