aace/ace comprehensive diabetes management algorithm

ENDOCRINE PRACTICE Rapid Electronic Article in Press

Rapid Electronic Articles in Press are preprinted manuscripts that have been accepted for publication in an issue of Endocrine Practice. This version of the manuscript will be replaced with the final, paginated version after it has been published in Volume 21, Issue 4, April 2015 Endocrine Practice. DOI:10.4158/EP15693.CS © 2015 AACE.

AACE/ACE COMPREHENSIVE DIABETES MANAGEMENT ALGORITHM

2015 TA S K F OR C E Alan J. Garber, MD, PhD, FACE, Chair Martin J. Abrahamson, MD

George Grunberger, MD, FACP, FACE

Joshua I. Barzilay, MD, FACE

Yehuda Handelsman, MD, FACP, FNLA, FACE

Lawrence Blonde, MD, FACP, FACE

Irl B. Hirsch, MD

Zachary T. Bloomgarden, MD, MACE

Paul S. Jellinger, MD, MACE

Michael A. Bush, MD

Janet B. McGill, MD, FACE

Samuel Dagogo-Jack, MD, DM, FRCP, FACE

Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU

Michael B. Davidson, DO, FACE

Paul D. Rosenblit, MD, PhD, FNLA, FACE

Daniel Einhorn, MD, FACP, FACE

Guillermo Umpierrez, MD, FACP, FACE

Jeffrey R. Garber, MD, FACP, FACE

Michael H. Davidson, MD, Advisor

W. Timothy Garvey, MD, FACE Copyright © 2015 AACE MAy not bE rEproduCEd in Any forM without ExprEss writtEn pErMission froM AACE.

This material is protected by US copyright law. For permission to reused material in any format, complete a permission form at www.aace.com/permissions. To purchase reprints of this article, please visit: www.aace.com/reprints. DOI:10.4158/EP15693.CS Copyright © 2015 AACE.

ENDOCRINE PRACTICE Vol 21 No. 4 April 2015 e1

e2 AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4)

TA BL E OF CONTENTS Compre he n sive Diabe t e s A lg orit h m I.

Complications-Centric Model for Care of the Overweight/Obese Patient

II.

Prediabetes Algorithm

III.

Goals of Glycemic Control

IV.

Glycemic Control Algorithm

V.

Algorithm for Adding/Intensifying Insulin

VI.

CVD Risk Factor Modifications Algorithm

VII.

Profiles of Antidiabetic Medications

VIII. Principles for Treatment of Type 2 Diabetes

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Complications-Centric Model for Care of the Overweight/Obese Patient

C A RDI O M E TA B OLIC D ISEASE

B IOMECHANIC A L COM P L IC AT IONS

NO COM PLIC AT IONS

B M I ≥ 2 7 WI TH COM P LI C ATIONS

BMI 25–26.9, or BMI ≥ 27

Stage Severity of Complications

S TEP 2

LOW

MEDIUM

Therapeutic targets for improvement in complications

SELEC T:

Lifestyle Modification:

Treatment modality

+

Treatment intensity for weight loss based on staging

MD/RD counseling; web/remote program; structured multidisciplinary program

Medical Therapy:

phentermine; orlistat; lorcaserin; phentermine/topiramate ER; naltrexone/bupropion; liraglutide

Surgical Therapy (BMI ≥ 35):

S TEP 3

+

HIGH

Lap band; gastric sleeve; gastric bypass

If therapeutic targets for improvements in complications not met, intensify lifestyle and/or medical and/or surgical treatment modalities for greater weight loss Copyright © 2015 AACE MAy not bE rEproduCEd in Any forM without ExprEss writtEn pErMission froM AACE.

AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4) e3

E VA L U AT I O N F O R C O M P L I C AT I O N S A N D S TA G I N G

S TEP 1

I F G ( 1 0 0 – 125) | IG T ( 140–199) | ME TABOLIC SYN D R OM E (NCE P 2005)

L I F E S T Y L E M O D I F I C AT I O N (Including Medically Assisted Weight Loss)

