AACE/ACE COMPREHENSIVE DIABETES ENDOCRINOLOGY MANAGEMENT ALGORITHM HORI Martin J, Abrahamson, MD Joshua |. Barzilay, MD, FACE Lawrence Blonde, MD, FACR, FACE ZacharyT. Bloomgarden, MD, MACE Michael A. Bush, MD Samuel Dagogo-ack, MD, DM, FRCP, FACE Michael B. Davidson, DO, FACE TASK FORCE Alan J. Garber, MD, PhD, FACE, Chair Daniel Einhorn, MD, FACP, FACE Jeffrey R, Garber, MD, FACP, FACE W.Timothy Garvey, MD, FAC George Grunberger, MD, FACP, FACE Yehuda Handelsman, MD, FACP, FNLA, FACE In. Hirsch, MD Paul S.Jellinger, MD, MACE Janet 8. McGil, MD, FACE Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU Paul D. Rosenbllt, MD, PhD, FNLA, FACE Guillermo Umpierrez, MD, FACP, FACE Michael H. Davidson, MD, AdvisorTABLE OF CONTENTS COMPREHENSIVE DIABETES ALGORITHM COMPLICATIONS-CENTRIC MODEL FOR CARE OF THE OVERWEIGHT/OBESE PATIENT PREDIABETES ALGORITHM GOALS FOR GLYCEMIC CONTROL a GLYCEMIC CONTROL ALGORITHM ALGORITHM FOR ADDING/INTENSIFYING INSULIN aval atl arene CVD RISK FACTOR MODIFICATIONS ALGORITHM PROFILES OF ANTIDIABETIC MEDICATIONS PRINCIPLES FOR TREATMENT OF TYPE 2 DIABETESCOMPLICATIONS-CENTRIC MODEL FOR CARE OF THE OVERWEIGHT/OBESE PATIENT EVALUATION FOR COMPLICATIONS AND STAGING anaes Pere Mee MTT Pree nreeney Peake peers ere eneny eee ‘Therapeutic targets for Treatment Treatment intensity for weight sement in complications modality loss based on staging Lifestyle Modification: | MD/RD counseling; web/remote program; structured multidisciplinary program a a bs phentermine; orlistat; lorcaserin; phentermine/topiramate ER; naltrexone/bupropion; liraglutide Te Ce ee ed Medical Therapy: Surgical Therapy (BMI > 35): eutic targets for improvements in complications not met, intensify lifestyle and/or medical and/or surgical treatment modalities for greater weight loss© PREDIABETES ALGORITHM IFG (100-125) | IGT (140-199) | METABOLIC SYNDROME (NCEP 2005) OTHER CVD WEIGHT Loss ANTIHYPERGLYCEMIC THERAPIES RISK FACTORS THERAPIES FPG > 100 | 2-hou ee Ene anac re ir eR GLYCEMIA Dd Low-risk Consider with ROUTE od a ution oe er Ec eas re Peo ir) es co ene aT Pi rors GLP RA DIABETES Eicrsst ae) CUseon cary If glycemia not normalized, ene) consider with cautionFOR GLYCEMIC CO Alcs 6.5% For patients without ool ac nes -TAloL Ly illness and at low hypoglycemic riskYCEMIC CONTROL ALGORITHM LIFESTYLE CASAC Including Medically Assisted Perna ETC PRES co cr as TS eras [— » see coo aie a ey ce (oe Pits INSULIN, ae head + oo ua GE Mer ee cu ora ci eos ped er orather | AZ =m Az oe eer ere me) uci) see ene pari Prt setae veer) AS a Bromocriptine OR pny ae a a Se wy io Seah ADD OR INTENSIFY core at = INSULIN alee A Payers ears lL LEE Ce cAN SOON Io CO cD SU SS© ALGORITHM FOR ADDING/INTENSIFYING INSULIN a ae SOD RC REL ROR ELL) eee coer ee eon Corer errant Ce eer eras Cer ero err APES EL) arena ar eee ere eee te err eee Se ere een rte Ce eee ee ee ee te eee ee Cee eee ee eee ts ee eyCVD RISK FACTOR MO LGORITHM © Ace DYSLIPIDEMIA LIPID PANEL: Assess CVD Risk EO OSE DCO nr) err eet! ose ee a Seen ei ad Bunnag SO ae eas Cena Misia Peete ony pesca ate Se re Tremaine toate oe pico es eee ey ‘mH soi as Risk LEVELS [UCD T7\ Sia isi Mc mean eet becker ‘Add 6-blocker or calcu channel reno blocker orthiaade duet ‘roup. repeat Intensify TL (weightloss, physical activity, detary changes Ce ar err sega ene ental agents a ee area en ‘spironolactonePROFILES OF ANTIDIABETIC MEDICATIONS su Gin COLSVL BCR-QR INSULIN. PRAML MET GLP-1RA SGIT-2i. DPP-4i = AGL_©==—TZD. veo SCR mt Perl WeIGHT Pen Per a re ou inectons (i be oe zi = Loss Ill Fewacverseeventsorpossiblebenefits J Use with caution J kelnood of adverse effects© 2 9 4 9 6 testye optimization and education are essential forall patents with diabetes, ifesyle modifi tion designed for weight loss inlading medal apd surgal interventions approved