SUN-0458 Success of Educational Interventions on Use of...
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Success of Educational Interventions on Use of Incretin Agents in the Management of Type 2 Diabetes introduction Despite recommendations of the importance of glycemic control in patients with type 2 diabetes (T2D), research continues to show that only around half of patients with diabetes achieve recommended hemoglobin A1c goals. [AHRQ 2013, Stark Casagrande 2013, Selvin 2014] These treatment gaps have received considerable attention in recent years, encouraging the development of novel antihyperglycemic therapies and new management paradigms. Many recommendations focus on the need for effective treatment plans that minimize the risk for hypoglycemia and also address comorbid conditions (including overweight and obesity) associated with T2D. [ADA 2013; Inzucchi 2012; Garber 2013] The ADA/EASD and AACE/ACE groups agree that based on the unique physiologic activity, efficacy and safety profiles, and additional (nonglycemic) benefits of incretin-based agents (GLP-1 receptor agonists and DPP-4 inhibitors), these therapies are important options for the management of T2D patients. [ADA 2013; Inzucchi 2012; Garber 2013] The overall goal of this initiative was to educate primary care physicians (PCPs) about differences between the two classes of incretin-modifying agents and improve their effective and appropriate use of these agents to treat those with T2D. The study objective was to determine if online educational interventions could improve knowledge about and/or appropriate use of incretin-related agents in patients with T2D by PCPs in the United States (US) and outside the US (OUS). methods The continuing medical education (CME) activity was developed as an online expert faculty panel discussion focused on differentiating incretin agents and making appropriate clinical decisions about practical use. The activity targeted both US and OUS PCPs who manage patients with T2D and was available online on Medscape Education. The educational content was developed by the Endocrine Society and Medscape. The effects of education were assessed, in conjunction with CE Outcomes, using clinical case vignettes.* Clinical case vignettes and a series of clinical assessment questions related to each case were developed within a multiple-choice survey format. Evidence-based responses to the case vignette questions were identified from educational content. Participants in the education were presented with a pre-assessment survery at the beginning of the CME activity and a post-assessment survey upon completion of the education. Data from the participant responses to the pre- and post-assessment case vignette surveys were analyzed using a statistical analysis package for the social sciences (IBM SPSS Statistics 20). For the case vignette questions, t-tests were conducted to detect significant differences between the pre- and post- assessment responses. When the analysis involved the comparison of responses where one answer is evidence-based and thus preferred, the P value represents the level of significant difference between the pre- and post-assessment in the selections of that response. The level of statistical significance for analytical tests was set at P ≤.05. In addition, overall mean scores and pooled standard deviations were calculated for aggregate pre- and post- assessment survey responses. Educational effect size was calculated using Cohen’s d formula to determine the average difference between pre- and post-assessment scores. Effect size representing the difference between the two groups is expressed as a percentage of nonoverlap between pre- and post-assessment survey scores. The difference in the likelihood of making evidence-based clinical choices in response to clinical case vignettes pre and post intervention, was expressed using the percentage of nonoverlap between pre- and post-assessment scores. Effect sizes greater than 0.8 are large, between 0.8 and 0.4 are medium, and less than 0.4 are small. Within the presented results, all percentage data are rounded to the nearest whole number. Furthermore, reported data are furnished on an aggregate level to maintain study participant confidentiality. results A total of 200 PCPs (100 US and 100 OUS) were included in the assessment (Table 1). Significant improvements were found as a result