ENDOCRINE PRACTICE Vol 19 No. 2 March/April 2013 327

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

Je�rey 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 FORCEAlan J. Garber, MD, PhD, FACE, Chair

AACE COMPREHENSIVEDIABETES MANAGEMENT

ALGORITHM

2013

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

To purchase reprints of this article, please visit: www.aace.com/reprints.Copyright © 2013 AACE.

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

TABLE of CONTENTS

Comprehensive DiabetesAlgorithm

Complications-CentricModel for Care of the

Overweight/Obese Patient

Prediabetes Algorithm

Goals of Glycemic Control

Algorithm forAdding/Intensifying Insulin

CVD Risk FactorModifications Algorithm

Profiles of AntidiabeticMedications

Principles for Treatmentof Type 2 Diabetes

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

AACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2013;19(No. 2) 329

CA

RD

IOM

ETA

BO

LIC

DIS

EA

SE

BIO

ME

CH

AN

ICA

L C

OM

PLI

CA

TIO

NS

ST

EP

1E

VA

LU

AT

ION

FO

R C

OM

PL

ICA

TIO

NS

AN

D S

TA

GIN

G

ST

EP

3If

ther

apeu

tic

targ

ets

for

impr

ovem

ents

in c

ompl

icat

ions

not

met

, int

ensi

fy li

fest

yle

and/

or m

edic

alan

d/or

sur

gica

l tre

atm

ent m

odal

itie

s fo

r gr

eate

r w

eigh

t los

s

BM

I ≥

27

WIT

H C

OM

PLI

CA

TIO

NS

Stag

e Se

veri

ty o

f C

om

pli

cati

on

s

LOW

MED

IUM

HIG

H

ST

EP

2(i)

Th

erap

euti

c ta

rget

s fo

r im

prov

emen

t in

com

plic

atio

ns,

(ii)

Trea

tmen

t mod

alit

y an

d (ii

i) Tr

eatm

ent i

nten

sity

for

wei

ght l

oss

base

d on

sta

ging

SE

LEC

T:

MD

/RD

cou

nsel

ing;

web

/rem

ote

prog

ram

; str

uctu

red

mul

tidi

scip

linar

y pr

ogra

mLi

fest

yle

Mo

di�

cati

on

:

phen

term

ine;

orl

ista

t; lo

rcas

erin

; phe

nter

min

e/to

pira

mat

e ER

Med

ical

Th

erap

y:

Lap

band

; gas

tric

sle

eve;

gas

tric

byp

ass

Surg

ical

Th

erap

y (B

MI ≥

35)

:

Co

mpl

icat

ion

s-C

ent

ric

Mo

del

fo

r C

ar

eo

f t

he

Ov

erw

eig

ht

/Obes

e Pat

ien

t

NO

CO

MP

LIC

AT

ION

S

BM

I 25–

26.9

,o

r B

MI ≥

27

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AAC

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

Proc

eed

toH

yper

glyc

emia

Alg

orit

hm

LIF

ES

TY

LE

MO

DIF

ICA

TIO

N(I

nclu

ding

Med

ical

ly A

ssis

ted

Wei

ght

Loss

)

OT

HE

R C

VD

RIS

K F

AC

TO

RS

TZD

GLP

-1 R

A

NO

RM

AL

GL

YC

EM

IA

OV

ER

TD

IAB

ET

ES

If gl

ycem

ia n

ot n

orm

aliz

ed,

cons

ider

wit

h ca

utio

n

AN

TIH

YP

ER

GLY

CE

MIC

TH

ER

AP

IES

FPG

> 1

00 |

2 h

ou

r PG

> 1

40

Hyp

erte

nsio

nD

yslip

idem

iaLo

w R

isk

Med

icat

ions

Met

form

in

Aca

rbos

e

CVD

Ris

k Fa

ctor

Mod

i�ca

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s A

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AN

TI-

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ITY

TH

ER

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Inte

nsif

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nti-

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E�or

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e-D

MCr

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Mul

tip

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re-D

MCr

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ia

Pr

edia

bet

es A

lgo

rit

hm

IFG

(100

–125

) |

IGT

(140

–199

) |

MET

AB

OLI

C S

YN

DR

OM

E (N

CEP

200

5)

Prog

ress

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AAC

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AACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2013;19(No. 2) 331

A1c

≤ 6

.5%

For

heal

thy

pati

ents

wit

hout

con

curr

ent

illne

ss a

nd a

t low

hypo

glyc

emic

ris

k

A1c

> 6

.5%

Indi

vidu

aliz

e go

als

for

pati

ents

wit

hco

ncur

rent

illn

ess

and

at r

isk

for

hypo

glyc

emia

Go

als

fo

r G

lyc

emic

Co

nt

ro

l

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AAC

E.

