You are on page 1of 10

ENDOCRINE PRACTICE Rapid Electronic Article in Press

Rapid Electronic Articles in Press are preprinted manuscripts that have been accepted for publication in an issue of
Endocrine Practice. This version of the manuscript will be replaced with the final, paginated version after it has been
published in Volume 21, Issue 4, April 2015 Endocrine Practice. DOI:10.4158/EP15693.CS
© 2015 AACE.

AACE/ACE COMPREHENSIVE
DIABETES MANAGEMENT
ALGORITHM
2015
TA S K F OR C E
Alan J. Garber, MD, PhD, FACE, Chair

Martin J. Abrahamson, MD George Grunberger, MD, FACP, FACE


Joshua I. Barzilay, MD, FACE Yehuda Handelsman, MD, FACP, FNLA, FACE
Lawrence Blonde, MD, FACP, FACE Irl B. Hirsch, MD
Zachary T. Bloomgarden, MD, MACE Paul S. Jellinger, MD, MACE
Michael A. Bush, MD Janet B. McGill, MD, FACE
Samuel Dagogo-Jack, MD, DM, FRCP, FACE Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU
Michael B. Davidson, DO, FACE Paul D. Rosenblit, MD, PhD, FNLA, FACE
Daniel Einhorn, MD, FACP, FACE Guillermo Umpierrez, MD, FACP, FACE
Jeffrey R. Garber, MD, FACP, FACE Michael H. Davidson, MD, Advisor
W. Timothy Garvey, MD, FACE

Copyright © 2015 AACE MAy not bE rEproduCEd in Any forM without ExprEss writtEn pErMission froM AACE.

This material is protected by US copyright law. For permission to reused material in any format, complete a permission form
at www.aace.com/permissions. To purchase reprints of this article, please visit: www.aace.com/reprints. DOI:10.4158/EP15693.CS
Copyright © 2015 AACE.

ENDOCRINE PRACTICE Vol 21 No. 4 April 2015 e1


e2 AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4)

TA BL E OF CONTENTS

Compre he n sive Diabe t e s


A lg orit h m
I. Complications-Centric
Model for Care of the
Overweight/Obese Patient

II. Prediabetes Algorithm

III. Goals of Glycemic Control

IV. Glycemic Control Algorithm

V. Algorithm for
Adding/Intensifying Insulin

VI. CVD Risk Factor


Modifications Algorithm

VII. Profiles of Antidiabetic


Medications

VIII. Principles for Treatment


of Type 2 Diabetes

Copyright © 2015 AACE MAy not bE rEproduCEd in Any forM without ExprEss writtEn pErMission froM AACE.
Complications-Centric Model for Care
of the Overweight/Obese Patient

AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4) e3


S TEP 1 E VA L U AT I O N F O R C O M P L I C AT I O N S A N D S TA G I N G

C A RDI O M E TA B OLIC D ISEASE B IOMECHANIC A L COM P L IC AT IONS

NO COM PLIC AT IONS B M I ≥ 2 7 WI TH COM P LI C ATIONS

BMI 25–26.9, Stage Severity of Complications


or BMI ≥ 27
LOW MEDIUM HIGH

S TEP 2 SELEC T:
Therapeutic targets for
improvement in complications + Treatment
modality + Treatment intensity for weight
loss based on staging

Lifestyle Modification: MD/RD counseling; web/remote program; structured multidisciplinary program

phentermine; orlistat; lorcaserin; phentermine/topiramate ER;


Medical Therapy:
naltrexone/bupropion; liraglutide

Surgical Therapy (BMI ≥ 35): Lap band; gastric sleeve; gastric bypass

If therapeutic targets for improvements in complications not met, intensify lifestyle and/or medical
S TEP 3 and/or surgical treatment modalities for greater weight loss

Copyright © 2015 AACE MAy not bE rEproduCEd in Any forM without ExprEss writtEn pErMission froM AACE.
e4 AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4)
PR EDIABETES ALGOR ITHM
I F G ( 1 0 0 – 125) | IG T ( 140–199) | ME TABOLIC SYN D R OM E (NCE P 2005)

L I F E S T Y L E M O D I F I C AT I O N
(Including Medically Assisted Weight Loss)

