Aace Comprehensive Diabetes Management Algorithm 2013

7/14/2019 Aace Comprehensive Diabetes Management Algorithm 2013

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George Grunberger, MD, FACP, FACE

Yehuda Handelsman, MD, FACP, FACE, FNLA

Irl B. Hirsch, MD

Paul S. Jellinger, MD, MACE

Janet B. McGill, MD, FACE

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

Paul D. Rosenblit, MD, FACE

Guillermo Umpierrez, MD, FACE

Michael H. Davidson, MD, Advisor

Martin J. Abrahamson, MD

Joshua I. Barzilay, MD, FACE

Lawrence Blonde, MD, FACP, FACE

Zachary T. Bloomgarden, MD, MACE

Michael A. Bush, MD

Samuel Dagogo-Jack, MD, FACE

Michael B. Davidson, DO, FACE

Daniel Einhorn, MD, FACP, FACE

W. Timothy Garvey, MD

TASK FORCE

Alan J. Garber, MD, PhD, FACE, Chair

AACE COMPREHENSIVEDIABETES MANAGEMENT

ALGORITHM

2013



328 AACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2013;19(No. 2)

TABLE of CONTENTS

Comprehensive Diabetes

Algorithm

Complications-Centric

Model for Care of the

Overweight/Obese Patient

Prediabetes Algorithm

Goals of Glycemic Control

Algorithm for

Adding/Intensifying Insulin

CVD Risk Factor

Modifications Algorithm

Profiles of Antidiabetic

Medications

Principles for Treatment

of Type 2 Diabetes



A A CE C om pr eh en si v eDi a b e t e sM a

n a g em en t A l g or i t h m ,E n d

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C ARDIOME TABOLI C DIS EASE B IOME CH ANIC AL COMPL IC ATIONS

STE P 1 E V A L U A T I O N F O R C O M P L I C A T I O N S A N D S T A G I N G

STEP 3If therapeutic targets for improvements in complications not met, intensify lifestyle and/or medical

and/or surgical treatment modalities for greater weight loss

B MI ≥ 2 7 W ITH CO MP LICATIO N S

Stage Severity of Complications

LOW MEDIUM HIGH

STE P 2(i) Therapeutic targets for improvement in complications,

(ii) Treatment modality and

(iii) Treatment intensity for weight loss based on stagingSELECT:

MD/RD counseling; web/remote program; structured multidisciplinary programLifestyle Modication:

phentermine; orlistat; lorcaserin; phentermine/topiramate ERMedical Therapy:

Lap band; gastric sleeve; gastric bypassSurgical Therapy (BMI ≥ 35):

Complications-Centric Model for Care

of the Overweight/Obese Patient

NO COMPLICATIONS

BMI 25–26.9,

or BMI ≥ 27

Copyright © 2013 AACE May not be reproduced in any form without express written permission from AACE.



3 3 0

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sM an a g em en t A l g or i t h m

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o.2 )

Proceed to

Hyperglycemia

Algorithm

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

O T H E R C V D

R I S K F A C T O R S

TZD

GLP-1 RA

N O R M A LG L Y C E M I A

O V E R T

D I A B E T E S

If glycemia not normalized,consider with caution

A N T I H Y P E R G L Y C E M I C T H E R A P I E SFPG > 100 | 2 hour PG > 140

HypertensionDyslipidemia

Low Risk

Medications

Metformin

Acarbose

CVD Risk FactorModications Algorithm

A N T I O B E S I T Y

T H E R A P I E S

Intensify

Anti-

Obesity

Eorts

1 Pre-DM

Criterion

Multiple Pre-DM

Criteria

Prediabetes Algorithm

IFG 100125 | IGT 140199 | METABOLIC SYNDROME NCEP 2005

Progression






o cr P r a c t .2 0 1 3 ; 1 9 ( N o.2 ) 3 3 1

A1c ≤ 6.5%For healthy patients

without concurrentillness and at low

hypoglycemic risk

A1c > 6.5%Individualize goals

for patients withconcurrent illness

and at risk for

hypoglycemia

Goals for Glycemic Control




3 3 2

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MONOTHERAPY *

If A1c > 6.5%

in 3 months add

second drug

(Dual Therapy)

INSULIN

± OTHER

AGENTS

EN TR Y A1 c < 7 .5 % ENT RY A1 c ≥ 7 .5% EN TRY A1c > 9 .0 %

ADD OR INTENSIFY INSULIN

NO SYMP TOMS SYMP TOMS

OR

DUAL

THERAPY

TRIPLE

THERAPY

P R O G R E S S I O N O F D I S E A S E

Glycemic Control Algorithm

* Order of medications listed are a suggested hierarchy of usage

* * Based upon phase 3 clinical trials data= Use with caution

Few adverse events

or possible benets=

LEGEND

Metformin

GLP-1 RA

DPP4-i

AG-i

SGLT-2 **

TZD

SU/GLN

DUAL THERAPY *

If not at goal in 3

months proceed

to triple therapy

GLP-1 RA

DPP4-i

TZD

** SGLT-2

Basal insulin

Colesevelam

Bromocriptine QR

AG-i

SU/GLN

METor other

rst-line

agent

TRIPLE THERAPY *

If not at goal in 3

months proceed

to or intensify

insulin therapy

GLP-1 RA

TZD

** SGLT-2

Basal insulin

DPP4-i

Colesevelam

Bromocriptine QR

AG-i

SU/GLN

METor other

rst-lineagent

2 N D L I N

E A

G E N T

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






o cr P r a c t .2 0 1 3 ; 1 9 ( N o.2 ) 3 3 3

TDD0.10.2 U/kg

TDD0.20.3 U/kg

** Glycemic Goal:

• For most patients with T2D, an A1c < 7%, fasting and

premeal BG < 110 mg/dL in the absence of hypoglycemia.