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

MO

NO

TH

ER

AP

Y*

If A

1c >

6.5

%in

3 m

on

ths

add

seco

nd

dru

g(D

ual

Th

erap

y)

INS

ULI

N±

OT

HE

RA

GE

NT

S

EN

TR

Y A

1c

< 7

.5%

EN

TR

Y A

1c

≥ 7

.5%

EN

TR

Y A

1c

> 9

.0%

AD

D O

R I

NT

EN

SIF

Y I

NS

ULI

N

NO

SY

MP

TOM

SS

YM

PTO

MS

OR

DU

AL

TH

ER

AP

Y

TR

IPLE

TH

ER

AP

Y

PR

OG

RE

SS

IO

N

OF

D

IS

EA

SE

Gly

cem

ic C

on

tr

ol

Alg

or

ith

m

*

Ord

er o

f med

icat

ions

list

ed a

re a

sug

gest

ed h

iera

rchy

of u

sage

* *

Bas

ed u

pon

phas

e 3

clin

ical

tria

ls d

ata

= U

se w

ith

caut

ion

Few

adv

erse

eve

nts

or p

ossi

ble

bene

�ts

=

LEG

EN

D

Met

form

in

GLP

-1 R

A

DPP

4-i

AG

-i

SGLT

-2 *

*

TZD

SU/G

LN

DU

AL

TH

ER

AP

Y*

If n

ot

at g

oal

in 3

mo

nth

s p

roce

edto

tri

ple

th

erap

y

GLP

-1 R

A

DPP

4-i

TZD

** S

GLT

-2

Basa

l ins

ulin

Cole

seve

lam

Brom

ocrip

tine

QR

AG

-i

SU/G

LN

MET

or o

ther

�rst

-line

agen

t

TR

IPLE

TH

ER

AP

Y*

If n

ot

at g

oal

in 3

mo

nth

s p

roce

edto

or

inte

nsi

fyin

suli

n t

her

apy

GLP

-1 R

A

TZD

** S

GLT

-2

Basa

l ins

ulin

DPP

4-i

Cole

seve

lam

Brom

ocrip

tine

QR

AG

-i

SU/G

LN

MET

or o

ther

�rst

-line

agen

t

2ND LINE AGENT

LIF

ES

TY

LE

MO

DIF

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TIO

N(I

nclu

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Med

ical

ly A

ssis

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Wei

ght

Loss

)

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from

AAC

E.

AACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2013;19(No. 2) 333

TDD

0.1–

0.2

U/k

gTD

D0.

2–0.

3 U

/kg

** G

lyce

mic

Goa

l:•

For m

ost p

atie

nts

wit

h T2

D, a

n A

1c <

7%

, fas

ting

and

pr

emea

l BG

< 1

10 m

g/dL

in th

e ab

senc

e of

hyp

ogly

cem

ia.

• A

1c a

nd F

BG ta

rget

s m

ay b

e ad

just

ed b

ased

on

pati

ent’s

ag

e, d

urat

ion

of d

iabe

tes,

pre

senc

e of

com

orbi

diti

es,

di

abet

ic c

ompl

icat

ions

, and

hyp

ogly

cem

ia ri

sk.

Cons

ider

dis

cont

inui

ng o

r red

ucin

g su

lfony

lure

a af

ter

basa

l ins

ulin

sta

rted

(bas

al a

nalo

gs p

refe

rred

to N

PH)

Ad

d P

ran

dia

l Ins

ulin

Insu

lin ti

trat

ion

ever

y 2–

3 d

ays

tore

ach

glyc

emic

goa

l:•

Fixe

d re

gim

en: I

ncre

ase

TDD

by

2 U

• A

djus

tabl

e re

gim

en:

• FB

G >

180

mg/

dL: a

dd 4

U•

FBG

140

–180

mg/

dL: a

dd 2

U•

FBG

110

–139

mg/

dL: a

dd 1

U•

If hy

pogl

ycem

ia, r

educ

e TD

D b

y:•

BG <

70

mg/

dL: 1

0% –

20%

• BG

< 4

0 m

g/dL

: 20%

– 4

0%

INT

EN

SIF

Y (p

rand

ial c

ontr

ol)