OTHE R C V D WE IG HT LOSS ANTIHYPE R GLYCE M IC T H E R A P IE S


RIS K FAC TO RS THER APIES FPG > 100 | 2-hour PG > 140

C VD RISK FAC TOR N ORMA L 1 PRE-DM MU LTIPL E PR E-DM


MODIFIC AT IONS ALGORIT HM G LYC E M I A C RI TE RI ON CR ITER IA

DYS L IPIDE M IA HYPE R T E NSION Low-risk Consider with


ROUTE ROUTE Medications Caution
Progression Intensify
Weight Metformin TZD
Loss
Therapies Acarbose GLP-1 RA
OV E R T
D I A B E TE S

PR OCE E D TO
HYPE R G LYCE MI A If glycemia not normalized,
ALG OR I T HM consider with caution

Copyright © 2015 AACE MAy not bE rEproduCEd in Any forM without ExprEss writtEn pErMission froM AACE.
G OA LS FOR G LYCE MIC CONT R OL

INDIVIDUA LIZ E G OA LS

AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4) e5


A1c ≤ 6.5% A1c > 6.5%
For patients without For patients with
concurrent serious concurrent serious
illness and at low illness and at risk
hypoglycemic risk for hypoglycemia

Copyright © 2015 AACE MAy not bE rEproduCEd in Any forM without ExprEss writtEn pErMission froM AACE.
e6 AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4)
G lyc e m ic Con t r ol A lg or ithm

L I F E S T Y L E M O D I F I C AT I O N
(Including Medically Assisted Weight Loss)

Entry A1c < 7.5% Entry A1c ≥ 7.5% Entry A1c > 9.0%

MON O T H E R A PY * S YM PTO M S
D UAL TH ER APY*
Metformin NO YE S
GLP-1 RA T R I PL E TH ER APY*
GLP-1 RA
SGLT-2i GLP-1 RA DUAL INSULIN
SGLT-2i
DPP-4i
Therapy ±
DPP-4i SGLT-2i
Other
AGi
MET TZD MET TZD
OR Agents
or other or other
1st-line Basal Insulin 1st-line TRIPLE
TZD Basal insulin
Therapy

+
agent agent +
Colesevelam DPP-4i
SU/GLN 2nd-line

+
agent
Bromocriptine QR Colesevelam
AGi Bromocriptine QR
SU/GLN AGi A DD O R I NTENS I F Y
If not at goal in 3 months
SU/GLN
I NS UL I N
If not at goal
proceed to Double Therapy Refer to Insulin Algorithm
in 3 months
proceed to If not at goal in
Triple Therapy 3 months proceed Few adverse events
to or intensify LEGEND or possible benefits
insulin therapy Use with caution
* Order of medications listed represents a suggested hierarchy of usage

P R O G R E S S I O N O F D I S E A S E
Copyright © 2015 AACE MAy not bE rEproduCEd in Any forM without ExprEss writtEn pErMission froM AACE.
A LG ORITH M FOR ADDING/INTENSIF YING INSULIN

S T A R T B A S A L (long-acting insulin) I N T E N S I F Y (prandial control)

AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4) e7


A1c < 8% A1c > 8% Add GLP-1 RA Add Prandial Insulin
or SGLT-2i
or DPP-4i
TDD 0.1–0.2 U/kg TDD 0.2–0.3 U/kg TDD 0.3–0.5 U/kg
• 50% Basal Analog
Glycemic • 50% Prandial Analog
Insulin titration every 2–3 days
to reach glycemic goal: Control Not • Less desirable: NPH
at Goal** and regular insulin
• Fixed regimen: Increase TDD by 2 U or premixed insulin
• Adjustable regimen:
• FBG > 180 mg/dL: add 20% of TDD
• FBG 140–180 mg/dL: add 10% of TDD
• FBG 110–139 mg/dL: add 1 Unit
• If hypoglycemia, reduce TDD by:
• BG < 70 mg/dL: 10% – 20%
• BG < 40 mg/dL: 20% – 40%

Consider discontinuing or reducing sulfonylurea after Insulin titration every 2–3 days to reach glycemic goal:
basal insulin started (basal analogs preferred to NPH)
• Increase prandial dose by 10% for any meal if the 2-hr
postprandial or next premeal glucose is > 180 mg/dL
**Glycemic Goal: • Premixed: Increase TDD by 10% if fasting/premeal BG > 180 mg/dL
• If fasting AM hypoglycemia, reduce basal insulin
• <7% for most patients with T2DM; fasting and premeal • If nighttime hypoglycemia, reduce basal and/or pre-supper or
BG < 110 mg/dL; absence of hypoglycemia pre-evening snack short/rapid-acting insulin
• A1c and FBG targets may be adjusted based on patient’s • If between-meal daytime hypoglycemia, reduce previous
age, duration of diabetes, presence of comorbidities, premeal short/rapid-acting insulin
diabetic complications, and hypoglycemia risk

