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American Association of Clinical Endocrinologists’ Comprehensive Diabetes Management Algorithm 2013
Citation preview
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
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.
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
tion
s A
lgor
ithm
AN
TI-
OB
ES
ITY
TH
ER
AP
IES
Inte
nsif
yA
nti-
Obe
sity
E�or
ts1 Pr
e-D
MCr
iter
ion
Mul
tip
le P
re-D
MCr
iter
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
ion
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.
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
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.
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
ICA
TIO
N(I
nclu
ding
Med
ical
ly A
ssis
ted
Wei
ght
Loss
)
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.
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)
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.
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
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.
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
eA
djus
tmen
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
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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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t © 2
013
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CE
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not
be
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oduc
ed in
any
form
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out e
xpre
ss w
ritte
n pe
rmis
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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
diab
etes
te
am. H
owev
er, s
uch
effor
ts s
houl
d no
t de
lay
need
ed p
harm
acot
hera
py, w
hich
can
be
initi
-at
ed s
imul
tane
ousl
y an
d ad
just
ed b
ased
on
the
resp
onse
to
lifes
tyle
effo
rts.
The
nee
d fo
r m
edic
al th
erap
y sh
ould
not
be
inte
rpre
ted
as
a fa
ilure
of
lifes
tyle
man
agem
ent,
but
as a
n ad
junc
t to
it.2)
Th
e A
1c t
arge
t m
ust
be in
divi
dual
ized
, bas
ed
on n
umer
ous
fact
ors,
suc
h as
age
, co-
mor
bid
cond
ition
s, d
urat
ion
of d
iabe
tes,
risk
of h
ypo-
glyc
emia
, pat
ient
mot
ivat
ion,
adh
eren
ce, l
ife
expe
ctan
cy, e
tc. A
n A
1c o
f 6.5
% o
r le
ss is
stil
l co
nsid
ered
opt
imal
if it
can
be
achi
eved
in a
sa
fe a
nd a
fford
able
man
ner,
but
high
er t
ar-
gets
may
be
appr
opria
te a
nd m
ay c
hang
e in
a
give
n in
divi
dual
ove
r tim
e.
3)
Gly
cem
ic c
ontr
ol t
arge
ts in
clud
e fa
stin
g an
d po
stpr
andi
al g
luco
se a
s de
term
ined
by
self
bloo
d gl
ucos
e m
onito
ring.
4)
The
choi
ce o
f the
rapi
es m
ust b
e in
divi
dual
ized
ba
sed
on a
ttrib
utes
of
the
patie
nt (
as a
bove
) an
d th
e m
edic
atio
ns t
hem
selv
es (
see
Profi
les
of A
nti-D
iabe
tic M
edic
atio
ns).
Att
ribu
tes
of
med
icat
ions
tha
t aff
ect
thei
r ch
oice
inc
lude
: ris
k of
indu
cing
hyp
ogly
cem
ia, r
isk
of w
eigh
t ga
in, e
ase
of u
se, c
ost,
and
safe
ty i
mpa
ct o
f ki
dney
, hea
rt, o
r liv
er d
isea
se. T
his
algo
rithm
in
clud
es e
very
FD
A-a
ppro
ved
clas
s of
med
ica-
tions
for d
iabe
tes.
Thi
s al
gorit
hm a
lso
stra
tifies
ch
oice
of t
hera
pies
bas
ed o
n in
itial
A1c
.5)
M
inim
izin
g ris
k of
hyp
ogly
cem
ia is
a p
riorit
y.
It is
a m
atte
r of s
afet
y, a
dher
ence
, and
cos
t.
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.