Insu

lin ti

trat

ion

ever

y 2–

3 d

ays

to r

each

gly

cem

ic g

oal:

• In

crea

se b

asal

TD

D a

s fo

llow

s:

• Fi

xed

regi

men

: Inc

reas

e TD

D b

y 2

U

• A

djus

tabl

e re

gim

en:

• FB

G >

180

mg/

dL: a

dd 4

U

•

FBG

140

–180

mg/

dL: a

dd 2

U

•

FBG

100

–139

mg/

dL: a

dd 1

U•

Incr

ease

pra

ndia

l dos

e by

10%

for a

ny m

eal i

f the

2-h

r

post

pran

dial

or n

ext p

rem

eal g

luco

se is

> 1

80 m

g/dL

• Pr

emix

ed: I

ncre

ase

TDD

by

10%

if fa

stin

g/pr

emea

l

BG >

180

mg/

dL•

If fa

stin

g A

M h

ypog

lyce

mia

, red

uce

basa

l ins

ulin

• If

nigh

ttim

e hy

pogl

ycem

ia, r

educ

e ba

sal a

nd/o

r pre

-sup

per

or

pre

-eve

ning

sna

ck s

hort

/rap

id-a

ctin

g in

sulin

• If

betw

een

mea

l day

time

hypo

glyc

emia

, red

uce

prev

ious

pr

emea

l sho

rt/r

apid

-act

ing

insu

lin

TDD

: 0.3

-0.5

U/k

g50

% B

asal

Ana

log

50%

Pra

ndia

l Ana

log

Less

des

irab

le: N

PHan

d r

egul

ar in

sulin

or

pre

mix

ed in

sulin

Gly

cem

ic C

ontr

olN

ot a

t Goa

l**

Add

GLP

-1 R

Aor

DPP

4-i

Alg

or

ith

m f

or

Ad

din

g/I

nte

nsi

fyin

g I

nsu

lin

A1c

< 8

%A

1c >

8%

ST

AR

T B

AS

AL

(lon

g-ac

ting

insu

lin)

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013

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ed in

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with

out e

xpre

ss w

ritte

n pe

rmis

sion

from

AAC

E.

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

LIP

ID P

AN

EL:

Ass

ess

CV

D R

isk

DY

SL

IPID

EM

IA

If st

atin

-into

lera

nt

Inte

nsify

ther

apie

s to

at

tain

goa

ls a

ccor

ding

to ri

sk le

vels

Stat

in T

hera

pyIf

TG >

500

mg/

dL, �

brat

es,

omeg

a-3

ethy

l est

ers,

nia

cin

Try

alte

rnat

e st

atin

, low

erst

atin

dos

e or

freq

uenc

y,or

add

non

stat

in L

DL-

C-lo

wer

ing

ther

apie

s

Repe

at li

pid

pane

l;as

sess

ade

quac

y,to

lera

nce

of th

erap

y

Ass

ess

adeq

uacy

& to

lera

nce

of th

erap

y w

ith fo

cuse

d la

bora

tory

eva

luat

ions

and

pat

ient

follo

w-u

p

HY

PE

RT

EN

SIO

N

RIS

K L

EV

ELS

MO

DER

ATE

HIG

H

DE

SIR

AB

LE

LE

VE

LS

DE

SIR

AB

LE

LE

VE

LS

LDL-

C (m

g/d

L)<

100

<70

Non

-HD

L-C

(mg/

dL)

<13

0<

100

TG (m

g/d

L)<

150

<15

0TC

/HD

L-C

<3.

5<

3.0

Ap

o B

(mg/

dL)

<90

<80

LDL-

P (n

mol

/L)

<12

00<

1000

DM

but

no

othe

rm

ajor

ris

k an

d/or

age

<40

DM

+ m

ajor

CV

D r

isk(

s) (H

TN, F

am H

x,

low

HD

L-C

, sm

okin

g) o

r C

VD

*

Inte

nsif

y TL

C (w

eigh

t los

s, p

hysi

cal a

ctiv

ity,

die

tary

cha

nges

)an

d gl

ycem

ic c

ontr

ol; C

onsi

der

addi

tion

al th

erap

yIf

not

at d

esir

able

leve

ls:

