eras AACE/ACE COMPREHENSIVE DIABETES MANAGEMENT ALGORITHM Martin J. Abrahamson, MD Joshua | Barzilay, MD, FACE Lawrence Blonde, MD, FACR, FACE Zachary, Bloomgarden, MD, MACE Michael A. Bush, MD Samuel Dagogo-ack, MD, DM, Michael B. Davidson, DO, FACE FRCP, FACE 2015 TASK FORCE Alan J. Garber, MD, PhD, FACE, Chair Daniel Einhorn, MD, FACP, FACE Jeffrey R, Garber, MD, FACP, FACE W.Timothy Garvey, MD, FACE George Grunberger, MD, FACP, FACE Yehuda Handelsman, MD, FACP, FNLA, FACE |e. Hirsch, MD Paul S. Jellinger, MD, MACE Janet 8. McGil, MD, FACE Jeffrey . Mechanick, MD, FACP, FACE, FACN, ECNU Paul D. Rosenbllt, MD, PhD, FNLA, FACE Guillermo Umpierrez, MD, FACP, FACE Michael H. Davidson, MD, AdvisorTABLE OF CONTENTS COMPREHENSIVE DIABETES ALGORITHM COMPLICATIONS-CENTRIC MODEL FOR CARE OF THE OVERWEIGHT/OBESE PATIENT PREDIABETES ALGORITHM I GOALS FOR GLYCEMIC CONTROL a GLYCEMIC CONTROL ALGORITHM V. wal VI watt ALGORITHM FOR ADDING/INTENSIFYING INSULIN CVD RISK FACTOR MODIFICATIONS ALGORITHM PROFILES OF ANTIDIABETIC MEDICATIONS PRINCIPLES FOR TREATMENT OF TYPE 2 DIABETESCOMPLICATIONS-CENTRIC MODEL FOR CARE OF THE OVERWEIGHT/OBESE PATIENT EVALUATION FOR COMPLICATIONS AND STAGING Nan ner Pere mee ame Prk neUes Pea kee Pope perenne ieten Creed Therapeutic targets for Treatment intensity fo Improvement in complications loss based on staging Lifestyle Modification: | MD/RD counseling; web/remote program; structured multidisciplinary program Pd a ad phentermine; orlistat; lorcaserin; phentermine/topiramate ER; naltrexone/bupropion; liraglutide Pear nae er nase ieee Surgical Therapy (BMI = 35): If therapeutic targets for improvements in complications not met, intensify lifestyle and/or medical and/or surgical treatment modalities for greater weight lossQ PREDIABETES ALGORITHM IFG (100-125) | IGT (140-199) | METABOLIC SYNDROME (NCEP 2005) OTHER CVD WEIGHT Loss ANTIHYPERGLYCEMIC THERAPIES RISK FACTORS THERAPIES Oana) Pers Meh ee inca Ena ad Low-tisk ore) ce pond eee mezby Peery Caution ae Tern 72} ae ee Br cen GLP-1 RA DCs essa Elastane eet ncn CoanWei Bobi) For patients without concurrent serious illness and at low hypoglycemic riskPec Cea on err eet m7 rs ety ras > GLYCEMIC CONTROL LIFEST YL E MODIFICATION LGORITHM Pence cats CLs ar cote con as AD eer ees PROGRESS 6 Sa Ge eter Pees rr rer = aN on) aa Sacre No Sia Pr fem id + other i ro a i) am) eae a es cd yo) a) pone eae aan ous > Pee iag noun) nsLGORITHM FOR ADDING/INTENSIFYING INSULIN fet ae Add GL-1 RA Add Prana nul SOD MCSE RRC ee APR) 0% Basal Analog Glycemic ee) Control Not eer at Goal** and regular insulin ent eee poorer ee eo ere errr eee eos Ceara iscontinuing o 7 sulin started (basal a toNPH) ee ent Ce ee oe es ee re ee Sigh dil eal yD Cas aan Reet nets eee Cera eens Doerner eee ee ea See eee eee Pee eee nen nts pene teLGORITHM @® cvp Risk GOAL: SYSTOLIC ~130, PCr e One) Sra Dee ets cn ents peer) = arene ema ry ape pana Intent therapies ta Thi enters tlerance of therapy een GEEEENEM MODERATE SSS ETAP MA) Hic occu ‘Add next agent rm the above eee ee eer) eno Se eee ees rere on een eer ere eee as tional choices a canta agents v ea ed ‘sproncectone)PROFILES OF ANTIDIABETIC MEDICATIONS = COLSVLBCR-QR INSULIN. PRAML MET GLP-1RA SGLT-2/.DPP-4) «= AGI_«STZD aa rye [CRE ae ce STs ir WeIGHT rer rr cenit (aa RENAL/ May be Mycotic i ror cu inecions nae cans ie GISx | Maderate | Moderate PTE Moderate Mild Moderate Moderate CHE Neutral Pee Moderate etn et ery rer vo eres fone LDL Moderate PONE Neural | Neutral | Nev Pete cone A ee ee Loss BB Few cdtcyccrencoexposstve benerto | QR) Uscwrthcaviont) |) Utcifvoodet evens erecta a 4 5 6 PRINCIPLES OF THE AACE ALGORITHM A FOR THE TREATMENT OF TYPE 2 DIABETES testy optimization and education are essential forall patients with labetes, Lifestyle modica- tion designed for weight