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Diabetes, Cardiovascular Risk, Obesity CE/CME ACCREDITED Watch Time: 44 mins

touchMDT Antihyperglycemic therapy in the patient with T2D and obesity: A multidisciplinary outlook

Watch leading specialists within an MDT plus a patient with T2D discuss the use of antihyperglycemic therapies to control both T2D and obesity

 Overview & Learning Objectives

Patient with type 2 diabetes and obesity
Endocrinologist, Primary Care Physician and Patient
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GLP-1 RAs & SGLT2is: Clinical benefits Prof. S Harris, Prof. M Nauck, Ms T Snowden

Watch an endocrinologist and a primary care specialist share their expert insights on the importance of achieving weight loss in T2D and provide an overview of GLP-1 RAs and SGLT2is and their association with weight loss. Plus, see a patient’s personal account on achieving weight loss with a GLP-1 RA

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Primary Care Physician and Endocrinologist
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Mechanism linking obesity with T2D Prof. S Harris, Prof. M Nauck

Watch a primary care specialist and an endocrinologist share their expert insights on why obesity is an important risk factor for T2D and the patient journey from obesity to T2D

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Nurse, Primary Care Physician and Patient
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GLP-1 RAs & SGLT2is: real-world use Dr S Idzik, Prof. S Harris, Ms T Snowden

Watch a diabetes nurse practitioner and a primary care specialist share their expert insights on real-world use of antihyperglycemic therapy for T2D and obesity. Plus, see a patient’s personal account of initiating GLP-1 RA therapy and the effects on their quality of life after achieving weight loss with a GLP-1 RA

Watch Video
Endocrinologist, Primary Care Physician and Patient

Watch an endocrinologist and a primary care specialist share their expert insights on the importance of achieving weight loss in T2D and provide an overview of GLP-1 RAs and SGLT2is and their association with weight loss. Plus, see a patient’s personal account on achieving weight loss with a GLP-1 RA
Expert Spotlight
Prof. Stewart Harris
Schulich School of Medicine & Dentistry, Western University, Ontario, Canada
Prof. Dr. med Michael Nauck
Katholisches Klinikum Bochum, St Josef-Hospital (Ruhr-Universität Bochum), Bochum, Germany
Ms Tammie Snowden
Houston, TX, USA

Prof. Dr. med Michael Nauck, Prof. Stewart Harris and Ms Snowden discuss the importance of achieving weight loss in T2D; GLP-1 RAs and SGLT2is and their association with weight loss; plus the patient’s personal experience of using a GLP-1 RA to treat their T2D and obesity

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 Learn more Back to MDT Hub Time: 14:52
 
Primary Care Physician and Endocrinologist

Watch a primary care specialist and an endocrinologist share their expert insights on why obesity is an important risk factor for T2D and the patient journey from obesity to T2D
Expert Spotlight
Prof. Stewart Harris
Schulich School of Medicine & Dentistry, Western University, Ontario, Canada
Prof. Dr. med Michael Nauck
Katholisches Klinikum Bochum, St Josef-Hospital (Ruhr-Universität Bochum), Bochum, Germany

Prof. Stewart Harris and Prof. Dr. med Michael Nauck discuss the mechanism linking obesity with T2D and share their observations from the clinic on the course of disease from obesity to T2D

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 Learn more Back to MDT Hub Time: 11:03
 
Nurse, Primary Care Physician and Patient

Watch a diabetes nurse practitioner and a primary care specialist share their expert insights on real-world use of antihyperglycemic therapy for T2D and obesity. Plus, see a patient’s personal account of initiating GLP-1 RA therapy and the effects on their quality of life after achieving weight loss with a GLP-1 RA
Expert Spotlight
Dr Shannon Idzik
University of Maryland School of Nursing, MD, USA
Prof. Stewart Harris
Schulich School of Medicine & Dentistry, Western University, Ontario, Canada
Ms Tammie Snowden
Houston, TX, USA

Dr Shannon Idzik, Prof. Stewart Harris and Ms Snowden discuss real-world use of antihyperglycemic therapies to achieve an effective combination of glycemic control, weight loss and cardiovascular benefits

LISTEN on the go

 Learn more Back to MDT Hub Time: 18:09
 
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Overview & Learning Objectives
Overview

In this activity, specialists in the MDT involved in caring for patients with T2D and obesity, plus a patient with both conditions, share their perspectives on the benefits of antihyperglycemic therapies that are associated with weight loss and reduction in cardiovascular risk in patients with T2D and obesity read more

This activity is jointly provided by USF Health and touchIME.