of participation in the educational intervention. PCPs (US and OUS) who participated in the CME activity were more likely to make evidence-based practice choices after participation in the educational activity. The effect sizes were large at 1.08 for US PCPs (56% non-overlap) and 0.72 for OUS PCPs (44% non-overlap). As of April 18, 2014, a total of 6,322 PCPs have participated in this activity. Based on the representative sample in the outcomes study that see, on average, 10 patients per week that they would consider for incretin-based therapy, over 63,000 patients may benefit from improved evidence-based care. For more information contact Amy Larkin, PharmD, Director of Clinical Strategy, Medscape, LLC at [email protected]. References Agency for Healthcare Research and Quality (AHRQ). Improving quality and patient experience. The state of health care quality 2013. https://www.ncqa.org/Portals/0/Newsroom/SOHC/2013/SOHC-web_version_report.pdf Accessed April 21, 2014. American Diabetes Association (ADA). Standards of medical care in diabetes--2013. Diabetes Care . 2013; 36 Suppl 1:S11-66 Garber AJ, Abrahamson MJ, Barzilay JI, et al. American Association of Clinical Endocrinologists. AACE comprehensive diabetes management algorithm 2013. Endocr Pract . 2013; 19:327-336. Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care . 2012;35:1364-1379. Selvin E, Parrinello CM, Sacks DB, Coresh J. Trends in prevalence and control of diabetes in the United States, 1988-1994 and 1999-2010. Ann Intern Med . 2014;160:517-525. Stark Casagrande S, Fradkin JE, Saydah SH, et al. The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988-2010. Diabetes Care . 2013;36:2271-2279. conclusion This study demonstrated that a target educational intervention can improve the knowledge, competence, and perforamce of US and OUS PCPs in the use of incretin-related agents in patients with T2D. Based on the results of this analysis, future education is needed regarding the mechanism of action of GLP-1 agonists, approaches to minimizing GLP-1 agonist side effects, and any potential relationship between pancreatitis and incretin-based therapies. Amy Larkin, PharmD*, Anne Le, PharmD*, Robert C. Bartel*, Anne L. Peters, MD*, Carol H. Wysham, MD*, Lawrence Blonde, MD* *Potential conflict of interest may exist. Refer to the abstract. Success of Educational Interventions on Use of Incretin Agents in the Management of Type 2 Diabetes source of support This CME-certified activity was supported by an independent educational grant from Sanofi. *Results from research demonstrate that case vignettes, compared with chart review and standardized patients, provide a valid, cost-effective, and noninvasive method to evaluate a physician’s processes of care. [1,2] Case vignettes have gained considerable support for their value in predicting physician practice patterns. Furthermore, case vignettes are most cost-effective than other means of measurement. [1,2,3,4] 1 Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M. Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality. JAMA. 2000; 283:1715-1722. 2 Peabody JW, Luck J, Glassman P, et al. Measuring the quality of physician practice by using clinical vignettes: a prospective validation study. Ann Intern Med. 2004; 141:771-780. 3 Luck J, et al. An automated scoring algorithm for computerized clinical vignettes: evaluating physician performance against explicit quality criteria. Int J Med Inform. 2006; 75:701-7. 4 Gould D. Using vignettes to collect data for nursing research studies: how valid are the findings? J Clinical Nursing. 1996; 5:207-212. SUN-0458 table 1 PCP US Participants PCP OUS Participants (n-100) (n=100) Patients seen per week who would be considered for incretin-based therapy (percent) 1-10 71% 73% 11-20 20% 21% 21-30 2% 4% 31-40 2% 1% 41-50 1% 0% >50 4% 1% Patients seen per week who would be considered for 11 9 incretin-based therapy (mean) Degree: MD/DO 100% 100% Specialty Family medicine 40% 40% General practice 20% 40% Internal medicine 40% 20% Years since graduation from medical school 1-10 years 17% 34% 11-20 years 23% 19% 21-30 25% 23% >30 years 35% 24% Demographics of Patients Case 1 Review the mechanism of incretin-based agents. Case 2 Differentiate the role of incretin-based therapies in clinical practice. A 58-year-old man, who works as a truck driver and has a history of hypertension and hyperlipidemia comes