AACE/ACE COMPREHENSIVE DIABETES MANAGEMENT ALGORITHM

2 015 TA S K FOR CE 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.

438 ENDOCRINE PRACTICE Vol 21 No. 4 April 2015

AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4) 439

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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SELEC T:

STEP 3

Therapeutic targets for improvement in complications

+

MEDIUM

Treatment modality

+

Treatment intensity for weight loss based on staging

HIGH

Lap band; gastric sleeve; gastric bypass

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If therapeutic targets for improvements in complications not met, intensify lifestyle and/or medical and/or surgical treatment modalities for greater weight loss

Surgical Therapy (BMI ≥ 35):

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

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

Medical Therapy:

Lifestyle Modification:

STEP 2

LOW

Stage Severity of Complications

BMI 25–26.9, or BMI ≥ 27

B IOMECHANIC AL COMP LIC AT IONS B M I ≥ 2 7 WI TH COM P LI C ATI ONS

C A R DIOM E TA BOL I C D ISEASE

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

NO COM PLIC ATIONS

STEP 1

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

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

DYSL IPIDE MIA ROUTE

OV E R T D I A B E TE S

Progression

Intensify Weight Loss Therapies

1 PRE-DM C RI TE RI ON

TZD GLP-1 RA

Metformin Acarbose

If glycemia not normalized, consider with caution

Consider with Caution Low-risk Medications

MU LTIPL E PR E- DM CR ITER IA

FPG > 100 | 2-hour PG > 140

ANTIHYPE R GLYCE MIC T H E R AP IE S

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HYPER T ENSION ROUTE

N ORMA L G LYC E M I A

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

W EI GHT LOSS TH ER APIES

C V D R ISK FAC TOR MO DIFIC ATIONS ALG ORI THM

OT HE R C VD R ISK FAC TOR S

(Including Medically Assisted Weight Loss)

L I F E S T Y L E M O D I F I C AT I O N

IFG (1 00– 1 2 5) | IG T ( 140–199) | ME TABOLIC SYN D R OM E (NCE P 2005)

PR EDIABETES ALGOR ITHM

AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4) 441

For patients with concurrent serious illness and at risk for hypoglycemia

For patients without concurrent serious illness and at low hypoglycemic risk

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A1c > 6.5%

A1c ≤ 6.5%

IN DIVIDUA LIZ E G OA LS

G OALS FOR G LYCE MIC CONT R OL

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

Triple Therapy

proceed to

in 3 months

If not at goal

+

or other 1st-line agent

MET

SU/GLN

AGi

Bromocriptine QR

Colesevelam

Basal Insulin

TZD

DPP-4i

SGLT-2i

GLP-1 RA

D UA L TH ER APY*

Entry A1c ≥ 7.5%

±

Other Agents

INSULIN

YES

Use with caution

Few adverse events or possible benefits

Refer to Insulin Algorithm

A DD O R I NTENS I FY I NS UL I N

TRIPLE Therapy

OR

DUAL Therapy

NO

S YMPTO MS

Entry A1c > 9.0%

LEGEND

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O F

insulin therapy

to or intensify

D I S E A S E

SU/GLN

AGi

Bromocriptine QR

Colesevelam

DPP-4i

Basal insulin

TZD

3 months proceed

If not at goal in

+

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

SGLT-2i

GLP-1 RA

T R I PL E TH ER APY*

MET

P R O G R E S S I O N

* Order of medications listed represents a suggested hierarchy of usage

proceed to Double Therapy

If not at goal in 3 months

SU/GLN

TZD

AGi

DPP-4i

SGLT-2i

GLP-1 RA

Metformin

M O NO TH E R A PY *

Entry A1c < 7.5%

(Including Medically Assisted Weight Loss)

L I F E S T Y L E M O D I F I C AT I O N

Glyc emic Con t r ol A lg or it hm

AACE/ACE Comprehensive Diabetes Management Algorithm, Endocr Pract. 2015;21(No. 4) 443

TDD 0.2–0.3 U/kg

TDD 0.1–0.2 U/kg

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%

•

•

Glycemic Control Not at Goal**

•

• • •

•

• • •

0.3–0.5 U/kg 50% Basal Analog 50% Prandial Analog Less desirable: NPH and regular insulin or premixed insulin

TDD

Add Prandial Insulin

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

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

or DPP-4i

or SGLT-2i

Add GLP-1 RA

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

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8%

A1c < 8%

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

ALGORITHM FOR ADDING/INTENSIF Y ING INSULIN

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

DM but no other major risk and/or age