Target Audience

This activity has been designed to meet the educational needs of diabetologists, endocrinologists, diabetes nurses, and primary care physicians involved in the management of patients with type 2 diabetes.

Disclosures

All individuals in a position to influence content have disclosed to USF Health any financial relationship with an ineligible organization. USF Health has reviewed and mitigated all relevant financial relationships related to the content of the activity. The relevant relationships are listed below. All individuals not listed have no relevant financial relationships.

Faculty

Prof. Stewart Harris discloses: Advisory board or panel fees from Abbott, AstraZeneca, Bayer Inc., Eli Lilly, Janssen, Novo Nordisk and Sanofi. Consultancy fees from Abbott, AstraZeneca, Bayer Inc., Eli Lilly, Janssen, Novo Nordisk and Sanofi. Grant/research support from Abbott, AstraZeneca, Eli Lilly, Janssen, Novo Nordisk and Sanofi. Salary and contractual services Abbott, AstraZeneca, Bayer Inc., Eli Lilly, Janssen, Novo Nordisk and Sanofi.

Prof. Dr. med Michael Nauck discloses: Advisory board or panel fees from AstraZeneca, Berlin-Chemie, Genentech, GlaxoSmithKline, Sun Pharma and Takeda (all relationships terminated). Advisory board or panel fees from Boehringer Ingelheim, Gasherbrum Bio, Eli Lilly, Merck Sharp & Dohme and Novo Nordisk. Consultant fees from Regor Pharmaceuticals. Other fees from Altimmune (Drug Monitoring and Safety Board).

Dr Shannon Idzik has no interests/relationships or affiliations to disclose in relation to this activity.

Ms Tammie Snowden has no interests/relationships or affiliations to disclose in relation to this activity.

Content Reviewer

Kaitlyn Rechenberg, PhD, MPH, APRN has no financial interests/relationships or affiliations in relation to this activity

Touch Medical Director

Sola Neunie has no financial interests/relationships or affiliations in relation to this activity.

USF Health Office of Continuing Professional Development and touchIME staff have no financial interests/relationships or affiliations in relation to this activity.

Requirements for Successful Completion

In order to receive credit for this activity, participants must review the content and complete the post-test and evaluation form. Statements of credit are awarded upon successful completion of the post-test and evaluation form.

If you have questions regarding credit please contact cpdsupport@usf.edu 

Accreditations
Physicians

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through a joint providership of USF Health and touchIME. USF Health is accredited by the ACCME to provide continuing medical education for physicians.

USF Health designates this enduring material for a maximum of 1 AMA PRA Category 1 CreditTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

The European Union of Medical Specialists (UEMS) – European Accreditation Council for Continuing Medical Education (EACCME) has an agreement of mutual recognition of continuing medical education (CME) credit with the American Medical Association (AMA). European physicians interested in converting AMA PRA Category 1 CreditTM into European CME credit (ECMEC) should contact the UEMS (www.uems.eu)

Advanced Practice Providers

Physician Assistants may claim a maximum of 1 Category 1 credit for completing this activity. NCCPA accepts AMA PRA Category 1 CreditTM from organizations accredited by ACCME or a recognized state medical society.

The AANPCP accepts certificates of participation for educational activities approved for AMA PRA Category 1 CreditTM by ACCME-accredited providers. APRNs who participate will receive a certificate of completion commensurate with the extent of their participation.

Nurses

USF Health is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center’s Commission on Accreditation.

A maximum of 1 contact hour may be earned by learners who successfully complete this continuing professional development activity. USF Health, the accredited provider, acknowledges touchIME as the joint provider in the planning and execution of this CNE activity.

