New AACE Algorithm Addresses All Aspects of Type 2 Diabetes

Miriam E. Tucker

April 23, 2013

A new type 2 diabetes treatment algorithm from the American Association of Clinical Endocrinologists (AACE) is the first to incorporate obesity, prediabetes, and cardiovascular risk factor management.

The AACE Comprehensive Diabetes Management Algorithm 2013 is published in the March/April issue of Endocrine Practice. The full document comprises 7 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. Cardiovascular disease (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 word that describes it is truly comprehensive," AACE task force chair Alan J. Garber, MD, PhD, professor of medicine, biochemistry and molecular biology, and molecular and cellular biology at Baylor College of Medicine, Houston, Texas, told Medscape Medical News. The new publication is "a real attempt to try and upgrade care of the diabetic patient. [It] deals with all the threats that confront a diabetic patient… Another reason we call this a comprehensive diabetes management algorithm is that you have to manage the whole patient," he noted.

Obesity Management Can Be First-Line for Prediabetes

Dr. Alan J. Garber

The new evidence-based document replaces the AACE's 2009 diabetes treatment algorithm and its 2008 prediabetes treatment guidelines, both of which focused primarily on lowering glucose.

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, Dr. 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," Dr. Garber said.

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.

For patients with diabetes, the goals for glycemic control are a hemoglobin A1c of 6.5% or lower for healthy patients without concurrent illness and at low risk for hypoglycemia and individualized goals greater than 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, Dr. Garber said.

Previously, the AACE had simply recommended a goal of 6.5% or below 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 hemoglobin A1c. Lifestyle modification, including medically assisted weight loss, underlies all of the treatments.

For patients under 7.5% at entry, monotherapy can include 1 of 7 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 hemoglobin A1c levels of 7.5% or greater at entry and for use of insulin or dual/triple therapy among patients with A1c greater than 9.0% at entry.

If patients are not at goal in 3 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," Dr. 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 CVD risk factor modifications algorithm includes previous lipid and blood-pressure recommendations, but this is the first time this information has been incorporated into 1 document addressing diabetes management.

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."

Dr. 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 Therapeutics, Vivus, Janssen, and Eisai.

Endocr Pract. 2013;19:327-336. Guideline