AACE/ACE Issues New, Practical Type 2 Diabetes Guidelines

Marlene Busko

April 10, 2015

(Updated with commentary April 15, 2015) The American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) have issued new, more comprehensive guidelines outlining optimal care for patients with type 2 diabetes. The guidelines include an algorithm, in an easy-to-use format, to help guide clinicians. The updated information also briefly addresses the use of insulin in type 1 diabetes.

"Both the guidelines and algorithm, while detailed, have been constructed in...a way, such as a question-and-answer format within the guidelines, to address specific problems in diabetes care in a concise, practical, and actionable manner that will assist in developing patient care plans," cochair of the guideline writing committee, Dr Yehuda Handelsman, American College of Endocrinology president and medical director at the Metabolic Institute of America, in Tarzana, California, summarized, in a statement issued by the AACE.

The updates to the 2011 guidelines and 2013 algorithm include significant changes related to choosing antihyperglycemic agents and managing hypertension, nephropathy, and hypoglycemia in patients with type 2 diabetes. The new guidelines also cover vaccinations, cancer risk, obesity, sleep disorders, and depression and how to manage patients with occupations where hypoglycemia is particularly dangerous.

Holistic Approach to Diabetes Management

The 24 questions in the guidelines cover the spectrum of management of type 2 diabetes — ranging from "how is diabetes screened and diagnosed?" to "which occupations have diabetes management requirements?" In between, questions cover the management of hypoglycemia, hypertension, dyslipidemia, nephropathy, retinopathy, CVD, obesity, diabetes in pregnancy, and other topics. One question asks about type 1 diabetes (focusing on insulin use).

In the replies to the questions, the guidelines provide 67 clinical-practice recommendations. An appendix that is organized using the same questions provides the supporting evidence.

The new algorithms address eight clinical scenarios, including:

  • A complications-centric model for the care of overweight/obese patient.

  • Prediabetes.

  • Goals of glycemic control.

  • Glycemic control.

  • Adding/intensifying insulin.

  • CVD risk-factor modifications.

  • Profiles of antidiabetic medications.

  • Principles for treatment of type 2 diabetes.

The glycemic-control algorithm covers all FDA-approved classes of diabetes therapies, stratified according to patients' initial HbA1c levels.

The guidelines recommend taking a more holistic approach to managing patients with diabetes. "When a routine consultation is made for type 2 diabetes management, these new guidelines advocate taking a comprehensive approach and suggest that the clinician should move beyond a simple focus on glycemic control," the authors write. They note that factors beyond HbA1c levels and fasting plasma glucose can affect a patient's quality of life and risk of microvascular complications, CVD, and earlier death.

The 2015 guidelines also stress the importance of "individualized targets for weight loss [and] glucose, lipid, and hypertension management" and "a special focus on safety beyond efficacy," according to the authors.

AACE/ACE Guidelines vs ADA Update

Asked to comment, Dr Anne Peters, director of the University of Southern California clinical diabetes program in Beverly Hills, California, said that although she has not yet closely reviewed these new guidelines, she disagrees that the initial HbA1c target should be 6.5%, especially with drugs that cause hypoglycemia.

Moreover, since the algorithm lacks an "if, then" structure, it can be confusing. For example, she says it is not clear where to "enter" a patient with an HbA1c of 8% on three agents, and that individual "has far different needs than someone with new-onset diabetes and an HbA1c of 8%," she says.

"However, to be fair, I would say that the style and approach [of the AACE/ACE Guidelines vs the 2015 update to a position statement of the American Diabetes Association and the European Association for the Study of Diabetes] differ, but the goal is to get people to as close to euglycemia as possible, minimizing risks and maximizing benefit," Dr Peters noted.

"Whether you start with one or two or three drugs doesn't matter nearly as much as whether there is consistent follow-up provided,"

Dr Handelsman told Medscape Medical News that the revised guidelines have a much broader scope than previous ones (with 67 vs 43 recommendations), and the algorithm reflects, for example, changes in the use of sodium-glucose cotransporter 2 (SGLT2) inhibitors and thiazolidinediones (TZDs). Importantly, the guidelines provide answers to questions such as "How do you prevent CVD?" and "What is the goal of blood-pressure control?"

These AACE/ACE Guidelines put more focus on the whole management of the patient, he said. And although there are different nuances (such as recommendations for statin and metformin use and for blood-pressure goals and HbA1c targets) between the AACE/ACE guidelines and the 2015 ADA update, "the core messages are very similar," he said.

Both guidelines stress the need to safely lower glucose levels and to set treatment goals based on the characteristics (such as age and comorbidities) of the individual patient.

The AACE/ACE Clinical Practice Guidelines For Developing A Diabetes Mellitus Comprehensive Care Plan – 2015 and the AACE/ACE Comprehensive Diabetes Management Algorithm are published in the April issue of Endocrine Practice.

All primary writers made disclosures regarding relevant financial relationships, listed in the papers, and attested that they are not employed by industry.

Endocr Pract. 2015. Guidelines, Algorithm


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