CV risk factor management included in new type 2 diabetes treatment plan

Miriam E Tucker

April 26, 2013

Jacksonville, FL - A new type 2 diabetes treatment algorithm developed by the American Association of Clinical Endocrinologists (AACE) is the first to incorporate obesity, prediabetes, and cardiovascular risk factor management[1].

The new publication is "a real attempt to try to upgrade care of the diabetic patient," AACE task force chair Dr Alan J Garber (Baylor College of Medicine, Houston, Texas) said in an interview. "[It] deals with all the threats that confront a diabetic patient."

The full document comprises seven separate color-coded graphics addressing these aspects of diabetes and prediabetes management:

  1. Complications-centric model for care of the overweight/obese patient.

  2. Prediabetes algorithm.

  3. Goals of glycemic control.

  4. Glycemic-control algorithm.

  5. Algorithm for adding/intensifying insulin.

  6. CVD risk factor modifications algorithm.

  7. Profiles of antidiabetes medications.

An eighth page summarizes the guiding principles for the algorithms, including the importance of lifestyle modification, the individualization of treatment targets, and the minimization of both hypoglycemia and weight gain.

The AACE Comprehensive Diabetes Management Algorithm 2013 is published online April 22, 2013 and in the March/April 2013 issue of Endocrine Practice. It replaces the AACE's 2009 diabetes treatment algorithm and its 2008 prediabetes treatment guidelines, both of which focused primarily on lowering glucose.

The prediabetes algorithm addresses cardiovascular risk factor modification and offers the choice of antihyperglycemic or antiobesity therapy. "The data do not yet address which is superior," he noted.

The CVD risk factor modifications algorithm includes previous lipid and blood-pressure recommendations, but this is the first time this information has been incorporated into one document addressing diabetes management.

Obesity management was incorporated into the new algorithm because recent evidence shows that weight loss, through lifestyle, medication, and/or surgery also reduces blood glucose. In fact, obesity management can be considered first-line treatment for people with prediabetes, Garber said.

"We now have medications approved that produce 6% to 12% body weight loss. That's enough to reduce hyperglycemia and normalize the average prediabetic patient," Garber said.

For patients with diabetes, the goals for glycemic control are an HbA1c of <6.5% for healthy patients without concurrent illness and at low risk for hypoglycemia and individualized goals of >6.5% for patients with concurrent illness and those who are at risk for hypoglycemia. The latter might include patients taking insulin or sulfonylureas who are elderly, have arrhythmias, or cerebrovascular disease, Garber said.

Previously, the AACE had simply recommended a goal of <6.5% for most patients.

Color-coded algorithms guide drug therapy

As with the previous glycemic-control algorithm, the intensity of treatment is based on the initial HbA1c. Lifestyle modification, including medically assisted weight loss, underlies all of the treatments.

For patients <7.5% at entry, monotherapy can include one of seven of the currently available drugs. However, those that are considered safer and therefore more desirable—displayed in green—are (in order of preference) metformin, a glucagonlike peptide-1 (GLP-1) receptor agonist, a dipeptidyl peptidase-4 (DPP-4) inhibitor, or an alpha-glucosidase inhibitor. Medications to be used with caution, listed in yellow, include sodium-dependent glucose cotransporter 2 (SGLT2) inhibitors, thiazolidinediones, and sulfonylureas.

The algorithm continues with dual- and triple-therapy options for HbA1c levels of >7.5% at entry and for use of insulin or dual/triple therapy among patients with HbA1c >9.0% at entry.

If patients are not at goal in three months, the algorithm advises a step up in therapy.

A separate algorithm addresses insulin treatment specifically, another new feature. "No other algorithm has really gone through the insulin titrations and what to do when basal insulin fails," Garber noted.

Here, the new thinking is that it may be preferable to add an incretin (GLP-1 agonist or DPP-4 inhibitor) rather than prandial insulin, although both options are listed in the algorithm. "When you add the prandial insulin, you get a lot more hypoglycemia and a lot more weight gain," he explained.

The final color-coded page profiles each of the currently available antidiabetes drugs' safety with regard to hypoglycemia, weight gain, renal/genitourinary risks, gastrointestinal risks, congestive heart failure, CVD, and bone loss. Blue boxes mean "neutral," green is "few adverse events or possible benefits," yellow means "use with caution," and red "likelihood of adverse events."

Garber is a consultant to, on the advisory board of, and/or on the speaker's bureau for Novo Nordisk, Merck, Halozyme, Janssen, Takeda, Vivus, Santarus, Tethys Bioscience, Viking Therapeut ics, Vivus, Janssen, and Eisai.


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