Copyright © 2015 AACE MAy not bE rEproduCEd in Any forM without ExprEss writtEn pErMission froM AACE.
e8 AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4)
CVD RISK FACTOR MODIFICATIONS ALGORITHM

dysLipidEMiA hypErtEnsion

thErApEutiC LifEstyLE ChAngEs (See Obesity Algorithm)

Lipid pA n E L: Assess CVd risk g oAL : systoL iC ~130,


diAstoL iC ~80 mm h g

If TG > 500 mg/dL, fibrates, omega-3 ACEi For initial blood pressure
stAt in t hE r Apy ethyl esters, niacin or >150/100 mm Hg:
If statin-intolerant ARB D UAL THER APY

Try alternate statin, lower statin Repeat lipid panel; Intensify therapies to Thiazide
dose or frequency, or add nonstatin assess adequacy, attain goals according ACEi Calcium
LDL-C- lowering therapies tolerance of therapy to risk levels
or Channel
Blocker
DM but no other major risk DM + major CVD risk(s) (HTN, Fam Hx,
ARB
risK LE VELs ModErAtE and/or age <40 high low HDL-C, smoking) or CVD* ß-blocker
dEsirAbLE LEVELs dEsirAbLE LEVELs
LDL-C (mg/dL) <100 <70
If not at goal (2–3 months)
Non-HDL-C (mg/dL) <130 <100
TG (mg/dL) <150 <150 Add ß-blocker or calcium channel
TC/HDL-C <3.5 <3.0 blocker or thiazide diuretic
Apo B (mg/dL) <90 <80
LDL-P (nmol/L) <1200 <1000 If not at goal (2–3 months)

Add next agent from the above


Intensify TLC (weight loss, physical activity, dietary changes)
if not At dEsirAbLE LEVELs: group, repeat
and glycemic control; Consider additional therapy
If not at goal (2–3 months)

to LowEr LdL-C: Intensify statin, add ezetimibe &/or colesevelam &/or niacin Additional choices (α-blockers,
to LowEr non-hdL-C, tg: Intensify statin &/or add OM3EE &/or fibrates &/or niacin central agents, vasodilators,
to LowEr Apo b, LdL-p: Intensify statin &/or ezetimibe &/or colesevelam &/or niacin spironolactone)

Assess adequacy & tolerance of therapy with focused laboratory evaluations and patient follow-up Achievement of target blood
pressure is critical
* E V E N M O RE I NT ENSI V E T HER APY MI GHT BE WAR R ANT ED

Copyright © 2015 AACE MAy not bE rEproduCEd in Any forM without ExprEss writtEn pErMission froM AACE.
Pr of i l es of AntidiA betic MedicAt ion s

MET GLP-1 RA sGLT-2i DPP-4i AGi TZD sU COLsVL BCR-QR INsULIN PRAML
GLN

AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4) e9


Moderate/
severe Moderate
HYPO Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral
Mild to severe

slight
WEIGHT Loss Loss Neutral Neutral Gain Gain Neutral Neutral Gain Loss
Loss

Dose
Contra-
Exenatide Adjustment May More
indicated Genital More
RENAL/ Contra- May be Worsen Hypo Risk
CKD Mycotic Neutral Hypo Neutral Neutral Neutral
GU stage
indicated
Infections
Necessary Fluid
Risk
& Fluid
CrCl < 30 (Except Retention Retention
3B,4,5
Linagliptin))

GI sx Moderate Moderate Neutral Neutral Moderate Neutral Neutral Mild Moderate Neutral Moderate

CHF Neutral Neutral Moderate Neutral Neutral


Neutral Neutral Neutral Neutral Neutral Neutral
Increased
CVD Benefit Neutral ? safe
LDL

Moderate
BONE Neutral Neutral Neutral Neutral Neutral Bone Neutral Neutral Neutral Neutral Neutral
Loss

Few adverse events or possible benefits Use with caution Likelihood of adverse effects

