New AACE Type 2 Diabetes Algorithm Individualizes Care

Miriam E. Tucker

May 05, 2023

SEATTLE — The latest American Association of Clinical Endocrinology (AACE) type 2 diabetes management algorithm uses graphics to focus on individualized care while adding newly compiled information about medication access and affordability, vaccinations, and weight loss drugs.

The clinical guidance document was presented May 5 at the AACE Annual Meeting 2023 and simultaneously published in Endocrine Practice.

Using text and colorful graphics, the document summarizes information from last year's update and other recent AACE documents, including those addressing dyslipidemia and use of diabetes technology.

"The algorithm takes from the larger clinical practice guideline and distills down those management principles in a much more digestible way, and a way that can be used every day in the clinic," lead author Susan L. Samson, MD, PhD, chair of endocrinology, diabetes & metabolism at the Mayo Clinic Florida, Jacksonville, told Medscape Medical News.

Asked to comment, Anne L. Peters, MD, professor of clinical medicine at Keck School of Medicine of the University of Southern California, Los Angeles, told Medscape Medical News: "I like their simple graphics. For the Department of Health Services in Los Angeles County, we have been painstakingly trying to create our own flow diagrams...These will help."

Eleven Separate Algorithms With Text and Graphics

Included are 11 visual management algorithms, with accompanying text for each one. The first lists 10 overall management principles, including "lifestyle modification underlies all therapy," "maintain or achieve optimal weight," "choice of therapy includes ease of use and access," "individualize all glucose targets," "avoid hypoglycemia," and "comorbidities must be managed for comprehensive care."

Three more algorithms cover the diabetes-adjacent topics of adiposity-based chronic disease, prediabetes, dyslipidemia, and hypertension.

Four separate graphics address glucose-lowering. Two are "complications-centric" and "glucose-centric" algorithms, another covers insulin initiation and titration, and a table summarizes the benefits and risks of currently available glucose-lowering medications, as well as cost.

Splitting the glucose-lowering algorithms into "complications-centric" and "glucose-centric" into two graphics is new, Samson said. "The complications one comes first, deliberately. You need to think about: Does my patient have a history of or high risk for cardiovascular disease, heart failure, stroke, or diabetic kidney disease? And, you want to prioritize those medications that have evidence to improve outcomes with those different diabetes complications versus a one-size-fits-all approach."

And for patients without those complications, the glucose-centric algorithm considers obesity, hypoglycemia risk, and access/cost issues. "So, overall the diabetes medication algorithm has been split in order to emphasize that personalized approach to decision-making," Samson explained.

Also new is a table listing the benefits and risks of weight-loss medications, and another covering immunization guidance for people with diabetes based on recommendations from the US Centers for Disease Control and Prevention. "Coming out of the pandemic, we're thinking about how can we protect our patients from infectious disease and all the comorbidities. In some cases, people with diabetes can have a much higher risk for adverse events," Samson noted. 

Regarding the weight-loss medications table, she pointed out that the task force couldn't include the blockbuster twincretin tirzepatide because it's not yet approved for weight loss by the US Food and Drug Administration. However, it is included in the glucose-lowering drug table with weight loss listed among its benefits.

"We want this to be a living document that should be updated in a timely fashion, and so, as these new indications are approved and we see more evidence supporting their different uses, this should be updated in a really timely fashion to reflect that," Samson said.

The end of the document includes a full page of each graphic, meant for wall posting.

Peters noted that for the most part, the AACE guidelines and algorithm align with joint guidance by the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD).  

"For many years there seemed to be big differences between the AACE and ADA guidelines for the management of type 2 diabetes. Although small differences still exist...the ADA and AACE guidelines have become quite similar," she said.

Peters also praised the AACE algorithm for providing "a pathway for people who have issues with access and cost."

"I am incredibly proud that in the County of Los Angeles you can get a [glucagon-like peptide-1 receptor agonist] and/or a [sodium-glucose cotransporter-2 inhibitor] even with the most restricted MediCal insurance if indications are met. But there remain many people in many places where access and cost limit options, and I am grateful that AACE includes this in their algorithms," she said.

Samson has reported receiving research support to the Mayo Clinic from Corcept, serving on a steering committee and being a national or overall principal investigator for Chiasma and Novartis, and being a committee chair for the American Board of Internal Medicine (ABIM). Peters has reported relationships with Blue Circle Health, Vertex, and Abbott Diabetes Care, receiving research grants from Abbott Diabetes Care and Insulet, and holding stock options in Teladoc and Omada Health.

Endo Pract. 2023;29:P305-340. Full text

AACE Annual Meeting 2023. Presented May 6, 2023.

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.

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