ENDOCRINOLOGY AACE COMPREHENSIVE DIABETES MANAGEMENT AURGLO) ON Neal — TASK FORCE Alan J. Garber, MD, PhD, FACE, Chair Martin J. Abrahamson, MD George Grunberger, MD, FACP, FACE Joshua |. Barzilay, MD, FACE Yehuda Handelsman, MD, FACP, FACE, FNLA, Lawrence Blonde, MD, FACP, FACE rl B. Hirsch, MD ZacharyT. Bloomgarden, MD, MACE Paul S. Jellinger, MD, MACE Michael A. Bush, MD Janet B. McGill, MD, FACE Samuel Dagogo-Jack, MD, FACE Jeffrey |. Mechanick, MD, FACE, ECNU, FACN, FACP Michael B. Davidson, DO, FACE Paul D. Rosenblit, MD, FACE Daniel Einhorn, MD, FACP, FACE Guillermo Umpierrez, MD, FACE W. Timothy Garvey, MD Michael H. Davidson, MD, Advisor ‘Copyright © 2013 AACE May not be reproduced in any form without express wten permission frm AACE. “Te prac print of hic arte plaace se wae aac ome Copyright 2013 AACE ‘This material is protected by US copyright law. To purchase commercial reprints ofthis article, visit wnww.aace.comvreprints. For permission to rouse material, please access www.copyright.com or cantact the Copyright Clearance Genter, Inc. (CC). Copyright © 2013 AACE ENDOCRINE PRACTICE Vol 19 No. 2 March/April 2013327828 AACE Comprehensive Diabetes Management Algorithm, Endoor Pract. 2013;19(No. 2) Copyright ® 2013 AACE. 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 (Copyright © 2013 AACE May not be reproduced any form without xpress witen permission ram AACE.2 2 a 2 PRINCIPLES OF THE AACE / Lifestyle optimization is essential for all pa- tients with diabetes. This is multifaceted, ‘ongoing, and engages the entire diabetes team, Howaver, such efforts should not delay needed pharmacotherapy, which can be init ated simultaneously and adjusted based on the response to lifestyle efforts. The need for ‘medical therapy should not be interpreted as 2 failure of ifestyle management, but as an adjunctto it. The Atc target must be individualized, based ‘on numerous factors, such as age, co-morbid conditions, duration of diabetes, risk of hypo glycemia, patient motivation, adherence, if expectancy, etc. An Alc of 6.5% or less is stil considered optimal i it can be achieved in a safe and affordable manner, but higher tar {gets may be appropriate and may change ina given individual over time, Glycemic control targets include fasting and postprandial glucose as determined by seit blood glucose monitoring The choice of therapies must be individualized based on attributes of the patient (as above) and the medications themselves (see Profiles of Anti-Diabetic Medications). Attributes of ‘medications that affect thelr cholee Include: tisk of inducing hypoglycemia, risk of weight. gain, ease of use, cost and safety Impact of Kidney, heart, oliver disease. This algorithm includes every FDA-approved class of medica- tions fr diabetes Ths algorithm aso statifies choice of therapies based on initial ATC Minimizing risk of hypoalycemia isa priority. Iisa matter of safety, adherence, and cost. 6 10) m 12) Minimizing risk of weight gain isa priority. It ‘too {s a matter of safety, adherence, and cost. The algorithm provides guidance to what therapies to initiate and add, but respects in- ‘vidual circumstances that would make dif- ferent choices Therapies with complementary mechanisms ‘of action must typically be used in combina- tions for optimum glycemic contol Effectiveness of therapy must be evaluated frequently until stable (eg. every 3 months) using multiple criteria including Ate, SMBG records including both fasting and post-pran- dial data, documented and suspected hypo- ‘lycemia, and monitoring for other potential adverse events (weight gain, fluid retention, hepati, renal, or cardiac disease), and moni- toring of co-morbidities, relevant