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For the week ending May 4, 2012 | |
Last week 480 articles were evaluated via DynaMed's Systematic Literature Surveillance and 207 were added to DynaMed content.
Based on the editors' criteria of selecting "articles most likely to change clinical practice," one article of significant interest was selected for the DynaMed Weekly Update. |
| Feature Article | |
Combination of Metformin plus Insulin May Not Reduce Mortality Compared to Insulin Alone in Patients with Type 2 Diabetes
For patients with type 2 diabetes mellitus inadequately treated with lifestyle modifications and oral antidiabetic agents, combined use of metformin and insulin is recommended by the American Diabetes Association and the European Association for the Study of Diabetes as part of a consensus treatment algorithm (Diabetologia 2009 Jan;52(1):17). A new systematic review of 26 randomized trials compared the effects of combination therapy vs. insulin alone on clinical outcomes in 2,286 patients with type 2 diabetes.
Trial durations ranged from 3 months to 4.3 years, with a median duration of 6 months. Most of the trials had some methodologic limitations including incomplete blinding, baseline differences between randomized groups, and unclear allocation concealment. In meta-analyses, there were no significant differences in all-cause mortality (risk ratio 1.3, 95% CI 0.57-2.99) or cardiovascular mortality (risk ratio 1.7, 95% CI 0.35-8.3) comparing the combination of metformin plus insulin to insulin alone (level 2 [mid-level] evidence). No deaths occurred in 11 of 16 trials that reported mortality as an outcome. There were also no significant differences in the incidence of severe or mild hypoglycemia. Combination therapy was associated with significant reductions in HbA1c, weight gain and insulin dose (BMJ 2012 Apr 19;344:e1771).
Follow-up was too short in most trials to draw reliable conclusions about mortality, and the statistical power was limited by the low event rates in all trials. However, the findings from the meta-analysis were consistent with the findings in the trial with the largest sample and longest follow-up. While these data cannot definitively rule out a mortality or cardiovascular benefit from continuing metformin in patients treated with intensive insulin, the systematic review establishes that to date, any such benefit remains unproven.
For more information, see the Metformin for diabetes topic in DynaMed.
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CME Information
CREDITS
Physicians: 0.25 AMA PRA Category I Credit(s)™
Family Physicians: 0.25 Prescribed credits
Nurse Practitioners: 0.25 Contact hours
Release Date: May 9, 2012
Expiration Date: May 9, 2013
Estimated Completion Time:
15 minutes
There is no fee for this activity.
To Receive Credit
In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon at the end of the article.
Program Overview
Learning Objectives
Upon successful completion of this educational program, the reader should be able to:
1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.
Faculty Information Alan Ehrlich, MD - Assistant Clinical Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Deputy Editor, DynaMed, Ipswich, Massachusetts, USA Michael Fleming, MD, FAAFP - Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company
Disclosures
Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.
No commercial support has been received for this activity.
Accreditation Statements
ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should only claim credit commensurate with the extent of their participation in the activity.
AAFP: This Enduring Material activity, DynaMed Weekly Update, has been reviewed and is acceptable for up to 13 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 7, 2012. Term of approval is for one year from this date with the option of yearly renewal. Each weekly update is worth .25 Prescribed credits. Physicians should claim only the credit commensurate with the extent of their participation in the activity. AANP: This program is approved for 0.25 contact hour of continuing education by the American Academy of Nurse Practitioners. Program ID 1102072J. |
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