To lo

wer

LD

L-C

: In

tens

ify

stat

in, a

dd e

zeti

mib

e &

/or

cole

seve

lam

&/o

r ni

acin

To lo

wer

Non

-HD

L-C

, TG

: In

tens

ify

stat

in &

/or

add

OM

3EE

&/o

r �b

rate

s &

/or

niac

inTo

low

er A

po

B, L

DL-

P:

Inte

nsify

sta

tin &

/or e

zetim

ibe

&/o

r col

esev

elam

&/o

r nia

cin

If n

ot a

t goa

l (2–

3 m

onth

s)

Add

ß-b

lock

er o

r cal

cium

cha

nnel

bloc

ker o

r thi

azid

e di

uret

ic

Add

nex

t age

nt fr

om th

e ab

ove

grou

p, re

peat

If n

ot a

t goa

l (2–

3 m

onth

s)

If n

ot a

t goa

l (2–

3 m

onth

s)

Add

itio

nal c

hoic

es (α

-blo

cker

s,ce

ntra

l age

nts,

vas

odila

tors

,sp

iron

olac

tone

)

Ach

ieve

men

t of t

arge

t blo

odpr

essu

re is

cri

tica

l

GO

AL:

SY

STO

LIC

~1

30

,D

IAS

TOLI

C ~

80

mm

Hg

For i

niti

al b

lood

pres

sure

>150

/100

mm

Hg:

Dua

l the

rapy

Thia

zide

Calc

ium

Chan

nel

Bloc

ker

ß-bl

ocke

r

ACE

ior ARB

ACE

ior ARB

* ev

en m

ore

inte

nsiv

e th

erap

y m

ight

be

war

rant

ed

TH

ER

AP

EU

TIC

LIF

ES

TY

LE

CH

AN

GE

S (S

ee O

besi

ty A

lgor

ithm

)

CV

D R

isk

Fac

tor

Mo

dif

icat

ion

s A

lgo

rit

hm

C

opyr

ight

© 2

013

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CE

May

not

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repr

oduc

ed in

any

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with

out e

xpre

ss w

ritte

n pe

rmis

sion

from

AAC

E.

AACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2013;19(No. 2) 335

Pr

ofi

les

of

An

tid

iabe

tic

Med

icat

ion

s

MET

DPP

-4i

GLP

-1 R

ATZ

DA

GI

COLS

VL

BCR-

QR

INSU

LIN

SGLT

-2PR

AM

L

HYP

ON

eutr

alN

eutr

alN

eutr

alN

eutr

alN

eutr

alN

eutr

alN

eutr

alM

oder

ate

to S

ever

eN

eutr

alN

eutr

al

WEI

GH

TSl

ight

Lo

ssN

eutr

alLo

ssG

ain

Neu

tral

Neu

tral

Neu

tral

Gai

nG

ain

Loss

Loss

REN

AL/

GU

Cont

ra-

indi

cate

dSt

age

3B,4

,5

Dos

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djus

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t M

ay b

eN

eces

sary

(E

xcep

tLi

nagl

iptin

)

Exen

atid

eCo

ntra

-in

dica

ted

CrCl

< 3

0

May

Wor

sen

Flui

dRe

tent

ion

Neu

tral

Neu

tral

Neu

tral

Mor

eH

ypo

Risk

Mor

eH

ypo

Risk

&

Flu

idRe

tent

ion

Infe

ctio

nsN

eutr

al

GI S

xM

oder

ate

Neu

tral

Mod

erat

eN

eutr

alM

oder

ate

Mild

Mod

erat

eN

eutr

alN

eutr

alN

eutr

alM

oder

ate

CHF

Neu

tral

Neu

tral

Neu

tral

Mod

erat

eN

eutr

alN

eutr

alN

eutr

alN

eutr

alN

eutr

alN

eutr

alN

eutr

alC

VD

Bene

fit

Neu

tral

Safe

?

BON

EN

eutr

alN

eutr

alN

eutr

alM

oder

ate

Bone

Loss

Neu

tral

Neu

tral

Neu

tral

Neu

tral

Neu

tral

?Bo

ne L

oss

Neu

tral

GLN

SU Mod

erat

e/Se

vere

Mild

Few

adv

erse

eve

nts

or p

ossi

ble

bene

fits

Use

wit

h ca

utio

nLi

kelih

ood

of a

dver

se e

ffec

ts

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oduc

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

Pr

inc

iple

s o

f t

he

AA

CE

Alg

or

ith

mfo

r t

he

Tr

eatm

ent

of

Typ

e 2

Dia

bet

es

1)

Life

styl

e op

timiz

atio

n is

ess

entia

l fo

r al

l pa

-ti

ents

wit

h di

abet

es.