laboratory date, concomitant drug administration, dia- btic complications, and psycho-social factors affecting patient care. Safety and efficacy should be given higher priorities than initial acquisition cost of medications per se since cost of medica tions is only a small part of the total cost of care of diabetes, In determining the cast of ‘a medication, consideration should be given ‘te monitoring requirements, risk of hypooly- emia and weight gain, etc. The algorithm should be as simple as possible ‘to.gain physician acceptance and improve its trlity and usability in clinical practic. The algorithm should serve to help educate ‘the clinician as well as to guide therapy atthe point of care. LGORITHM FOR THE TREATMENT OF TYPE 2 3) ") 15) 16 IABETES ca ‘The algorithm should conform, as neatly as possible, o a consensus for current standard ‘of practice of care by expert endoctinologists who specialize in the management of patients with type 2 diabetes and have the broadest ‘experience in outpatient clinical practice The algorithm should be as specific as pos- sible, and provide guidance to the physician With prioritization and a rationale for selec- ton of any particular regimen, Rapid-acting insulin analogs are superior to Regular because they are more predictable ‘Long-acting insulin analogs are superior to INPH insulin because they provide a fairly lat tesponse for approximately 24 hours and pro- vide better reproducibility and consistency both between subjects and within subjects, with a coresponding reduction in the risk of hypoglycemia, ret ee ee ca eer oa et iia eee Pekar ee eee Pr ee en uld not be ee ae es Copyright ©2015 AACE May not be reproduced in any form without express wit prmision fom AACE BOW E102 @:1BUKdoD (e-oNI6t'Ct0Z Toeg J00pU ‘uNAHOBy juOWoBCUEWY SeIoqeIG On:MPLICATIONS-CENTRIC MODEL FOR CARE OF THE OVERWEIGHT/OBESE PATIENT ag EVALUATION FOR COMPLICATIONS AND STAGING PVT e ah 14 BIOMECHANICAL COMPLICATIONS CIE AU Mas ae keno Stage Severity of Complications Therapeutic targets for improvement in complications, Treatment modality and Treatment intensity for weight loss based on staging v If therapeutic targets for improvements in complications not met, intensify lifestyle and/or medical and/or surgical treatment modalities for greater weight loss Copyright ©2013 AACE Moy not be reproduced in any for without expres writen permisian fiom AACE 6ze (2 “ON)6L e102 aed soopug ‘wiyHOBY weuIsBeUEW So}OqeIG an!SUOYeIdIOD 3OVY FOVV ELOZ @ 1UBUAdODPREDIABETES ALGORITHM IFG (100-125) | IGT (140-199) | METABOLIC SYNDROME (NCEP 2005) LIFESTYLE MODIFICATION (including Medically Assisted Weight Loss) SSS cg ery. ue Perec na) GLYCEMIA Progression Ley Caer aad Prec Copyright ©2013 AACE Hoy nt be reproduc in any form without expres writen perminsion fiom AACE BOW £107 © BUKdoD (Z“ON)GLEL0z 7081d JOOpUT ‘UNAHOBIY uOMeBEUEW SerogeIG BAISUOYOXdWOD ZOVY OSEAlc s 6.5% Alc > 6.5% For healthy patients Individualize goals Miaeleimcoladelac-lig for patients with illness and at low concurrent illness hypoglycemic risk and at risk for hypoglycemia Copyright © 2013 AACE May ot be erode mony form without xpress wien permission from AACE Hee (2 “ONI6He10z 70014 o0pU “wAALOBIy jwoWeBeUEY soyoqeIq ensuayexdWIOD JOVY JOVW E10Z @ 14SUKdeDGLYCEMIC CONTROL ALGORITHM LIFESTYLE MODIFICATION (Including Medically Assisted Weight Loss) NO SYMPTOMS | SYMPTOMS. DUAL THERAPY ioe MONOTHERAPY Caran Gari Ca CES 1 scur-2 DUAL THERAPY Cro) INSULIN = OTHER AGENTS TRIPLE THERAPY Gaol 7 ae TRIPLE THERAPY 1120 1 SUIGLN. ce oe econd drug ce ieee) sour Basalinsulin 1 Ce) Co) ere) Ren SUIGLN 1 ocr col Order of medications listed are a suggested hierarchy of usage emg Based upon