In episode 59, the fifth podcast in our diatribe on type-2 diabetes, we finally get to the evidence surrounding specific treatments. The importance of lifestyle is discussed and then the rest of the time is spent talking about the who, what, why, where, and when’s of metformin. James asks lots of rhetorical questions and Mike tries to answer them in a grandiloquent way.
Show Notes
1) UKPDS (original trial)
2) UKPDS (recent results)
In episode 58, the fourth in our installment of podcasts on diabetes, we briefly talk about the evidence surrounding intensive glucose lowering (ACCORD, ADVANCE, VADT and UKPDS trials) – podcasts #9 and #38 did this in more detail. At the end of the podcast, Mike identifies many of James’ flaws, but does it with compassion and kindness; at least he says he does.
Show Notes
1) Does tight glycemic control burden patients with complex treatment programs, hypoglycemia, weight gain, and costs and offers uncertain benefits in return?
2) ACCORD and ADVANCE studies
Click here for a synopsis of the results
N Engl J Med 2008 358:2545-2559
N Engl J Med 2008 358:2560-2572
Also listen to Episode 9: News Flash: Aggressive Blood Sugar Control Not All Sweet
3) VADT trial N Engl J Med 2009;360:129-39
Also listen to Episode 38: New trials you need to know about
4) Glucose lowering meta-analysis – do the results support the conclusions?
5) UKPDS data
6)UKPDS – 10 year update (recent results)
In episode 57, we continue yet again with the topic of type 2 diabetes. In this podcast, we talk about monitoring HbA1C, self-monitoring of blood glucose and, diabetes education in general. We hear Jillian Popel suggest not only is self-monitoring of glucose not really useful when it comes to overall glucose control, it in fact might be harmful. We also discuss what we think diabetes education should really focus upon. Finally, after 56 episodes, Mike and James actually agree on an issue, but it was just that all complaints about any of the content in the podcasts should be sent directly to Jillian.
Show Notes
1) Self-monitoring of blood glucose ESMON
DiGEM
2) Calculating cardiovascular risk for type 2 diabetics
3) Diabetes education – Cochrane reviews
Individual patient education for people with type 2 diabetes mellitus
Group based training for self-management strategies in people with type 2 diabetes mellitus
Episode 56 continues from where we left off last time with type 2 diabetes. In this podcast, we bring out the numbers and put the risks of diabetes into context by discussing the absolute cardiovascular risks associated with different levels of HbA1c. In addition, we talk about other things to look at in the evaluation of type 2 diabetes and Jillian Popel again joins us for the ride. She is quite shocked by what she hears about how “absolutely low” the renal risks associated with type 2 diabetics really are. She is also quite shocked by most of what Mike and James have to say in general, but that’s a whole other issue for another time.
Show Notes
1) Diabetes is NOT a CHD risk equivalent
2) Calculating cardiovascular risk for type 2 diabetics<
3) The risks associated with diabetes
Episode 55 starts off a “sweet” new topic – type 2 diabetes. In the first podcast on this topic we talk about the whole issue of the diagnosis of diabetes, how to make the diagnosis and to some degree what the diagnosis means.
Episode 54 finishes off the whole issue of CRP measurement by looking at the evidence we have about what happens to patients when they take drugs that lower CRP – glitazones, COX-2s, fibrates, vitamin E, niacin, ezetimibe, and statins. Other than statins and maybe niacin, it doesn’t look good – in contrast to Mike and James of course that is.
Show Notes
1) Drugs that lower CRP
Cardiovasc Drug Rev 2006;24:33-50
Atherosclerosis 2005;179:361-7
2)Drugs that lower CRP and their effect on outcome
Glitazones
COX-2s
Fenofibrate
Bezafibrate
Vitamin E
Niacin
Ezetimibe
Statins
High dose statins – not treating to target
Episode 53 continues where we left with the whole CRP measurement or no measurement discussion. James and Mike start with the Reynolds Risk Score and show how even at the extremes of CRP, absolute risks only change by around +/- 2% or so. Far more interesting is that there are now 2 studies showing clearly that good estimates of cardiovascular risk can be made without knowing lab values like cholesterol and CRP. All you have to basically do is look at the patient. Mike looks at James and declares that James is at very high risk of annoying Mike – so he does, just to show the evidence is solid.
Show Notes
1) Reynolds Risk Score
2) CRP goes up as weight goes up
3) Estimating cardiovascular risk estimates without knowing cholesterol or CRP
Episode 52 goes back in time to look in more detail at what we talked about in episode 30; the whole issue of CRP measurement. Mike and James start at the “large” issue of intra-subject variability, then focus on the “small” impact CRP has on absolute risk assessment, and briefly discuss how “accurate” risk assessments are in the first place. Finally they come to the conclusion that, as with most of the podcasts, they are very accurately vague and there is huge intra-podcaster variability.
Show Notes
1) Issues of intra-subject CRP measurement variability
Clinical Chemistry 2001;47:444–50
2) Need for repeat and multiple values
Clinical Chemistry 1997;43:52–8
3) Impact on risk assessment of adding CRP to other risk factors
“Our findings suggest that routine measurement of these novel markers [CRP] is not warranted for risk assessment”
Arch Intern Med 2006;166:1368-73
“the addition of multimarker scores [CRP] to conventional risk factors resulted in only small increases in the ability to classify risk”
“CRP does not perform better than the Framingham risk equation for discrimination. The improvement in risk stratification or reclassification …is small and inconsistent”
4) Reclassification in risk level when using CRP
Women
Net reclassification less than that seen in the above studies
Circ Cardiovasc Qual Outcomes 2008;1:92-7
5) Issue of confidence intervals around risk assessments
In episode 51, we again bring in the charming Dr. Tina Korownyk to help us work through 4 more recent studies that hopefully will have relevance to your practice. We find out that Vitamin B12 works for apthous ulcers, inhaled corticosteroids should be continued in pregnancy, that NSAID risks can be reduced – but not to zero, and an ARB (telmisartan) provides no benefit when given to stroke patients. Finally, it is revealed that Mike and James have very limited absolute charm.
Show Notes
1) Apthous ulcers – sublingual Vitamin B12
J Am Board Fam Med 2009;22:9 –16
2) GI protection for NSAIDs
Am J Gastroenterol 2009; 104:728-38
3) Asthma control in pregnancy – OK to use inhaled corticosteroids
Ann Allergy Asthma Immunol 2008;101:137–43
4) Telmisartan for stroke – no benefit
In episode 50, we talk about 4 more clinical trials that might help you in your practice. We cover topics ranging from fever control with acetaminophen or ibuprofen, injections for rotator cuff injuries, diabetes, and osteoarthritis. Mike and James finally bring in a much needed female flavour to the show, by asking Dr. Tina Korownyk to help out with the evaluation of these studies. Unfortunately we quickly realise that the past 49 shows have, much to our chagrin, lacked any significant sex appeal.
Show Notes
1) Treatment of fever with acetaminophen, ibuprofen or both
Arch Pediatr Adolesc Med 2004;158:521-6
2) Rotator cuff injections – do they need to go in the shoulder
3) Diabetes is NOT a CHD risk equivalent
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