This

is

mul

tifa

cete

d,

ongo

ing,

and

eng

ages

the

ent

ire d

iabe

tes

team

. How

ever

, suc

h eff

orts

sho

uld

not

dela

y ne

eded

pha

rmac

othe

rapy

, whi

ch c

an b

e in

iti-

ated

sim

ulta

neou

sly

and

adju

sted

bas

ed o

n th

e re

spon

se t

o lif

esty

le e

ffort

s. T

he n

eed

for

med

ical

ther

apy

shou

ld n

ot b

e in

terp

rete

d as

a

failu

re o

f lif

esty

le m

anag

emen

t, bu

t as

an

adju

nct t

o it.

2)

The

A1c

tar

get

mus

t be

indi

vidu

aliz

ed, b

ased

on

num

erou

s fa

ctor

s, s

uch

as a

ge, c

o-m

orbi

d co

nditi

ons,

dur

atio

n of

dia

bete

s, ri

sk o

f hyp

o-gl

ycem

ia, p

atie

nt m

otiv

atio

n, a

dher

ence

, life

ex

pect

ancy

, etc

. An

A1c

of 6

.5%

or

less

is s

till

cons

ider

ed o

ptim

al if

it c

an b

e ac

hiev

ed in

a

safe

and

affo

rdab

le m

anne

r, bu

t hi

gher

tar

-ge

ts m

ay b

e ap

prop

riate

and

may

cha

nge

in a

gi

ven

indi

vidu

al o

ver t

ime.

3)

G

lyce

mic

con

trol

tar

gets

incl

ude

fast

ing

and

post

pran

dial

glu

cose

as

dete

rmin

ed b

y se

lf bl

ood

gluc

ose

mon

itorin

g.4)

Th

e ch

oice

of t

hera

pies

mus

t be

indi

vidu

aliz

ed

base

d on

att

ribut

es o

f th

e pa

tient

(as

abo

ve)

and

the

med

icat

ions

the

mse

lves

(se

e Pr

ofile

s of

Ant

i-Dia

betic

Med

icat

ions

). A

ttri

bute

s of

m

edic

atio

ns t

hat

affec

t th

eir

choi

ce i

nclu

de:

risk

of in

duci

ng h

ypog

lyce

mia

, ris

k of

wei

ght

gain

, eas

e of

use

, cos

t, an

d sa

fety

im

pact

of

kidn

ey, h

eart

, or

liver

dis

ease

. Thi

s al

gorit

hm

incl

udes

eve

ry F

DA

-app

rove

d cl

ass

of m

edic

a-tio

ns fo

r dia

bete

s. T

his

algo

rithm

als

o st

ratifi

es

choi

ce o

f the

rapi

es b

ased

on

initi

al A

1c.

5)

Min

imiz

ing

risk

of h

ypog

lyce

mia

is a

prio

rity.

It

is a

mat

ter o

f saf

ety,

adh

eren

ce, a

nd c

ost.

6)

Min

imiz

ing

risk

of w

eigh

t ga

in is

a p

riorit

y. It

to

o is

a m

atte

r of s

afet

y, a

dher

ence

, and

cos

t.7)

Th

e al

gori

thm

pro

vide

s gu

idan

ce t

o w

hat

ther

apie

s to

initi

ate

and

add,

but

resp

ects

in-

divi

dual

circ

umst

ance

s th

at w

ould

mak

e di

f-fe

rent

cho

ices

. 8)

Th

erap

ies

with

com

plem

enta

ry m

echa

nism

s of

act

ion

mus

t ty

pica

lly b

e us

ed in

com

bina

-tio

ns fo

r opt

imum

gly

cem

ic c

ontr

ol.

9)

Effe

ctiv

enes

s of

the

rapy

mus

t be

eva

luat

ed

freq

uent

ly u

ntil

stab

le (

e.g.

eve

ry 3

mon

ths)

us

ing

mul

tiple

crit

eria

inc

ludi

ng A

1c,

SMBG

re

cord

s in

clud

ing

both

fast

ing

and

post

-pra

n-di

al d

ata,

doc

umen

ted

and

susp

ecte

d hy

po-

glyc

emia

, and

mon

itorin

g fo

r ot

her

pote

ntia

l ad

vers

e ev

ents

(w

eigh

t ga

in, fl

uid

rete

ntio

n,

hepa

tic, r

enal

, or

card

iac

dise

ase)

, and

mon

i-to

ring

of c

o-m

orbi

ditie

s, r

elev

ant

labo

rato

ry

data

, co

ncom

itant

dru

g ad

min

istr

atio

n, d

ia-

betic

com

plic

atio

ns, a

nd p

sych

o-so

cial

fact

ors

affec

ting

patie

nt c

are.