OTHE R C V D RIS K FAC TO RS

WE IG HT LOSS THER APIES

C VD RISK FAC TOR MODIFIC AT IONS ALGORIT HM DYS L IPIDE M IA ROUTE

HYPE R T E NSION ROUTE

ANTIHYPE R GLYCE M IC T H E R A P IE S FPG > 100 | 2-hour PG > 140

N ORMA L G LYC E M I A

Progression

OV E R T D I A B E TE S

PR OCE E D TO HYPE R G LYCE MI A ALG OR I T HM

1 PRE-DM C RI TE RI ON

Intensify Weight Loss Therapies

MU LTIPL E PR E-DM CR ITER IA

Low-risk Medications

Consider with Caution

Metformin

TZD

Acarbose

GLP-1 RA

If glycemia not normalized, consider with caution

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e4 AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4)

PR EDIABETES ALGOR ITHM

G OA LS FOR G LYCE MIC CONT R OL

A1c ≤ 6.5%

A1c > 6.5%

For patients without concurrent serious illness and at low hypoglycemic risk

For patients with concurrent serious illness and at risk for hypoglycemia

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AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4) e5

INDIVIDUA LIZ E G OA LS

L I F E S T Y L E M O D I F I C AT I O N (Including Medically Assisted Weight Loss)

Entry A1c < 7.5%

Entry A1c ≥ 7.5%

Entry A1c > 9.0%

MON O T H E R A PY *

S YM PTO M S D UAL TH ER APY*

Metformin

GLP-1 RA

GLP-1 RA SGLT-2i DPP-4i AGi TZD SU/GLN

MET

GLP-1 RA

DPP-4i

SGLT-2i

Basal Insulin

+

Colesevelam Bromocriptine QR AGi SU/GLN

If not at goal in 3 months proceed to Double Therapy

MET

or other 1st-line agent + 2nd-line agent

+

TZD

OR

Other Agents

±

DPP-4i Colesevelam

AGi

A DD O R I NTENS I F Y I NS UL I N

SU/GLN

Refer to Insulin Algorithm

If not at goal in 3 months proceed to or intensify

* Order of medications listed represents a suggested hierarchy of usage

INSULIN

TRIPLE Therapy

Basal insulin

in 3 months Triple Therapy

DUAL Therapy

Bromocriptine QR

If not at goal proceed to

YE S

T R I PL E TH ER APY*

SGLT-2i

TZD

or other 1st-line agent

NO

LEGEND

insulin therapy

P R O G R E S S I O N

O F

Few adverse events or possible benefits Use with caution

D I S E A S E

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e6 AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4)

G lyc e m ic Con t r ol A lg or ithm

A LG ORITH M FOR ADDING/INTENSIF YING INSULIN S T A R T B A S A L (long-acting insulin)

Add GLP-1 RA

A1c > 8%

Add Prandial Insulin

or SGLT-2i

TDD 0.1–0.2 U/kg

Insulin titration every 2–3 days to reach glycemic goal: • •

•

**Glycemic Goal:

•

TDD • • •

Glycemic Control Not at Goal**

Fixed regimen: Increase TDD by 2 U Adjustable regimen: • FBG > 180 mg/dL: add 20% of TDD • FBG 140–180 mg/dL: add 10% of TDD • FBG 110–139 mg/dL: add 1 Unit If hypoglycemia, reduce TDD by: • BG < 70 mg/dL: 10% – 20% • BG < 40 mg/dL: 20% – 40%

Consider discontinuing or reducing sulfonylurea after basal insulin started (basal analogs preferred to NPH)

•

or DPP-4i

TDD 0.2–0.3 U/kg

180 mg/dL Premixed: Increase TDD by 10% if fasting/premeal BG > 180 mg/dL If fasting AM hypoglycemia, reduce basal insulin If nighttime hypoglycemia, reduce basal and/or pre-supper or pre-evening snack short/rapid-acting insulin If between-meal daytime hypoglycemia, reduce previous premeal short/rapid-acting insulin

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AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4) e7

A1c < 8%

I N T E N S I F Y (prandial control)

hypErtEnsion

dysLipidEMiA thErApEutiC LifEstyLE ChAngEs

(See Obesity Algorithm)

g oAL : systoL iC ~130, diAstoL iC ~80 mm h g

Lipid pA n E L: Assess CVd risk If TG > 500 mg/dL, fibrates, omega-3 ethyl esters, niacin

stAt in t hE r Apy If statin-intolerant Try alternate statin, lower statin dose or frequency, or add nonstatin LDL-C- lowering therapies

risK LE VELs

DM but no other major risk and/or age