The American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) published an annual update to their joint algorithm for the management of type 2 diabetes (T2D). This guide incorporates evidence-based approaches to aid in choosing treatment courses for patients, based on underlying risk factors and personal preferences. With a focus on obesity, prediabetes, and macrovascular complications in T2D, the 2019 algorithm has been updated to include all diabetes medications approved by the United States Food and Drug Administration (FDA) since December 2018.
Guiding principles of the AACE/ACE T2D management algorithm include the following:
- Lifestyle modification should underlie all therapy
- Avoidance of hypoglycemia in patients
- Avoidance of weight gain in patients
- All glycemic targets should be individualized
- Optimal level of glycated hemoglobin (HbA1c) is ≤6.5%
- Treatment decisions should account for initial HbA1c, diabetes duration, and obesity status
- Treatment choices should reflect risk for cardiac, cerebrovascular, and renal events
- Comprehensive care includes management of comorbidities
- Achieve treatment goals as soon as possible; adjust treatment plans at intervals of ≤3 months until goal is reached
- Consider ease of use and affordability in treatment choices
- HbA1c should be ≤6.5% for patients on insulin regimens using continuous glucose monitoring
Lifestyle Therapy
Lifestyle therapy, including interventions for nutrition, physical activity, sleep, behavior, and tobacco use, should be intensified based on the severity of obesity and other complications. In patients with T2D who have less severe comorbidities, the AACE recommended plant-based diets, ≥150 minutes/week of moderate exercise, basic sleep hygiene, and moderate alcohol consumption. In patients with severe obesity and several complications, structured nutritional counseling, a specific weight-loss curriculum, and medically supervised interventions are recommended.
Obesity
Regardless of body mass index, clinicians should evaluate patients for obesity-related complications relating to either insulin resistance/cardiometabolic disease or negative biomechanical effects of excess adiposity. Considering that patients with the greatest number of obesity-related complications will benefit most from medical or surgical intervention, the AACE has adopted a complications-centric model, as opposed to a body mass index-centric approach. After assessing the extent of these complications in patients with T2D, treatment should be personalized and intensified, from lifestyle adjustments, to medical intervention, to surgical treatment, as necessary.
Prediabetes
Weight loss is the main focus in patients with prediabetes. Lifestyle therapy alone or in combination with pharmacotherapy should be considered to meet weight loss goals. For patients who meet criteria, bariatric surgery has been shown to be very effective in preventing progression of prediabetes to T2D.
Although excess weight is the main trigger of insulin resistance, functional decline of pancreatic beta-cells may be attributable to other underlying causes, and pharmacologic intervention may be required in prediabetes. No medication has been approved by the FDA strictly for the prevention of T2D; however, metformin and acarbose have been shown to reduce the risk of developing diabetes by 25% to 30%. In addition, thiazolidinediones were shown to prevent diabetes development in 60% to 75% of patients with prediabetes in clinical trials, but should only be considered in patients who do not have success with metformin, given the greater known adverse effects.
Blood Pressure and Lipid Control
The AACE recommends a target of <130/80 mm Hg for blood pressure (BP) in most patients. Lower targets are appropriate for patients at a high risk for stroke (ie, <120/80 mm Hg), and slightly less aggressive targets may be appropriate for patients who are frail with several comorbidities. Patients with both hypertension and T2D will likely require medication to achieve an appropriate BP target, but weight loss, sodium restriction, and physical activity can also lower BP and should be recommended. If BP goals are not met within a period of 2 to 3 months, clinicians should consider adding a calcium channel blocker, β-blocker, or thiazide diuretic to treatment with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers.
In addition to BP control, early and intensive management of dyslipidemia is key to preventing macrovascular complications in T2D. The AACE recommends the following lipid targets for patients with T2D, stratified by risk for atherosclerotic cardiovascular disease (ASCVD)
High risk, defined as T2D with no additional risk factors
- Low-density lipoprotein cholesterol (LDL-C) <100 mg/dL
- Non-high-density lipoprotein cholesterol (non-HDL-C) <130 mg/dL
- Apolipoprotein B <90 mg/dL
Very high risk, defined as T2D with ≥1 additional risk factor
- LDL-C <70 mg/dL
- Non-HDL-C <100 mg/dL
- Apolipoprotein B <80 mg/dL
Extreme risk, defined as T2D plus prior ASCVD or chronic kidney disease (stage 3 or 4)
- LDL-C <55 mg/dL
- Non-HDL-C <80 mg/dL
- Apolipoprotein B <70 mg/dL
If patients do not meet these targets, the AACE recommends intensifying lifestyle therapy and glycemic control. Therapeutic success should be measured through focused laboratory evaluations and patient follow-up.
Pharmacology
To reach an HbA1c target ≤6.5% with monotherapy, the hierarchy for medication usage as recommended by the AACE is as follows: metformin, glucagon-like peptide-1 (GLP-1) receptor agonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors, dipeptidyl peptidase 4 (DPP-4) inhibitors, thiazolidinediones, and alpha-glucosidase inhibitors. Monotherapy should be initiated in patients with a baseline HbA1c of <7.5% and increased to dual therapy if targets have not been achieved within 3 months. With more severe cases and comorbidities, intensified therapy is indicated.
As part of the 2019 update, the AACE/ACE algorithm includes a summary of antidiabetic medications to outline risk and benefits for each drug class. Below is an overview of this summary highlighting the benefits and possible contraindications or adverse effects in several diabetes drug classes.
| Agent | Possible benefits | Adverse effects |
| Metformin | Slight weight loss | · Contraindicated in patients with estimated glomerular filtration rates <30 mL/minute/1.73 m2 · Use with caution in patients with gastrointestinal symptoms |
| GLP-1 receptor agonists | · Weight loss · Liraglutide may have benefits in patients with renal complications · Liraglutide is approved by the FDA for the prevention of major adverse cardiac events | · Exenatide not indicated in patients with creatinine clearance <30 mL/minute · Use with caution in patients with gastrointestinal symptoms |
| SGLT2 inhibitors | · Weight loss · Empagliflozin may have benefits in patients with renal complications · Empagliflozin is approved by the FDA to reduce cardiovascular mortality · Canagliflozin has been shown to reduce major adverse cardiac events | · Not indicated for patients with estimated glomerular filtration rates <45 mL/minute/1.73 m2 · May cause genital mycotic infections · Mild risk for fracture · Risk for diabetic ketoacidosis in various stress settings |
| DPP-4 inhibitors | Alogliptin and saxagliptin may carry increased risk for hospitalizations for heart failure | |
| Alpha-glucosidase inhibitors | Use with caution in patients with gastrointestinal symptoms | |
| Thiazolidinediones | May reduce risk for stroke | · Slight weight gain · Moderate risk for coronary heart failure · Moderate risk for fracture |
| Sulfonylureas | · Moderate to severe risk for hypoglycemia · Weight gain · Heightened risk for hypoglycemia in patients with renal complications · May carry risk for ASCVD | |
| Insulin | · Moderate to severe risk for hypoglycemia · Weight gain · Heightened risk for hypoglycemia in patients with renal complications · Risk for coronary heart failure |
To download the entire visual algorithm, click here.
Some authors declared associations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.
Reference
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 – 2019 Executive Summary. Endocr Pract. 2019;25(1):69-100.
This article originally appeared here.
