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Severe Insulin Resistance in Diabetes

Daniel Einhorn, MD, FACE, FACP; George Grunberger, MD, FACE, FACP; Robert R. Henry, MD; Fernando Ovalle, MD, FACE

Date of Original Release: May 3, 2013

Activity Format: Webcast

 


This activity is sponsored by the American Association of Clinical Endocrinologists. Program management provided by Integritas Communications


This activity is supported by an educational grant from Lilly USA, LLC. For further information regarding Lilly grant funding visit www.lillygrantoffice.com.

Faculty

Daniel Einhorn, MD, FACE, FACP
Program Chair

Clinical Professor of Medicine
University of California, San Diego
Diabetes and Endocrine Associates
Medical Director, Scripps Whittier Diabetes Institute
La Jolla, California

George Grunberger, MD, FACE, FACP
Clinical Professor, Internal Medicine and Molecular Medicine & Genetics
Wayne State University School of Medicine
Detroit, Michigan
Chairman, Grunberger Diabetes Institute
Bloomfield Hills, Michigan

Robert R. Henry, MD
Professor of Medicine
University of California, San Diego
Chief, Section of Diabetes, Endocrinology & Metabolism
VA San Diego Healthcare System
San Diego, California

Fernando Ovalle, MD, FACE
Professor of Medicine
Director, Diabetes and Glycemic Control Programs
University of Alabama at Birmingham School of Medicine
Birmingham, Alabama

Target Audience

This activity is intended for endocrinologists and other health care professionals who manage diabetic patients with marked insensitivity to the effects of insulin.

Educational Objectives

Upon completion of these educational activities, participants will be better prepared to:

  • Evaluate potential causes of severe insulin resistance in diabetic patients and relationships with co-occurring conditions, such as obesity and dyslipidemia
  • Tailor high-dose insulin therapy to help achieve patient-centered glycemic targets in the setting of severe insulin resistance
  • Combine insulin with incretin-based pharmacologics, lifestyle modifications, and other medical interventions for diabetic patients with severe insulin resistance
  • Employ newer insulin-based treatments, techniques, and technologies, including concentrated formulations, continuous glucose monitoring, and continuous subcutaneous insulin infusion
  • Counsel patients with severely insulin-resistant diabetes on the importance of treatment adherence and addressing signs of hypoglycemia

Needs Assessment

With increasing frequency, endocrinologists and other health care providers are encountering diabetic patients with severe insulin resistance—defined as total daily insulin requirements exceeding 2.0 units/kg/day to achieve glycemic control.1,2 Although some patients develop significant insensitivities to insulin because of genetic, autoimmune, or other relatively rare disorders, the majority of cases involve obesity and the range of associated metabolic disturbances.1,3,4 Indeed, one of the greatest challenges facing endocrinologists in the United States is the significant upward trend in average body mass index over the last 3 decades.5 Thus, practicing endocrinologists will benefit from evidence-based discussions on interdisciplinary management of diabetic patients with severe insulin resistance, including multimodal therapeutic regimens that can be carefully tailored to achieve patient-centered treatment goals.3,6,7

  1. Tritos NA, Mantzoros CS. Clinical review 97: Syndromes of severe insulin resistance. J Clin Endocrinol Metab. 1998;83(9):3025-3030.
  2. Lane WS, Cochran EK, Jackson JA, et al. High-dose insulin therapy: is it time for U-500 insulin? Endocr Pract. 2009;15(1):71-79.
  3. Brown A, Desai M, Taneja D, Tannock LR. Managing highly insulin-resistant diabetes mellitus: weight loss approaches and medical management. Postgrad Med. 2010;122(1):163-171.
  4. DeFronzo RA. Insulin resistance, lipotoxicity, type 2 diabetes and atherosclerosis: the missing links. Diabetologia. 2010;53(7):1270-1287.
  5. Ogden CL, Carroll MD, McDowell MA, Flegal KM. Obesity among adults in the United States—No statistically significant change since 2003–2004. NCHS data brief no 1. 2007. National Center for Health Statistics: Hyattsville, MD.
  6. Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing diabetes mellitus comprehensive care plan. Endocr Pract. 2011;17 (suppl 2):1-53.
  7. Cochran E, Musso C, Gorden P. The use of U-500 in patients with extreme insulin resistance. Diabetes Care. 2005;28(5):1240-1244.