to see you for worsening blood glucose control. He was diagnosed with diabetes mellitus three years ago when he presented with blood glucose of 338 mg/dL. His initial treatment regimen was metformin 1000 mg daily along with an unsuccessful diet and exercise program. Over the last six months, he saw higher sugars and increased to metformin twice a day and despite the adjustment has hemoglobin A1c (HbA1c), remains at 8.1%. The rest of his labs are unremarkable. His physical exam is normal except for BMI 38 kg/m 2 . Decreased satiety and promotion of gastric emptying 100% 80% 60% 40% 20% 0% 16% Inhibition of gastric emptying and increase in body weight Reduction in body weight and higher postprandial sugars Low risk of hypoglycemia and inhibition of gastric emptying* Higher postprandial sugars and increased hypoglycemia 7% 16% 9% 3% 2% 1% 1% 9% 2% 5% 5% 70% 89% 74% 84% 2% 0% 4% 1% US PCP P <.001* OUS PCP P = .03* The medication works in a glucose-dependent manner to secrete insulin, making hypoglycemic episodes less likely* 100% 80% 60% 40% 20% 0% 54% He will see higher glucagon levels with the medication, which will lessen hypoglycemia The med will cause low sugar; however, since diabetic patients have low glocagon levels, he will be able to accommodate The medication works independent of glucose and has counter-regulatory hormones will limit any potential hypoglycemia 66% 77% 77% 31% 21% 14% 12% US PCP P = .004* OUS PCP P > .99 14% 12% 6% 7% 1% 1% 3% 4% Eating more frequent meals will alleviate his symptom complex 100% 80% 60% 40% 20% 0% 30% Down titration of his dose and eating slower may help improve his symptom complex* He should consider switching to a GLP-1 agonist given twice a day He should stop GLP-1 agonist and switch to insulin 10% 29% 10% 1% 0% 0% 0% US PCP P < .001* OUS PCP P < .001* 60% 87% 63% 85% 9% 3% 8% 5% Sulfonylurea 100% 80% 60% 40% 20% 0% 8% TZD Lower dosage of metformin DPP 4 inhibitor* Alpha glucosidase inhibitor 0% 6% 1% 4% 1% 2% 1% 6% 4% 2% 4% 76% 90% 81% 95% 6% 5% 7% 1% US PCP P = .001* OUS PCP P < .001* Cholelithiasis 100% 80% 60% 40% 20% 0% 8% Cholecystitis Pancreatitis* Pyelonephritis Hepatitis 1% 10% 2% 6% 0% 8% 2% 85% 98% 94% 69% 0% 0% 1% 0% 1% 1% 12% 2% US PCP P < .001* OUS PCP P < .001* Pre US PCPs (n=100) Pre OUS PCPs (n=100) Post US PCPs (n=100) Post OUS PCPs (n=100) Pre US PCPs (n=100) Pre OUS PCPs (n=100) Post US PCPs (n=100) Post OUS PCPs (n=100) Pre US PCPs (n=100) Pre OUS PCPs (n=100) Post US PCPs (n=100) Post OUS PCPs (n=100) Pre US PCPs (n=100) Pre OUS PCPs (n=100) Post US PCPs (n=100) Post OUS PCPs (n=100) Pre US PCPs (n=100) Pre OUS PCPs (n=100) Post US PCPs (n=100) Post OUS PCPs (n=100) He returns for a follow-up visit 3 weeks later and reports that his boss is concerned that he may develop low sugars while on his new medication affecting his ability to operate his truck. Question 3: In addition to concerns for hypoglycemia, he reports that he has become nauseated after injecting his GLP-1 agonist. Which of the following is correct? (Select only one.) Question 2: Which of the following statements is correct in regards to hypoglycemia with this medication (GLP-1 agonist)? (Select only one.) Question 1: In addition to improving glycemic control, which action would you also expect from this agent (GLP-1 agonist)? (Select only one.) A 53-year-old woman with Type 2 diabetes mellitus (T2DM) recently saw her family practitioner for recurrent vaginal yeast infections. Her BMI is 30 kg/m 2 and HbA1c is 7.4%. She has been on metformin 500mg twice a day for six months and recently stopped due to GI side effects. Her physical examination is normal except for 2+ lower extermity (LE) edema. You have encouraged her to improve her insulin resistance with diet and exercise. On review of her initial labs, you note normal liver enzymes, a creatinine of 1.8 mg/dL, and albumin 3.4 mg/dL. She does well on her new regimen for several months and then returns with complaints of upper abdominal pain and lack of appetite. She is afebrile though has some nausea. Question 5: Which of the following disorders has been associated with this class of drugs (DPP-4 inhibitors)? (Select only one.) Question 4: Which of the following agents would be your treatment of choice to improve her glycemic control with the fewest adverse effects? (Select only one.)
Transcript of SUN-0458 Success of Educational Interventions on Use of...
