By Andy Skean, Senior Editor, Physician’s Weekly
The American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE) recently published an update to their comprehensive type 2 diabetes management algorithm. “The update provides clinicians with a practical guide that considers the whole patient, their spectrum of cardiovascular risks and complications, and evidence-based approaches to treatment,” explains Alan J. Garber, MD, PhD, FACE, who was the AACE/ACE Task Force chair for the updated algorithm. “It’s designed to serve as a practical and easy-to-use decision-making tool for patients’ medical management.”
The AACE/ACE algorithm, which was published in Endocrine Practice, has been updated to reflect the role of newer therapies, management approaches, and important clinical data. It includes an updated section on lifestyle therapy and discusses all classes of obesity as well as anti-hyperglycemic, lipid-lowering, and antihypertensive medications that have most recently been approved by the FDA. The document also details specific lipid targets for patients with type 2 diabetes based on their unique characteristics (Table). The recommendations for blood pressure and lipid control are critical as these have been identified as the two most important risk factors for cardiovascular disease (CVD).
An Emphasis on Obesity
It is important to note that the updated algorithm emphasizes obesity as one of the underlying risk factors for type 2 diabetes and its microvascular complications. Placing a great emphasis on obesity and its role in the development and management of type 2 diabetes may guide physicians in providing tailored care to optimize patient outcomes. The update also includes important information on necessary weight loss therapies as well as details regarding the evaluation and treatment of cardiovascular risks.
The AACE/ACE Task Force notes that the updated algorithm reiterates the organizations’ recently published position that obesity is fundamentally a chronic, complications-centric disease that is progressive and requires patients to have a long-term commitment to weight loss and to maintain use of important lifestyle therapies. Specifically, weight loss therapy should consist of a lifestyle prescription that incorporates a reduced-calorie healthy meal plan in addition to prescriptions for physical activity and behavioral interventions. According to the AACE/ACE Task Force, clinicians should consider using FDA-approved weight loss medications for obesity if they are needed to achieve the degree of weight loss required to reach therapeutic goals.
Stratifying CVD Risk
According to Dr. Garber, the AACE/ACE algorithm also focuses on stratifying CVD risk factors and treatment recommendations based on each patient’s risk profile. “The document provides clinicians with a detailed assessment of all FDA-approved anti-diabetic medications and their impact on congestive heart failure and artherosclerotic CVD,” he says. “This update is thoroughly constructed to address specific problems in diabetes care in a concise, practical, and actionable manner in order to help healthcare providers develop effective patient care plans.”
Follow Guiding Principles
The AACE/ACE algorithm is organized into discrete sections that address various aspects that are critical to improving the management of type 2 diabetes. It is recommended that all clinicians follow the founding principles of the algorithm. This includes guidance on using lifestyle therapies and insulin as well as recommendations for treating obesity, prediabetes, hypertension, and dyslipidemia.
According to the AACE/ACE document, lifestyle therapy—which includes medically-supervised weight loss—is key to managing type 2 diabetes. Weight loss should be considered a lifelong goal, and behavioral interventions and weight loss medications should be used as required to achieve chronic therapeutic goals. Glycemic control targets include fasting and postprandial glucoses.
When choosing therapies, clinicians are recommended to use initial A1C levels as a guide. “Treatments must be individualized on the basis of patient characteristics, the impact of net cost to patients, formulary restrictions, and personal preferences,” Dr. Garber says. “The algorithm is also flexible with regard to applicability because guidance is offered based on each patient’s unique characteristics and needs.”
Clinicians are urged to titrate all diabetes medications appropriately and in a timely manner when managing this patient group in order to optimize outcomes. Doses of medications may vary depending on the drug being used. As such, physicians will likely need to adjust doses, regardless the medication class.
AACE/ACE also emphasizes that minimizing risks of hypoglycemia and weight gain should be top priorities. The document notes that initial acquisition cost of medications is only a part of the total care for patients. Clinicians should regularly monitoring requirements, risk of hypoglycemia, weight gain, and safety.
Recommendations are also provided for using combination therapy, which is usually required and should involve agents with complementary actions. To comprehensively manage patients, efforts should include lipid and blood pressure therapies and treatments for related comorbidities. Therapies should be evaluated frequently—about every 3 months—until patients are stable before seeing them less often. Importantly, doctors are urged to make therapeutic regimens as simple as possible to optimize adherence.
Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm – 2017 executive summary. Endocrine Pract. 2017 Jan 17 [Epub ahead of print]. Available at: https://www.aace.com/publications/algorithm and at: http://journals.aace.com/doi/abs/10.4158/EP161682.CS.
Handelsman Y, Bloomgarden ZT, Grunberger G, et al. American Association of Clinical Endocrinologists and American College of Endocrinology: clinical practice guidelines for developing a diabetes mellitus comprehensive care plan–2015. Endocr Pract. 2015;21:1-87.
Mechanick JI, Garber AJ, Handelsman Y, Garvey WT. American Association of Clinical Endocrinologists’ position statement on obesity and obesity medicine. Endocrine Pract. 2012;18:642-648.