Accreditation Statements

The American Association of Clinical Endocrinologists (AACE) designates this enduring material for a maximum of 1.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Declaration of Disclosure and Conflicts of Interest

It is the policy of AACE to ensure balance, independence, objectivity and scientific rigor in all of its CME activities. Presentation content may include discussion of an unlabeled or an investigational use of a product. AACE requires that participating faculty disclose to the audience any product(s) and its use(s) discussed in the educational activity that are unapproved/unlabeled for the use by the FDA or still considered investigational in nature.

Everyone who is in a position to control the content of an educational activity must disclose all relevant financial relationships. "Relevant financial relationships" are financial relationships in any amount occurring within the past 12 months that create a conflict of interest. AACE requires speakers, faculty, CME Committee and other individuals who are in a position to control the content of this educational activity to disclose any real or apparent conflict of interest they may have as related to the content of this activity. All identified conflicts of interest are thoroughly evaluated by AACE for fair balance, scientific objectivity of studies mentioned in the presentation and educational materials used as basis for content, and appropriateness of patient care recommendations.

The intent of this disclosure is not to prevent a speaker with commercial affiliations from presenting, but rather to provide learners with information from which they may make their own judgments. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial influence.

AACE has reviewed all disclosures and resolved or managed all identified conflicts of interest for this educational activity, as applicable.

CME Accreditation Committee Disclosures

  • Dr. Myriam Allende-Vigo reports that she has received speaker honoraria from Bristol-Myers Squibb Company/AstraZeneca, Janssen Pharmaceuticals, Inc., Merck & Co, Inc., and Pfizer, Inc.
  • Dr. Stephen R. Crespin reports that he has received speaker honoraria from Bristol-Myers Squibb Company/AstraZeneca and Merck & Co., Inc.
  • Dr. Dorothy S. Martinez reports that she does not have any relevant financial relationships with any commercial interests.
  • Dr. Dace L. Trence reports that she has received research grant support from Eli Lilly and Company and is a stockholder of Medtronic, Inc. and sanofi-aventis U.S. LLC.

Faculty Disclosures

Dr. Daniel Einhorn reports that he has received consultant honoraria from Bristol-Myers Squibb Company/AstraZeneca-Amylin Pharmaceuticals, LLC., Halozyme, Inc., and Novo Nordisk A/S; consultant honoraria and research grant support from Eli Lilly and Company; and research grant support from AstraZeneca, Janssen Pharmaceuticals, Inc., MannKind Corporation, sanofi-aventis U.S. LLC., and Takeda Pharmaceutical Company Limited. He also reports that his presentation will not include discussion of any investigational or unlabeled use(s) of a product. Dr. Einhorn has an identified conflict of interest and it has been resolved accordingly. He has been advised by the AACE CME Accreditation Committee to base his presentation and recommendations on the best available, preferably published evidence/information.

Dr. George Grunberger reports that he has received speaker honoraria and research support for his role as Investigator from Amylin Pharmaceuticals, LLC, Eli Lilly and Company, Novo Nordisk A/S, and Valeritas, Inc.; speaker honoraria from Amarin Corp. and Santarus Inc.; and research support for his role as Investigator from GlaxoSmithKline plc. and Janssen Pharmaceuticals, Inc. He also reports that his presentation will not include discussion of any investigational or unlabeled use(s) of a product. Dr. Grunberger has an identified conflict of interest and it has been resolved accordingly. He has been advised by the AACE CME Accreditation Committee to base his presentation and recommendations on the best available, preferably published evidence/information.