forthe Wea ment of obesity shouldbe considered as primary approaches for therapeutic benefits in ove weightand obese pant with dabetes and for prevention of dlabetes in igh risk patents with prediabetes, The teatment of overveight/abe sity in patients wih type 2 diabetes and pred betes should proceed according to the Obesity Treatment Algorithm. Efective interventions for weight loss involve a multspinary tea. The need for media therapy fr weight sso ace re contol should not be considered a fae of fesyle management butas an adjunct ot The Atcarget must be individualized based on numerous factors, such s age, comorbid cond tions duration of labetes, risk of hypoaycemia, patlent motivation, adherence, le expectancy, {tc An Alcof 65% ores esl considered ot rmalifitcan be achieved ina safe and affordable ‘manner, but higher targets may be appropriate and may changein a given individual overtime Minimizing iskofhypoa}ycemia isa prion. is amatter of safety, adherence, and cost. Minimizing risk of weight galnis 2 prion to0 isa mattrof safety, adherence, and cost. Glycemic contol targets include fasting and postprandial glucose as determined by self blood glucose monitoring, ‘The choice of therapies must be individualized based on attibutes of the patient (as above) and the medications themselves see Profiles oF ‘Antidiabetic Medications. Aributes of mei 10) 2 Cations that affect ther choice include: sk of inducing hypoglycemia, risk of weight gain, tense of vse, cost, and safety impact of kidney, heart, over disease This algorithm Includes every FDA-approved class of medications for Giabetes. This algorithm also statis choice of therapies based on intial Ate The algorithm provides guidance to what thes esto inate and ad, but respects invidual ‘cumstances that would make diferent choices. Therapies with complementary mechanisms of action must rypically be used in combinations for optimum gycemic conto Effectiveness of therapy must be evaluated fe ‘quently until stable (eg, every 3 months) using rultiple criteria including Ae, SMG records Including both fasting and postprandial data, documented and suspected hypoglycemia, and ‘monitoring for other potential adverse events (weight gain, fd retention, hepatic renal, of cardiac seas}, and monitoring of comorbi ties relevant laboratory data, concomitant drug ‘edminstaton, diabetic complications, and psy ‘cho-fckal factor affecting patient care Safety and efcacy shouldbe given higher por ies than inal acqustion cost of medications ers since cost of mediation only 2 small partofthetota cost of care of diabetes.n deter ining the cost ofa medication, consideration should be glen to monitoring requlements, "isk f hypoglycemia and weight gain, et The algorithm should bea simple as posible to 2 physician aceeptance and improves uty and usbilty in cna practice The algorithm should serve to help educate » 15) 16) PRINCIPLES OF THE AACE ALGORITHM A FOR THE TREATMENT OF TYPE 2 DIABETES ‘the cliniclan as well as to guide therapy atthe point of care ‘The algorithm should conform, a8 neatly a5 pos sible, to a consensus for curent standard of practic of are by expert endocrincogists who Specialize inthe management of patients with ‘ype 2 diabetes and have the broadest expert cence in outpatient circa practice, The algorithm should be as specficas possible and provide guidance to the physician with prioritization and a rationale for selection of ny particular regimen, Rapi-acting insulin analogs are superior to Re, ular because they are more predictable Long-acting insulin analogs are superior to NPH insulin because they provide a fairy fat re ‘sponse for approximately 28 houts and provide beter reproducibility and consistency both be tween subjects and within subjects tha core sponding reduction nthe risk of hypoghycemia fuer inguin,