Copyright © 2015 AACE MAy not bE rEproduCEd in Any forM without ExprEss writtEn pErMission froM AACE.
e10 AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4)
Princ iPles of the AAce AlgorithM
f or the tr eAtMent of t yPe 2 diAbetes

1) Lifestyle optimization and education are essential cations that affect their choice include: risk of the clinician as well as to guide therapy at the
for all patients with diabetes. Lifestyle modifica- inducing hypoglycemia, risk of weight gain, point of care.
tion designed for weight loss, including medical ease of use, cost, and safety impact of kidney, 13) The algorithm should conform, as nearly as pos-
and surgical interventions approved for the treat- heart, or liver disease. This algorithm includes sible, to a consensus for current standard of
ment of obesity, should be considered as primary every FDA-approved class of medications for practice of care by expert endocrinologists who
approaches for therapeutic benefits in over- diabetes. This algorithm also stratifies choice specialize in the management of patients with
weight and obese patients with diabetes, and for of therapies based on initial A1c. type 2 diabetes and have the broadest experi-
prevention of diabetes in high risk patients with 7) The algorithm provides guidance to what thera- ence in outpatient clinical practice.
prediabetes. The treatment of overweight/obe- pies to initiate and add, but respects individual 14) The algorithm should be as specific as possible,
sity in patients with type 2 diabetes and predia- circumstances that would make different choices. and provide guidance to the physician with
betes should proceed according to the Obesity 8) Therapies with complementary mechanisms of prioritization and a rationale for selection of
Treatment Algorithm. Effective interventions for action must typically be used in combinations any particular regimen.
weight loss involve a multidisciplinary team. The for optimum glycemic control. 15) Rapid-acting insulin analogs are superior to Reg-
need for medical therapy for weight loss or glyce- 9) Effectiveness of therapy must be evaluated fre- ular because they are more predictable.
mic control should not be considered as a failure quently until stable (e.g. every 3 months) using 16) Long-acting insulin analogs are superior to NPH
of lifestyle management, but as an adjunct to it. multiple criteria including A1c, sMBG records insulin because they provide a fairly flat re-
2) The A1c target must be individualized, based on including both fasting and post-prandial data, sponse for approximately 24 hours and provide
numerous factors, such as age, comorbid condi- documented and suspected hypoglycemia, and better reproducibility and consistency both be-
tions, duration of diabetes, risk of hypoglycemia, monitoring for other potential adverse events tween subjects and within subjects, with a corre-
patient motivation, adherence, life expectancy, (weight gain, fluid retention, hepatic, renal, or sponding reduction in the risk of hypoglycemia.
etc. An A1c of 6.5% or less is still considered opti- cardiac disease), and monitoring of comorbidi-
mal if it can be achieved in a safe and affordable ties, relevant laboratory data, concomitant drug
manner, but higher targets may be appropriate administration, diabetic complications, and psy- This document represents the official position of the
American Association of Clinical Endocrinologists and
and may change in a given individual over time. cho-social factors affecting patient care.
the American College of Endocrinology. Where there
3) Minimizing risk of hypoglycemia is a priority. It is 10) safety and efficacy should be given higher prior-
were no RCTs or specific FDA labeling for issues in clin-
a matter of safety, adherence, and cost. ities than initial acquisition cost of medications ical practice, the participating clinical experts utilized
4) Minimizing risk of weight gain is a priority. It too per se since cost of medications is only a small their judgment and experience. Every effort was made
is a matter of safety, adherence, and cost. part of the total cost of care of diabetes. In deter- to achieve consensus among the committee mem-
5) Glycemic control targets include fasting and mining the cost of a medication, consideration bers. Many details that could not be included in the
postprandial glucose as determined by self should be given to monitoring requirements, graphic summary (Figure) are described in the text.
blood glucose monitoring. risk of hypoglycemia and weight gain, etc.
6) The choice of therapies must be individualized 11) The algorithm should be as simple as possible to
based on attributes of the patient (as above) gain physician acceptance and improve its utility All necessary author disclosures are made to AACE and are on
and the medications themselves (see Profiles of and usability in clinical practice. file at the main office. Please contact Lori Clawges at AACE for
Antidiabetic Medications). Attributes of medi- 12) The algorithm should serve to help educate further inquiries.

Copyright © 2015 AACE MAy not bE rEproduCEd in Any forM without ExprEss writtEn pErMission froM AACE.

You might also like