Success of Educational Interventions on Use of Incretin Agents in the Management of Type 2 Diabetes
introductionDespite recommendations of the importance of glycemic control in patients with type 2 diabetes (T2D), research continues to show that only around half of patients with diabetes achieve recommended hemoglobin A1c goals. [AHRQ 2013, Stark Casagrande 2013, Selvin 2014] These treatment gaps have received considerable attention in recent years, encouraging the development of novel antihyperglycemic therapies and new management paradigms. Many recommendations focus on the need for effective treatment plans that minimize the risk for hypoglycemia and also address comorbid conditions (including overweight and obesity) associated with T2D. [ADA 2013; Inzucchi 2012; Garber 2013]
The ADA/EASD and AACE/ACE groups agree that based on the unique physiologic activity, efficacy and safety profiles, and additional (nonglycemic) benefits of incretin-based agents (GLP-1 receptor agonists and DPP-4 inhibitors), these therapies are important options for the management of T2D patients. [ADA 2013; Inzucchi 2012; Garber 2013]
The overall goal of this initiative was to educate primary care physicians (PCPs) about differences between the two classes of incretin-modifying agents and improve their effective and appropriate use of these agents to treat those with T2D. The study objective was to determine if online educational interventions could improve knowledge about and/or appropriate use of incretin-related agents in patients with T2D by PCPs in the United States (US) and outside the US (OUS).
methodsThe continuing medical education (CME) activity was developed as an online expert faculty panel discussion focused on differentiating incretin agents and making appropriate clinical decisions about practical use. The activity targeted both US and OUS PCPs who manage patients with T2D and was available online on Medscape Education. The educational content was developed by the Endocrine Society and Medscape. The effects of education were assessed, in conjunction with CE Outcomes, using clinical case vignettes.*
Clinical case vignettes and a series of clinical assessment questions related to each case were developed within a multiple-choice survey format. Evidence-based responses to the case vignette questions were identified from educational content. Participants in the education were presented with a pre-assessment survery at the beginning of the CME activity and a post-assessment survey upon completion of the education. Data from the participant responses to the pre- and post-assessment case vignette surveys were analyzed using a statistical analysis package for the social sciences (IBM SPSS Statistics 20). For the case vignette questions, t-tests were conducted to detect significant differences between the pre- and post-assessment responses.
When the analysis involved the comparison of responses where one answer is evidence-based and thus preferred, the P value represents the level of significant difference between the pre- and post-assessment in the selections of that response. The level of statistical significance for analytical tests was set at P ≤.05.
In addition, overall mean scores and pooled standard deviations were calculated for aggregate pre- and post-assessment survey responses. Educational effect size was calculated using Cohen’s d formula to determine the average difference between pre- and post-assessment scores. Effect size representing the difference between the two groups is expressed as a percentage of nonoverlap between pre- and post-assessment survey scores. The difference in the likelihood of making evidence-based clinical choices in response to clinical case vignettes pre and post intervention, was expressed using the percentage of nonoverlap between pre- and post-assessment scores. Effect sizes greater than 0.8 are large, between 0.8 and 0.4 are medium, and less than 0.4 are small. Within the presented results, all percentage data are rounded to the nearest whole number. Furthermore, reported data are furnished on an aggregate level to maintain study participant confidentiality.
resultsA total of 200 PCPs (100 US and 100 OUS) were included in the assessment (Table 1).
Significant improvements were found as a result of participation in the educational intervention. PCPs (US and OUS) who participated in the CME activity were more likely to make evidence-based practice choices after participation in the educational activity. The effect sizes were large at 1.08 for US PCPs (56% non-overlap) and 0.72 for OUS PCPs (44% non-overlap).
As of April 18, 2014, a total of 6,322 PCPs have participated in this activity. Based on the representative sample in the outcomes study that see, on average, 10 patients per week that they would consider for incretin-based therapy, over 63,000 patients may benefit from improved evidence-based care.
For more information contact Amy Larkin, PharmD, Director of Clinical Strategy, Medscape, LLC at [email protected].
References
Agency for Healthcare Research and Quality (AHRQ). Improving quality and patient experience. The state of health care quality 2013. https://www.ncqa.org/Portals/0/Newsroom/SOHC/2013/SOHC-web_version_report.pdf Accessed April 21, 2014.
American Diabetes Association (ADA). Standards of medical care in diabetes--2013. Diabetes Care. 2013; 36 Suppl 1:S11-66
Garber AJ, Abrahamson MJ, Barzilay JI, et al. American Association of Clinical Endocrinologists. AACE comprehensive diabetes management algorithm 2013. Endocr Pract. 2013; 19:327-336.