• A1c and FBG targets may be adjusted based on patient’s

age, duration of diabetes, presence of comorbidities,

diabetic complications, and hypoglycemia risk.

Consider discontinuing or reducing sulfonylurea after

basal insulin started (basal analogs preferred to NPH)

Add Prandial Insulin

Insulin titration every 2–3 days to

reach glycemic goal:

• Fixed regimen: Increase TDD by 2 U

• Adjustable regimen:

• FBG > 180 mg/dL: add 4 U

• FBG 140–180 mg/dL: add 2 U

• FBG 110–139 mg/dL: add 1 U• If hypoglycemia, reduce TDD by:

• BG < 70 mg/dL: 10% – 20%

• BG < 40 mg/dL: 20% – 40%

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

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

• Increase basal TDD as follows:

• Fixed regimen: Increase TDD by 2 U

• Adjustable regimen:

• FBG > 180 mg/dL: add 4 U

• FBG 140–180 mg/dL: add 2 U

• FBG 100–139 mg/dL: add 1 U

• Increase prandial dose by 10% for any meal if the 2-hr

postprandial or next premeal glucose is > 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

TDD: 0.30.5 U/kg

50% Basal Analog

50% Prandial Analog

Less desirable: NPH

and regular insulin or

premixed insulinGlycemic Control

Not at Goal**

Add GLP1 RAor DPP4-i

Algorithm for Adding/Intensifying Insulin

A1c < 8% A1c > 8%

S T A R T B A S A L (long-acting insulin)




3 3 4

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LI PI D PAN EL: Assess CVD Risk

D Y S L I P I D E M I A

If statin-intolerant

Intensify therapies to

attain goals according

to risk levels

Statin TherapyIf TG > 500 mg/dL, brates,

omega-3 ethyl esters, niacin

Try alternate statin, lower

statin dose or frequency,

or add nonstatin LDL-C-

lowering therapies

Repeat lipid panel;

assess adequacy,

tolerance of therapy

Assess adequacy & tolerance of therapy with focused laboratory evaluations and patient follow-up

H Y P E R T E N S I O N

RISK LEVELS MODERATE HIGHD E S I R A B L E L E V E L S D E S I R A B L E L E V E L S

LDL-C (mg/dL) <100 <70

Non-HDL-C (mg/dL) <130 <100

TG (mg/dL) <150 <150

TC/HDL-C <3.5 <3.0

Apo B (mg/dL) <90 <80

LDL-P (nmol/L) <1200 <1000

DM but no othermajor risk and/or age <40 DM + major CVD risk(s) (HTN, Fam Hx,low HDL-C, smoking) or CVD*

Intensify TLC (weight loss, physical activity, dietary changes)

and glycemic control; Consider additional therapy

If not at desirable levels:

To lower LDL-C: Intensify statin, add ezetimibe &/or colesevelam &/or niacin

To lower Non-HDL-C, TG: Intensify statin &/or add OM3EE &/or brates &/or niacin

To lower Apo B, LDL-P: Intensify statin &/or ezetimibe &/or colesevelam &/or niacin

If not at goal (2–3 months)

Add ß-blocker or calcium channel

blocker or thiazide diuretic

Add next agent from the above

group, repeat



Additional choices (α-blockers,

central agents, vasodilators,

spironolactone)

Achievement of target blood

pressure is critical

GO AL: SYSTOLIC ~130,

DIASTOLIC ~80 mm Hg

For initial bloodpressure

>150/100 mm Hg:

Dual therapy

Thiazide

Calcium

Channel

Blocker

ß-blocker

ACEi

or

ARB

ACEior

ARB

* even more intensive therapy might be warranted

T H E R A P E U T I C L I F E S T Y L E C H A N G E S (See Obesity Algorithm)

CVD Risk Factor Modifications Algorithm




A A CE C om

pr eh en si v eDi a b e t e sM a


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3 3 5

Profiles of Antidiabetic Medications

MET DPP4i GLP1 RA TZD AGI COLSVL BCRQR INSULIN SGLT-2 PRAML

HYPO Neutral Neutral Neutral Neutral Neutral Neutral NeutralModerate

to SevereNeutral Neutral

WEIGHTSlight

LossNeutral Loss Gain Neut ral Neutral Neutral Gain Gain Loss Loss

RENAL/

GU

Contra

indicatedStage

3B,4,5

DoseAdjustment

May beNecessary

(ExceptLinagliptin)

Exenatide

Contraindicated

CrCl < 30

May

Worsen

Fluid

Retention

Neut ral Neutral Neutral

More

Hypo

Risk

More

Hypo Risk

& Fluid

Retention

Infections Neutral

GI Sx Moderate Neutral Moderate Neutral Moderate Mild Moderate Neutral Neutral Neutral Moderate

CHF Neutral

Neutral Neutral

Moderate

Neutral Neutral

Neutral Neutral

Neut ral Neut ral Neutral

CVD Benefit Neutral Safe ?

BONE Neutral Neutral Neutral

Moderate

Bone

Loss

Neutral Neutral Neutral Neutral Neutral?

Bone LossNeutral

GLNSU

Moderate/Severe

Mild

Few adverse events or possible benefits Use with caution Likelihood of adverse effects




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Aace Comprehensive Diabetes Management Algorithm 2013