los. including medial 2nd surgical ier ventions approved forthe wat ment of obesity, shouldbe considered s primary approaches for therapeutic bene in. ovr eight and obese patents with dabetes and for prevention of dabetes i igh isk patents wth predabetes, The treatment of overweght/obe sty in patients with type 2 dabets ad pred betes should proceed according to the Obesity “Treatment Algorithm. Effective interventions for eight loi involve a multscipknary team. The need for medical therapy fr weight ss or giyce- re contol should not be considered a fale of festyle management butasanadjunet ot The Atc target must be individualized, based on numerous factors, such a ge, comorbid cond tions duration of labetes rskofhyponiycemia, patent motivation, adherence, te expecancy, fc. An Atcof6% or less ctllconsideredopt rmalfitcan be achieved in safe and affordable ‘manner, but higher targets may be appropriate 2nd may change ina given Individual overtime Minimizing riskofrypog}ycemiaisa prio. Ris mate of safety, adherence and cost. Minimizing risk of weight gal a pionty 100 Isa matter of safety, adherence, and cost. Glycemic contol targets include fasting and postprandial glucose as determined by seit blood alucase monitoring ‘The choice of therapies must be individualized based on attabutes of the patient (as above) and the medications themselves (se Profle of ‘Antidiabetic Medications). Atributes of met 10) 2 ‘ations that affect ther choice include: sk of Inducing hypoglycemia, risk of weight gain, fase of use, cost, and safety impact of kidney heart, a iver aisease Thi algorithm includes every FDA-approved cass f medications for iabetes. Ths algorithm also statis choice of therapies based on intl Ale The algorithm provides guidance to what ther ples to inate and add, but respects indivi ‘cumstances tht would make diferent chokes. “herapes with complementary mechanisms of action must rypially be used in combiations for optimum glycemic contol Effectiveness of therapy must be evaluated f= ‘quently until stable (e9, every 3 month) using rmuttple criteria including Ae, SMEG records Including both fasting and postprandial data, documented and suspected hypoglycemia, and ‘monitoring for other potential adverse events (weight goin, ld retention, hepatic rena, ot cardiac desc), and monitoring of comorbid ties relevant laboratory data, concomitant rug sedminstration, diabetic complications, an psy ‘cho-socll factor affecting patient care Safety and efcay shouldbe given higher pir ities than inal acquisition cost of medications per te ence cost of mediation only 2 small part ofthe total cost ofcare of diabees.n deter mining the cost of @ medication, consideration should be given to monitoring requirements, "iskof hypoglycemia and weight gain, et The algorithm shouldbe as simple as possible to gain physicanaceeptance an improve ts uly and usability in nial practice The algorithm should serve to help educate ») 15) 16) ‘the diniclan as well as to guide therapy at point of eae ‘The algorithm should conform, 38 neat a8 pos sible, ta consensus for current standard of practic af ae by expert endocrncogists who specialize in the management of patients with Iype 2 dabetes and have the broadest exper ence ln outpatient cnc practice. ‘The algorithm shouldbe as specific as possible and provide guidance to the physician with Prioritization and a rationale for selection of dry particular regimen, Fapi-acting insulin analogs are superior to Re ar because they ate more predictable Long-acing insulin analogs ae superior to NPHL insulin because they provide a fairy Mat re: Sense for approximately 24 hours and provide beter reproducibly and consistency both be ‘ween subjects and within subject, witha core sponding reductonin theriskof hypoglycemia A neces autor dss are made to AACE an oon lerter ngs