Inzucchi SE, Bergenstal RM, Buse JB, et al. Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care. 2012;35:1364-1379.
Selvin E, Parrinello CM, Sacks DB, Coresh J. Trends in prevalence and control of diabetes in the United States, 1988-1994 and 1999-2010. Ann Intern Med. 2014;160:517-525.
Stark Casagrande S, Fradkin JE, Saydah SH, et al. The prevalence of meeting A1C, blood pressure, and LDL goals among people with diabetes, 1988-2010. Diabetes Care. 2013;36:2271-2279.
conclusionThis study demonstrated that a target educational intervention can improve the knowledge, competence, and perforamce of US and OUS PCPs in the use of incretin-related agents in patients with T2D. Based on the results of this analysis, future education is needed regarding the mechanism of action of GLP-1 agonists, approaches to minimizing GLP-1 agonist side effects, and any potential relationship between pancreatitis and incretin-based therapies.
Success of Educational Interventions on Use of Incretin Agents in the Management of Type 2 Diabetes Amy Larkin, PharmD*, Anne Le, PharmD*, Robert C. Bartel*, Anne L. Peters, MD*, Carol H. Wysham, MD*, Lawrence Blonde, MD* *Potential conflict of interest may exist. Refer to the abstract.
Success of Educational Interventions on Use of Incretin Agents in the Management of Type 2 Diabetes
source of supportThis CME-certified activity was supported by an independent educational grant from Sanofi.
*Results from research demonstrate that case vignettes, compared with chart review and standardized patients, provide a valid, cost-effective, and noninvasive method to evaluate a physician’s processes of care. [1,2] Case vignettes have gained considerable support for their value in predicting physician practice patterns. Furthermore, case vignettes are most cost-effective than other means of measurement. [1,2,3,4]
1 Peabody JW, Luck J, Glassman P, Dresselhaus TR, Lee M. Comparison of vignettes, standardized patients, and chart abstraction: a prospective validation study of 3 methods for measuring quality. JAMA. 2000; 283:1715-1722.
2 Peabody JW, Luck J, Glassman P, et al. Measuring the quality of physician practice by using clinical vignettes: a prospective validation study. Ann Intern Med. 2004; 141:771-780.
3 Luck J, et al. An automated scoring algorithm for computerized clinical vignettes: evaluating physician performance against explicit quality criteria. Int J Med Inform. 2006; 75:701-7.
4 Gould D. Using vignettes to collect data for nursing research studies: how valid are the findings? J Clinical Nursing. 1996; 5:207-212.
SUN-0458
table 1PCP US Participants PCP OUS Participants
(n-100) (n=100)
Patients seen per week who would be considered for incretin-based therapy (percent) 1-10 71% 73% 11-20 20% 21% 21-30 2% 4% 31-40 2% 1% 41-50 1% 0% >50 4% 1%
Patients seen per week who would be considered for 11 9incretin-based therapy (mean)
Degree: MD/DO 100% 100%
Specialty Family medicine 40% 40% General practice 20% 40% Internal medicine 40% 20%
Years since graduation from medical school 1-10 years 17% 34% 11-20 years 23% 19% 21-30 25% 23% >30 years 35% 24%
Demographics of Patients
Case 1 Review the mechanism of incretin-based agents.
Case 2 Differentiate the role of incretin-based therapies in clinical practice.
A 58-year-old man, who works as a truck driver and has a history of hypertension and hyperlipidemia comes to see you for worsening blood glucose control. He was diagnosed with diabetes mellitus three years ago when he presented with blood glucose of 338 mg/dL. His initial treatment regimen was metformin 1000 mg daily along with an unsuccessful diet and exercise program. Over the last six months, he saw higher sugars and increased to metformin twice a day and despite the adjustment has hemoglobin A1c (HbA1c), remains at 8.1%. The rest of his labs are unremarkable. His physical exam is normal except for BMI 38 kg/m2.