10)

Safe

ty a

nd e

ffic

acy

shou

ld b

e gi

ven

high

er

prio

riti

es

than

in

itia

l ac

quis

itio

n co

st

of

med

icat

ions

per

se

sinc

e co

st o

f m

edic

a-ti

ons

is o

nly

a sm

all p

art

of t

he t

otal

cos

t of

ca

re o

f di

abet

es. I

n de

term

inin

g th

e co

st o

f a

med

icat

ion,

con

side

rati

on s

houl

d be

giv

en

to m

onit

orin

g re

quire

men

ts, r

isk

of h

ypog

ly-

cem

ia a

nd w

eigh

t gai

n, e

tc.

11)

The

algo

rithm

sho

uld

be a

s si

mpl

e as

pos

sibl

e to

gai

n ph

ysic

ian

acce

ptan

ce a

nd im

prov

e its

ut

ility

and

usa

bilit

y in

clin

ical

pra

ctic

e.

12)

The

algo

rithm

sho

uld

serv

e to

hel

p ed

ucat

e th

e cl

inic

ian

as w

ell a

s to

gui

de th

erap

y at

the

poin

t of c

are.

13)

The

algo

rithm

sho

uld

conf

orm

, as

nea

rly a

s po

ssib

le, t

o a

cons

ensu

s fo

r cu

rren

t st

anda

rd

of p

ract

ice

of c

are

by e

xper

t end

ocrin

olog

ists

w

ho sp

ecia

lize

in th

e m

anag

emen

t of p

atie

nts

with

typ

e 2

diab

etes

and

hav

e th

e br

oade

st

expe

rienc

e in

out

patie

nt c

linic

al p

ract

ice.

14)

The

algo

rith

m s

houl

d be

as

spec

ific

as p

os-

sibl

e, a

nd p

rovi

de g

uida

nce

to th

e ph

ysic

ian

wit

h pr

iori

tiza

tion

and

a r

atio

nale

for

sel

ec-

tion

of a

ny p

arti

cula

r reg

imen

.15

) Ra

pid-

actin

g in

sulin

ana

logs

are

sup

erio

r to

Re

gula

r bec

ause

they

are

mor

e pr

edic

tabl

e.16

) Lo

ng-a

ctin

g in

sulin

ana

logs

are

sup

erio

r to

N

PH in

sulin

bec

ause

the

y pr

ovid

e a

fairl

y fla

t re

spon

se fo

r app

roxi

mat

ely

24 h

ours

and

pro

-vi

de b

ette

r re

prod

ucib

ility

and

con

sist

ency

bo

th b

etw

een

subj

ects

and

wit

hin

subj

ects

, w

ith a

cor

resp

ondi

ng r

educ

tion

in t

he r

isk

of

hypo

glyc

emia

.

This

doc

umen

t re

pres

ents

the

offi

cial

pos

i-tio

n of

the

Am

eric

an A

ssoc

iatio

n of

Clin

ical

En

docr

inol

ogis

ts a

nd t

he A

mer

ican

Col

-le

ge o

f En

docr

inol

ogy.

Whe

re t

here

wer

e no

RC

Ts o

r sp

ecifi

c FD

A l

abel

ing

for

is-

sues

in c

linic

al p

ract

ice,

the

par

tici

pati

ng

clin

ical

exp

erts

uti

lized

the

ir j

udgm

ent

and

expe

rienc

e. E

very

effo

rt w

as m

ade

to

achi

eve

cons

ensu

s am

ong

the

com

mitt

ee

mem

bers

. Man

y de

tails

tha

t co

uld

not

be

incl

uded

in t

he g

raph

ic s

umm

ary

(Fig

ure)

ar

e de

scri

bed

in th

e te

xt.

Copy

righ

t © 2

013

AA

CE

May

not

be

repr

oduc

ed in

any

form

with

out e

xpre

ss w

ritte

n pe

rmis

sion

from

AAC

E.