phase 3 clinical tals data ey MS PROGRESSION OF DISEAS! > Copyright ©2013 AACE Moy not be reproduced in ny for without expres witen permision fiom AACE Crees Set) roy ADD OR INTENSIFY INSULIN LEGEND Few advese events A Use yt caution Sr BOW £107 © BUKdoD (Z“ON)6LELOZ 7081¢ JOOpUT UNAHOBIY UOWOBEUEW SerOgeIG eAISUOYOXdWOD ZOVY Zo@® ALGORITHM FOR ADDING, == ayy 0.2-0.3 U/kg Insulin titration every 2-3 days to teach glycemic goal + Fixed regimen: Increase TDD by 2U + Adjustable regimen: + FBG > 180 mg/dl: add 4U + FBG 140-180 mg/dl: add 2U + FBG 110-139 mg/dl: add 1 U + IFhypogiycemia, reduce TDD by: + BG<70 mg/dl: 10% ~ 20% ‘mg/dL: 20% ~ 40% ** Glycemic Goal: For most patients with 12D, an Alc < 7% fasting and premeal 8G < 110 mg/dL in the absence of hypoglycemia, Alcand FBG targets may be adjusted based on patient's age, duration of diabetes, presence of comorbidities, diabetic complications, and hypoglycemia tsk. Glycemic Control Not at Goal** /INTENSIFYING INSULIN Add GLP-1 RA . Add Prandial insulin | Roem) Pore Eo ener ee on Bieta Searcy Insulin titration every 2-3 days to reach glycemic goal Increase basal TDD as follows: Fixed regimen: Increase TDD by 2 U Adjustable regimen: FRG > 180 mg/dl: add 4 U FBG 140-180 mg/dl: add 2 U FBG 100-139 mg/dL: add 1U Increase prandial dose by 10% for any meal ifthe 2-hr postprandial or next premeal glucose is > 180 mg/dl Premixed: Increase TOD by 1096 if fasting/prameal 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 ppremeal short/rapid-acting insulin Copyright ©2013 AACE Moy not be reproduced in any for without expres witen permision fiom AACE 268 (2 ‘ONJ61!e102 208d soopug ‘WyyLOBY weweBEUEW so}OqEIC anISUOYe:WIOD ZOYY ZOVV E10Z @ UBUDae ees Cepia) Try alternate statin, statin dose or frequency, fr add nonstatin LDL lowering therapies RISK LEVELS Repeat lipid panel: Intensify therapies to assess adequacy, attain goals according {olerance-of therapy. torisklevels ey on HL cma ‘Ape mpd Intensify TLC (weightloss, physical activity, dietary changes) and glycemic control; Consider additional therapy, Intensify statin, add ezetimibe &/or colesevelam &/ornlacin| Intensify statin &/or add OMSEE W/or fibres @/or niacin Intensify statin &/r ezetmibe &/or colesevelam &/ornlacin Assess adequacy & tolerance of therapy with focused laboratory evaluations and patient GOAL: SYSTOLIC ~130, DIASTOLIC ~80 mm Hg ecg) Ce Eases COCOA Catt recy racy crn Cond Coed Cris ee een [Add B-blocker or calcium channel blocker or thiazide diuretic een) ‘Add next agent fromthe above ‘roup, repeat fone Additional choices (a ‘central agents, vasodilators, spironolactone) Pees peel ‘Copyright ©2013 AACE May not be reproduced nay orm without expres ten permision om AACE BOW £102 © UBUKdoD (Z“ON)GLELOZ 708d JOOpUT ‘UNALOBIY OMBEUEW SerOgeIG BAISUOYOXdWLOD ZOVY PEEPROFILES OF ANTIDIABETIC MEDICATIONS £& porn are | pram free toSevere Neutral | Neute Neutral Neutral | Neutral | Neutral Neutral Ca Neutral | Neutral | Neutral Dose Adjustment raed CUM Moy be Cnn Cs cu Stage [DMESSNIM indicated Fluid Parr) EM (Except coer cee Linaatiptin) Neutral | Neutral | Neutral rae Neutral Moderate| Neutral | Moderate | Neutral | Moderate | mild | Moderate | Neutral | Neutral | Neutral | Moderate Neutral Moderate Neutral | Neutral Neutral | Neurad Neutral | Neutral Neutral | neutral | Neutra etal : a i Moderate , wewwal | neural [fone | newtat | neural | nourat | seutal | nesta! ponds) Neva [EE Fewadverseoventsorposbtebenets i) Usewith caution] Ukehood of adverse tects (Copyright ©2013 AACE May not be reproduced nny fo without express wit permission fom AACE Ste (2 “ON)61!e102 208d soopug ‘WYyWOBY weweBEUEW so}OqEIG anISUOYe:WED ZOVY ZOVV E10Z @ 1HBUAOD