Decreased satiety and promotion of gastric
emptying
100%
80%
60%
40%
20%
0%
16%
Inhibition of gastric emptying and increase in
body weight
Reduction in body weight and higher
postprandial sugars
Low risk of hypoglycemia and
inhibition of gastric emptying*
Higher postprandial sugars and increased
hypoglycemia
7%16% 9%
3% 2%1% 1%
9%2% 5%5%
70%
89%
74%84%
2% 0%4% 1%
US PCP P <.001* OUS PCP P = .03*
The medication works in a glucose-dependent manner to secrete insulin, making
hypoglycemic episodes less likely*
100%
80%
60%
40%
20%
0%
54%
He will see higher glucagon levels with the
medication, which will lessen hypoglycemia
The med will cause low sugar; however, since
diabetic patients have low glocagon levels, he will be
able to accommodate
The medication works independent of glucose and has
counter-regulatory hormones will limit any potential hypoglycemia
66%
77% 77%
31%21%
14% 12%
US PCP P = .004* OUS PCP P > .99
14% 12%6% 7%
1% 1%3% 4%
Eating more frequent meals will alleviate his
symptom complex
100%
80%
60%
40%
20%
0%
30%
Down titration of his dose and eating slower
may help improve his symptom complex*
He should consider switching to a GLP-1
agonist given twice a day
He should stop GLP-1 agonist and switch to
insulin
10%
29%
10%1% 0%0% 0%
US PCP P < .001* OUS PCP P < .001*
60%
87%
63%
85%
9% 3%8% 5%
Sulfonylurea
100%
80%
60%
40%
20%
0%
8%
TZD Lower dosage of metformin
DPP 4 inhibitor* Alpha glucosidase inhibitor
0%6%
1% 4% 1%2% 1%6% 4% 2%4%
76%
90%81%
95%
6% 5%7%1%
US PCP P = .001* OUS PCP P < .001*
Cholelithiasis
100%
80%
60%
40%
20%
0%
8%
Cholecystitis Pancreatitis* Pyelonephritis Hepatitis
1%10%
2% 6%0%
8%2%
85%
98% 94%
69%
0% 0%1% 0% 1% 1%
12%
2%
US PCP P < .001* OUS PCP P < .001*
Pre US PCPs (n=100)
Pre OUS PCPs (n=100)
Post US PCPs (n=100)
Post OUS PCPs (n=100)
Pre US PCPs (n=100)
Pre OUS PCPs (n=100)
Post US PCPs (n=100)
Post OUS PCPs (n=100)
Pre US PCPs (n=100)
Pre OUS PCPs (n=100)
Post US PCPs (n=100)
Post OUS PCPs (n=100)
Pre US PCPs (n=100)
Pre OUS PCPs (n=100)
Post US PCPs (n=100)
Post OUS PCPs (n=100)
Pre US PCPs (n=100)
Pre OUS PCPs (n=100)
Post US PCPs (n=100)
Post OUS PCPs (n=100)
He returns for a follow-up visit 3 weeks later and reports that his boss is concerned that he may develop low sugars while on his new medication affecting his ability to operate his truck.
Question 3:In addition to concerns for hypoglycemia, he reports that he has become nauseated after injecting his GLP-1 agonist. Which of the following is correct? (Select only one.)
Question 2:Which of the following statements is correct in regards to hypoglycemia with this medication (GLP-1 agonist)? (Select only one.)
Question 1:In addition to improving glycemic control, which action would you also expect from this agent (GLP-1 agonist)? (Select only one.)
A 53-year-old woman with Type 2 diabetes mellitus (T2DM) recently saw her family practitioner for recurrent vaginal yeast infections. Her BMI is 30 kg/m2 and HbA1c is 7.4%. She has been on metformin 500mg twice a day for six months and recently stopped due to GI side effects. Her physical examination is normal except for 2+ lower extermity (LE) edema. You have encouraged her to improve her insulin resistance with diet and exercise.
On review of her initial labs, you note normal liver enzymes, a creatinine of 1.8 mg/dL, and albumin 3.4 mg/dL. She does well on her new regimen for several months and then returns with complaints of upper abdominal pain and lack of appetite. She is afebrile though has some nausea.
Question 5:Which of the following disorders has been associated with this class of drugs (DPP-4 inhibitors)? (Select only one.)
Question 4:Which of the following agents would be your treatment of choice to improve her glycemic control with the fewest adverse effects? (Select only one.)
