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Co-interests. Editor: ACP Journal Club, Evidence-Based Medicine Supplier: bmjupdates+, PIER, Clinical Evidence, Medscape. CANADIAN SOCIETY OF INTERNAL MEDICINE ANNUAL SCIENTIFIC MEETING NOVEMBER 1-4, 2006. 1500-1730 SHORT SNAPPERS 1. Perioperative AMI - Dr. Akbar Panju, Hamilton

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co interests
Co-interests
  • Editor: ACP Journal Club, Evidence-Based Medicine
  • Supplier: bmjupdates+, PIER, Clinical Evidence, Medscape
slide2

CANADIAN SOCIETY OF INTERNAL MEDICINE

ANNUAL SCIENTIFIC MEETING

NOVEMBER 1-4, 2006

1500-1730 SHORT SNAPPERS

1. Perioperative AMI - Dr. Akbar Panju, Hamilton

2. Optimal Asthma Management - Dr. Tony Bai, Vancouver

3. Incretins – TBA

4. New Insulins – TBA

5. New Method for Rapid HIV Testing - Dr. Donna Sweet, Wichita

Incretin Therapy in Type 2 Diabetes

Type 2 Diabetes in Canada. Where are we going. Irene Hramiak, UWO (sponsored by Merck) 11:45 – 13:00

Peter Bolli approached me to make a presentation at the ACP meeting in Toronto

advances in resources for evidence based clinical practice
Advances in Resources for Evidence-Based Clinical Practice

How to Determine for Yourself What Recent Studies You Should be Paying Attention To

Brian Haynes

Health Information Research Unit

McMaster University

slide4

58 y/o obese male with …type 2 DM …A1c 9% on glyburide and rosiglitazone, with metformin intolerance…continuing to gain weight…veryreluctant to take insulin

Can incretin therapy help?

(exenatide, pramlintide, sitagliptin)

ebhc is
EBHC is...

…a set of procedures, pre-appraised resources and information tools to assist practitioners to apply evidence from research in the care of individual patients.

slide6

Examples

Computerized decision support

Evidence-based textbooks

Evidence-based journal abstracts

Systematic reviews

Original journal articles

New School EBM

Olde School EBM

evidence based push pull prompt
Evidence-basedPush, Pull, Prompt

…ways to deal with

too much information

evidence based journals
Evidence-Based Journals

Critical Appraisal Filters

~3000 articles/yr

meet critical appraisal

and content criteria

(95% noise reduction)

60,000 articles/yr

from 120 journals

mcmaster plus project
McMaster PLUS Project

Clinical Relevancy Filter (MORE)

~25 articles/yr for

clinicians (99.995%

noise reduction)

~3,000 articles/yr meet critical appraisal

and content criteria

(95% noise reduction)

~5-50 articles/yr for

authors of evidence-based clinical topic reviews

user end
User End
  • Users sign up according to discipline
  • Users control relevance and flow
  • Users can change disciplines at any time, and can sign up for as many as they wish
  • Users can search according to discipline – or not
  • Users can access PubMed Clinical Queries
randomized trial of plus
Self Serve Version

Ovid

Stat!Ref

Pyramid of Evidence

Full Serve Version

Ovid

Stat! Ref

Pyramid of Evidence

PLUS Email Alerts

PLUS Search Engine

Randomized Trial of PLUS

Randomization to 2 different trial interfaces:

PULL + PUSH

PULL

plus findings of participants using plus by month

RCT begins

Control cross-over begins

PLUS Findings: % of Participants Using PLUS by Month

Self-servevsFull-serve

Baseline (5 mo)

Full-Serve

70

60

50

40

30

20

10

0

Percentage Using PLUS

Relative increase 58.7%, P=0.001

Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

03 03 04 04 04 04 04 04 04 04 04 04 04 04 05 05 05 05 05 05

Month

Haynes et al,

JAMIA Nov 2006

Self-serve Full-Serve

slide15

CONCLUSIONS: Exenatide and insulin glargine achieved similar improvements in overall glycemic control in patients with type 2 diabetes that was suboptimally controlled with oral combination therapy. Exenatide was associated with weight reduction and had a higher incidence of gastrointestinal adverse effects than insulin glargine. (19% withdrew on exenatide, 9.7% on glargine)

slide16

The major adverse effects associated with pramlintide include an increase in nausea or anorexia, and possible hypoglycemia…several concerns with the published literature still exist.