This activity is awarded .75 ANCC pharmacotherapeutic contact hour.

Date of original release: 14 October 2021. Date credit expire: 14 October 2022.

If you have any questions regarding credit please contact cpdsupport@usf.edu 

Learning Objectives

After watching this activity, participants should be better able to:

  • Describe the relationship between T2D and obesity
  • Predict the beneficial effects of weight loss with a GLP-1 RA based therapy or SGLT2i on outcomes in patients with T2D and obesity
  • Perform appropriate selection of antihyperglycemic therapy with weight-loss benefits for patients with T2D and obesity
Faculty & Disclosures
Prof. Stewart Harris

Western University, Ontario, Canada

Stewart Harris has joint appointments as Professor of Family Medicine and of Epidemiology and Biostatistics in the Division of Endocrinology and Metabolism at the Schulich School of Medicine and Dentistry at Western University, in Ontario, Canada. He is also a research scientist at Lawson Health Research Institute. He is currently in his third 5-year term as the Diabetes Canada Chair in Diabetes Management and recently completed his final term as the Dr Ian McWhinney Chair of Family Medicine Studies. read more

In 2007, Prof. Harris founded the Primary Care Diabetes Support Program (PCDSP) at St. Joseph’s Health Care, London, Ontario, an integrated team-based diabetes clinic for disenfranchised and marginalized populations, where he is the lead physician and Medical Director.

In addition to his published articles in peer-reviewed journals, he has participated extensively in clinical practice guideline development, including serving as chair of the Canadian Diabetes Association (CDA) clinical practice guidelines committee.

Prof. Harris is a recipient of the Ontario Ministry of Health Career Scientist award, the Dr Gerald S. Wong Service Award of the CDA, the Hellmuth Prize for Achievement in Research at Western University, and a Fellow in the Canadian Academy of Health Sciences. He was appointed to the Order of Canada for his contributions to the development of strategies to manage and reduce diabetes in Aboriginal communities and other vulnerable populations.

Prof. Stewart Harris discloses: Advisory board or panel fees from Abbott, AstraZeneca, Bayer Inc., Eli Lilly, Janssen, Novo Nordisk and Sanofi. Consultancy fees from Abbott, AstraZeneca, Bayer Inc., Eli Lilly, Janssen, Novo Nordisk and Sanofi. Grant/research support from Abbott, AstraZeneca, Eli Lilly, Janssen, Novo Nordisk and Sanofi. Salary and contractual services Abbott, AstraZeneca, Bayer Inc., Eli Lilly, Janssen, Novo Nordisk and Sanofi.

Prof. Dr. med Michael Nauck

Katholisches Klinikum Bochum, St. Josef-Hospital (Ruhr-Universität Bochum), Bochum, Germany

Michael Nauck is Professor of Diabetology and Head of Clinical Research at the Diabetes Division of St. Josef-Hospital (Ruhr-University Bochum) in Bochum, Germany. He teaches at Georg-August University, Göttingen, and Ruhr-University, Bochum, both in Germany.

Prof. Dr. med Nauck has a particular research interest in the role of gastrointestinal peptide hormones (incretins: glucose-dependent insulinotropic polypeptide [GIP] and glucagon-like peptide-1 [GLP-1]) in the physiological regulation of metabolism and in the pathophysiology of type 2 diabetes. read more

He has contributed to pivotal studies proving the therapeutic potential of GLP-1 in type 2 diabetes and has contributed to the development of incretin-based glucose-lowering medications such as GLP-1 receptor agonists and inhibitors of dipeptidyl peptidase-4. Additional areas of interest include spontaneous hypoglycemia (insulinomas), pancreas transplantation, cardiovascular complications of type 2 diabetes, and the modification of cardiovascular risk in patients with type 2 diabetes with glucose-lowering pharmacotherapy.

His scientific contributions have been honoured with several awards, including the Ferdinand-Bertram Award (1993), the Werner-Creutzfeldt Award (2007) and the Paul Langerhans Medal (2012) of the German Diabetes Association.