Dr. Robert R. Henry reports that he has received research grant support for his role as Principal Investigator and Advisory Board honoraria from Amylin Pharmaceuticals, LLC, AstraZeneca, and Bristol-Myers Squibb Company; consultant/Advisory Board honoraria from Amgen Inc., F. Hoffman La-Roche Ltd./Genentech, Inc., Gilead, Intarcia Therapeutics, Inc., and Novo Nordisk A/S; consultant honoraria from Isis Pharmaceuticals, Inc.; Advisory Board honoraria from Johnson & Johnson Services, Inc. and Merck & Co., Inc.; consultant/Advisory Board/speaker honoraria from Boehringer Ingelheim GmbH; research grant support for his role as Principal Investigator and consultant honoraria from Eli Lilly and Company and sanofi-aventis U.S. LLC.; and research grant support for his role as Principal Investigator from Medtronic, Inc. He also reports that his presentation will not include discussion of any investigational or unlabeled use(s) of a product. Dr. Henry has an identified conflict of interest and it has been resolved accordingly. He has been advised by the AACE CME Accreditation Committee to base his presentation and recommendations on the best available, preferably published evidence/information.

Dr. Fernando Ovalle reports that he has received consultant fees and research support from Bristol-Myers Squibb Company, Janssen Pharmaceuticals, Inc., Medtronic, Inc., Novo Nordisk A/S, and sanofi-aventis U.S. LLC. He also reports that his presentation will not include discussion of any investigational or unlabeled use(s) of a product. Dr. Ovalle has an identified conflict of interest and it has been resolved accordingly. He has been advised by the AACE CME Accreditation Committee to base his presentation and recommendations on the best available, preferably published evidence/information.

Learner Bill of Rights

The American Association of Clinical Endocrinologists (AACE) recognizes that you are a lifelong learner who has chosen to engage in continuing medical education to identify or fill a gap in knowledge, skill or performance. As part of AACE's duty to you as a learner, you have the right to expect that your continuing medical education experience with AACE includes:

CONTENT that:

  • Promotes improvements or quality in healthcare;
  • Is valid, reliable and accurate;
  • Offers balanced presentations that are free of commercial bias for or against a product/service;
  • Is vetted through a process that resolves any conflicts of interests of planners, teachers or authors;
  • Is driven and based on learning needs, not commercial interests;
  • Addresses the stated objectives or purpose; and
  • Is evaluated for its effectiveness in meeting the identified educational need.

A LEARNING ENVIRONMENT that:

  • Supports learners' ability to meet their individual needs;
  • Respects and attends to any special needs of the learners;
  • Respects the diversity of groups of learners; and
  • Is free of promotional, commercial and/or sales activities.

DISCLOSURE of:

  • Relevant financial relationships planners, teachers and authors have with commercial interests related to the content of the activity; and
  • Commercial support (funding or in-kind resources) of the activity.

Hardware/Software Requirements

  • Computer with an Internet connection
  • Internet Explorer 8.x or higher, Firefox 4.x or higher, Safari 2.x or higher, or any other W3C standards compliant browser
  • Adobe Flash Player and/or an HTML5 capable browser may be required for video or audio playback.
  • Occasionally other additional software may be required such as Adobe Acrobat Reader

Method of Participation

To claim credit for this activity, view the program and complete the post test and evaluation. A passing grade of 70% or higher is required to receive credit. Participants have two (2) attempts to successfully pass the post test.

Copyright 2013, AACE. All rights reserved. No part of this publication may be reproduced or transmitted in any other form or by any other means, electronic or mechanical, without first obtaining written permission from AACE.

Provider Contact Information

For questions regarding this CME activity, please contact:
AACE c/o Lauren Hogan
Phone: (904) 353-7878
Email:  lhogan@aace.com

Click "Begin Activity" to acknowledge that you have revlewed the preamble information for this activity.

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credit amount 1.75

credit type AMA PRA

release 10/29/2013

expiration 10/29/2014

type Webcast