Must be injected.

Costs $100-200/mo.

slide17

CONCLUSIONS: In this 24-week study, once-daily sitagliptin monotherapy improved glycemic control in the fasting and postprandial states {vs placebo}, improved measures of beta-cell function, and was well tolerated in patients with type 2 diabetes.

my push conclusions
(My) “push” conclusions
  • Interesting but not enough to warrant a change in practice
    • Short-term trials with wrong comparators
    • Adverse effects
    • Expensive
      • Sitagliptin (Januvia) - $6/pill
      • Exenatide (Byetta) - $10/dose
      • Pramlintide ??

Metformin $0.25/pill

Glyburide $0.20/pill

Pioglitazone $1.00/pill

slide20

Examples

Computerized decision support

Evidence-based textbooks

Evidence-based journal abstracts

Systematic reviews

Original journal articles

premier evidence resources for internal medicine
Premier evidence resources for internal medicine
  • Systems: EMR with decision support
  • Summaries: Clinical Evidence, PIER, UpToDate, Dynamed
  • Synopses: ACP Journal Club
  • Syntheses: via BMJUpdates+
  • Studies: via BMJUpdates, PubMed Clinical Queries
slide22

58 y/o obese male with …type 2 DM …A1c 9% on glyburide and rosiglitazone, with metformin intolerance…continuing to gain weight…very reluctant to take insulin

Can exenatide, pramlintide or sitagliptin help?

for type 2 diabetes what are the effects good and bad of incretin therapy
For type 2 diabetes, what are the effects- good and bad -of incretin therapy?
  • Systems: none
  • Summaries: in UTD, PIER, Dynamed, not CE
  • Synopses: sitagliptin in ACP JC
  • Syntheses: one for pramlintide in BMJUpdates+
  • Studies: exenatide and pramlintide in UTD, PIER, CE, BMJUpdates+; more on exenatide, pramlintide and sitagliptin in Clinical Queries
slide24

Januvia is approved for use by people with type 2 diabetes

that can't be controlled adequately with diet and exercise.

Section updated June 2006; update scheduled February 2007 (not available; no GRADE yet)

“Many questions remain unanswered regarding clinical use and long-term outcomes with these drugs.”

Sitagliptin is stated to be “experimental” {but is now FDA approved (October 17, 2006)}

$6 per pill

slide25
Includes exenatide, pramlintide, and sitagliptin, with drug monographs for each
  • “Consider metformin as a first-line agent because it causes less hypoglycemia and weight gain, along with possible improvements in cardiovascular risk.”
  • “Consider other oral agents, such as sulfonylureas, thiazolidinediones, and DPP-IV inhibitors, as reasonable first-line agents, although some are costly and the long-term benefits of these drugs have not been well studied.”
slide26

CONCLUSIONS: Exenatide and insulin glargine achieved similar improvements in overall glycemic control in patients with type 2 diabetes that was suboptimally controlled with oral combination therapy. Exenatide was associated with weight reduction and had a higher incidence of gastrointestinal adverse effects than insulin glargine. (19% withdrew on exenatide, 9.7% on glargine)

slide27

CONCLUSIONS: In this 24-week study, once-daily sitagliptin monotherapy improved glycemic control in the fasting and postprandial states {vs placebo}, improved measures of beta-cell function, and was well tolerated in patients with type 2 diabetes.

slide28

The major adverse effects associated with pramlintide include an increase in nausea or anorexia, and possible hypoglycemia…several concerns with the published literature still exist.

Must be injected.

Costs $100-200/mo.

survey of traditional texts
Survey of traditional texts
  • Harrison’s – no; Harrison’s Practice - yes
  • Books@Ovid – no
  • Stat!Ref – in PIER and Mosby Drug Consult
  • Kelley’s Textbook - no
my conclusions about exenatide pramlintide gliptins
My conclusions about exenatide, pramlintide, gliptins
  • Interesting new options for diabetes
  • Not well studied (eg, no head-to-head studies with current agents)
  • Exenatide and pramlintide would likely be out for this patient (injections)
  • Sitagliptin would be a possibility, but not until better known options tried (acarbose, Avandamet, repaglinide)
to keep up
To keep up
  • Pull
  • Push
  • Prompt…some labs and EMRs with a credible evidence-based pedigree (Zynx)