Prof. Dr. med Nauck has served as reviewer for all major diabetes journals and has published more than 240 original articles and 130 reviews and book chapters. His publications have been quoted >55,000 times, his ‘H-index’ is 102, and he has been a ‘highly-cited researcher’ (among the top 1%) in 2019 (Web of Science).
Prof. Dr. med Nauck is a member of a number of professional societies, including the German, European and American Diabetes Associations and the International Diabetes Federation.

Prof. Dr. med Michael Nauck discloses: Advisory board or panel fees from AstraZeneca, Berlin-Chemie, Genentech, GlaxoSmithKline, Sun Pharma and Takeda (all relationships terminated). Advisory board or panel fees from Boehringer Ingelheim, Gasherbrum Bio, Eli Lilly, Merck Sharp & Dohme and Novo Nordisk. Consultant fees from Regor Pharmaceuticals. Other fees from Altimmune (Drug Monitoring and Safety Board).

Dr Shannon Idzik

University of Maryland School of Nursing, MD, USA

Shannon Idzik is a nurse practitioner and Associate Professor of Organizational Systems and Adult Health at the University of Maryland, Baltimore, USA. She received her degree in nursing from York College of Pennsylvania. Her master’s degree as an adult primary care nurse practitioner and her Doctorate in Nursing Practice (DNP) were earned from the University of Maryland. read more

Dr Idzik has worked clinically as a nurse practitioner in bariatric surgery, endocrinology, primary care, aesthetics, pre-operative health, and emergency medicine. She is the director of the DNP Program at the University of Maryland. She has been a member of the Nurse Practitioner Association of Maryland since 2003 and has served as Secretary and President. She is an active member of the membership committee.

Dr Idzik has authored over 140 publications and currently serves on the editorial board of the Journal of Doctoral Nursing Practice. She is a reviewer for the Journal of Advanced Nursing, the Journal of Professional Nursing and the Journal for Nurse Practitioners.

Dr Shannon Idzik has no interests/relationships or affiliations to disclose in relation to this activity.

Ms Tammie Snowden

Houston, TX, USA

Tammie Snowden lives in Houston, Texas and was diagnosed with type 2 diabetes approximately 5 years ago.

She works for the federal government and uses her spare time to discuss weight management, type 2 diabetes and treatments from a patient participant point of view on her social media channels (tammietype2inreview on Instagram, Facebook and YouTube). read more

Tammie’s goal is to reduce the stigma surrounding type 2 diabetes and lessen the taboos about weight management by respectfully addressing obesity and its link to type 2 diabetes.

Ms Tammie Snowden has no interests/relationships or affiliations to disclose in relation to this activity.

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This Activity Is Funded By:

An independent medical education grant from Lilly.
This activity is jointly provided by USF Health and touchIME.

The information provided by this CE activity is for continuing education purposes only and is not meant to substitute for the independent medical/clinical judgment of a healthcare provider relative to diagnostic and treatment options of a specific patient’s medical condition.

USF is an Equal Opportunity / Affirmative Action / Equal Access Institution.

USF Health is accredited by the Accreditation Council for Continuing Medical Education, the American Nurses Credentialing Center and the Accreditation Council for Pharmacy Education to provide continuing education to healthcare professionals. As an accredited provider, USF Health is required to disclose personal information to relevant accredited bodies that certify CE to process credits/contact hours, comply with reporting requirements, and for internal recordkeeping and regulatory purposes. USF Health does not share or sell any individual’s contact information or unique identifiers to any commercial supporter, advertiser, or third party without the specific permission of the individual.

Unapproved products or unapproved uses of approved products may be discussed by the faculty; these situations may reflect the approval status in one or more jurisdictions. The presenting faculty have been advised by touchIME and USF Health to ensure that they disclose any such references made to unlabelled or unapproved use. No endorsement by touchIME or USF Health of any unapproved products or unapproved uses is either made or implied by mention of these products or uses in touchIME or USF Health activities. touchIME and USF Health accept no responsibility for errors or omissions.

This content is intended for healthcare professionals.

Date of original release: 14 October 2021. Date credits expire: 14 October 2023.

This content is intended for healthcare professionals outside of the UK.

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Question 1/4
What have diabetes prevention studies demonstrated in terms of the minimum weight loss (over a 2–3-year period) that can significantly reduce an overweight person’s risk of developing type 2 diabetes?
 Correct

The benefit of modest weight loss achieved by lifestyle intervention over 2 years on diabetes prevention was demonstrated in a study that included 154 overweight individuals with a parental history of diabetes. Irrespective of whether weight change was achieved by diet or diet and exercise combined, modest weight loss of 4.5 kg reduced the risk of type 2 diabetes by ∼30% when compared with the no-treatment control group.1,2
Similarly, the Finnish Diabetes Prevention Study randomized 522 middle-aged, overweight individuals to either lifestyle intervention (weight-loss counselling, diet and physical activity) or control. After a mean duration of follow-up of 3.2 years, lifestyle intervention achieved a mean weight loss of 4.2 kg in the intervention group and 0.8 kg in the control group. The cumulative incidence of diabetes in the two groups after 4 years was 11% and 23%, respectively. Therefore, during the trial, the risk of diabetes was reduced by 58% (p<0.001) in the intervention group.1,3

References

  1. Van Gaal L. Eur Heart J Suppl. 2005;7:L21–6.
  2. Wing RR, et al. Diabetes Care. 1998;21:350–9.
  3. Tuomilehto J, et al. Finnish Diabetes Prevention Study Group. N Engl J Med. 2001;344:1343–50.
Question 2/4
Your patient is a 54-year-old man, recently diagnosed with type 2 diabetes, with a BMI of 32.5 kg/m2. He has been on metformin for 18 months and at his latest visit, his A1c is 8.3%. You decide to prescribe the GLP-1 RA s.c. semaglutide once weekly as an add-on to metformin, but your patient is not familiar with this agent and asks about the main clinical benefits of the treatment class. What would you advise?

A1c, glycated hemoglobin; BMI, body mass index; CKD, chronic kidney disease; GLP-1 RA, glucagon-like peptide-1 receptor agonist; s.c. subcutaneous.
 Correct

In the phase III SUSTAIN 4 trial (NCT02128932), 1,089 insulin-naive adults with type 2 diabetes who had insufficient glycemic control with metformin were randomized 1:1:1 to receive semaglutide s.c. 0.5 mg or 1.0 mg once-weekly, or insulin glargine once-daily (starting dose 10 IU/day) for 30 weeks. From a mean baseline A1c of 8.2%, semaglutide 0.5 and 1.0 mg achieved reductions of 1.2% and 1.6%, respectively, versus 0.8% with insulin glargine (both p<0.0001).1
From a mean baseline body weight of 93.5 kg, semaglutide 0.5 and 1.0 mg achieved weight losses of 3.5 kg and 5.2 kg, respectively, versus a weight gain of 1.2 kg with insulin glargine (both p<0.0001).1
The American Diabetes Association guidelines recommend treatment with a GLP-1 RA or an SGLT2i as second-line treatment if there is a compelling need to minimize weight gain or promote weight loss.2
Small amounts of weight loss (~5%) can improve glycemic control in patients with type 2 diabetes, and patients who lose weight are more likely to achieve goal A1c than those who show stable weight or weight gain.3–6

A1c, glycated hemoglobin; GLP-1 RA, glucagon-like peptide-1 receptor agonist; s.c. subcutaneous; SGLT2i, sodium–glucose co-transporter 2 inhibitor.

References

  1. Aroda VR, et al. Lancet Diabetes Endocrinol. 2017;5:355–66.
  2. American Diabetes Association. Diabetes Care. 2021;44(Suppl. 1):S111–24.
  3. Horton ES, et al. Diabetes Care. 2010;33:1759–65.
  4. Goldstein DJ. Int J Obes Relat Metab Disord. 1992;16:397–415.
  5. Williamson DF, et al. Diabetes Care. 2000;23:1499–504.
  6. Feldstein AC, et al. Diabetes Care. 2008;31:1960–5.
Question 3/4
Your patient is a 57-year-old woman with a BMI of 31.0 kg/m2 and coronary artery disease. She has been taking metformin and made lifestyle modifications to control her A1c, but at her latest visit, her A1c was still high at 8.8%. What would you consider next to intensify treatment?

A1c, glycated hemoglobin; BMI, body mass index; GLP-1 RA, glucagon-like peptide-1 receptor agonist; SGLT2i, sodium–glucose co-transporter 2 inhibitor; SU, sulfonylurea; TZD, thiazolidinedione.
 Correct

The American Diabetes Association guidelines recommend treatment with an SGLT2i or a GLP-1 RA as second-line treatment if there is a compelling need to minimize weight gain or promote weight loss.
There are now multiple large RCTs reporting statistically significant reductions in CV events in patients with type 2 diabetes treated with a GLP-1 RA (dulaglutide, liraglutide, semaglutide) or an SGLT2i (canagliflozin, dapagliflozin, empagliflozin). Because this patient has coronary artery disease and is ≥55 years old, there may be a risk of ASCVD. In such cases, a GLP-1 RA or an SGLT2i with proven CVD benefit is recommended, regardless of baseline A1c, glycemic target or metformin use.

A1c, glycated hemoglobin; ASCVD, atherosclerotic CVD; CV, cardiovascular; CVD, cardiovascular disease; GLP-1 RA, glucagon-like peptide-1 receptor agonist; RCT, randomized controlled trial; SGLT2i, sodium–glucose co-transporter 2 inhibitor.

Reference
American Diabetes Association. Diabetes Care. 2021;44(Suppl. 1):S111–24.

Question 4/4
Your patient is a 60-year-old woman with type 2 diabetes. She has a BMI of 30.5 kg/m2, and was recently diagnosed with stage 3a CKD. She has been taking metformin for 2 years, but at her latest visit, her A1c was 9.0%. When discussing treatment intensification, the patient mentions having heard about an agent called canagliflozin (an SGLT2i), and asks whether it is suitable for her. What do you advise?

A1c, glycated hemoglobin; BMI, body mass index; CKD, chronic kidney disease; SGLT2i, sodium–glucose co-transporter 2 inhibitor.
 Correct

In a meta-analysis of phase III clinical trials of the SGLT2i canagliflozin in adults with type 2 diabetes, the change in A1c (n=2,130) at 26 weeks was -0.63 (95% CI -0.77 to -0.49) with canagliflozin 100 mg versus placebo (p<0.001), while the change in body weight (n=1,950) was -2.23% (95% CI -2.56 to -1.91) with canagliflozin 100 mg versus placebo.1
In the CREDENCE trial (NCT02065791), patients with type 2 diabetes and albuminuric CKD were randomized to receive canagliflozin at a dose of 100 mg daily, or placebo. The primary outcome was a composite of end-stage kidney disease, doubling of serum creatinine level, or death from renal or CV causes. At a median follow-up of 2.6 years, at which time 4,401 patients had undergone randomization, the event rate of the primary composite outcome was significantly lower with canagliflozin than with placebo (HR 0.70; 95% CI 0.59 to 0.82; p=0.00001).2 There were no significant differences between groups in the event rates of nonfatal myocardial infarction (HR 0.81; 95% CI 0.59 to 1.10) or nonfatal stroke (HR 0.80; 95% CI 0.56 to 1.15).3
The American Diabetes Association guidelines recommend treatment with an SGLT2i with primary evidence of reducing CKD progression in patients with established CKD, as well as in patients with a compelling need to promote weight loss.4

A1c, glycated hemoglobin; CI, confidence interval; CKD, chronic kidney disease; CV, cardiovascular; HR, hazard ratio; SGLT2i, sodium–glucose co-transporter 2 inhibitor.

References

  1. Xiong W, et al. Medicine. 2016;95:48(e5473).
  2. Perkovic V, et al. N Engl J Med. 2019;380:2295–306.
  3. Invokana Prescribing Information, 2020. Available at: www.janssenlabels.com/package-insert/product-monograph/prescribing-information/INVOKANA-pi.pdf (accessed 17 September 2021).
  4. American Diabetes Association. Diabetes Care. 2021;44(Suppl. 1):S111–24.
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