New management recommendations for the treatment of type 2 diabetes.
The American Association of Clinical Endocrinologists (AACE), in conjunction with the American College of Endocrinology (ACE), has published updates for the Comprehensive Diabetes Management Algorithm and Executive Summary as a clinical guide to help healthcare professionals manage the care of patients with type 2 diabetes. This 2016 algorithm introduces new treatments, disease management tactics, and vital clinical data; it also incorporates the following modifications: a new segment on lifestyle therapy optimization, a complications-centric model for treatment of the overweight patient, stratification of treatment choices created on the patient’s initial A1C level and a thorough analysis of all anti-hyperglycemic, anti-hypertensive and lipid-lowering medications. The algorithm ranks safety in any anti-diabetic treatment in order to reduce hypoglycemia in patients and the consequences related to it.
Alan J. Gaber, chair of the AACE/ACE Comprehensive Diabetes Management Algorithm Task Force, stated that, “although the algorithm is comprehensive in nature, its presentation as an illustrated, action-driven treatment pathway should assist decision-making for physicians who are regularly challenged with managing the many facets of this disease in the most effective and safe manner.”
The principles, which the diabetes algorithm is modeled after, include the following: lifestyle optimization in all patients with diabetes, individualizing the hemoglobin A1C in patients based on contributing factors, glycemic control targets, including fasting and post-prandial glucose based off of self-monitoring of blood glucose, diabetic therapy options based on individual attributes of patients and the medications they are already taking, reducing the risk of weight gain, the cost of initial acquisition of the medication, stratification of therapies based on initial A1C levels, combination therapy, comprehensive management, which includes both lipid and blood pressure therapy and treatment, simplifying the therapeutic regimen so adherence can be optimized and the inclusion of all FDA-approved class of medications for type 2 diabetes.
One of the most prominent highlights from the new update includes obesity and prediabetes as primary risk factors for the advancement of type 2 diabetes and other macrovascular complications and the recommendation for tighter blood pressure and lipid control since they are cited as the two most important risk factors for cardiovascular disease.
Some of the key recommendations that are important to note, including testing to assess the risk for potential diabetes in asymptomatic patients who are overweight, obese, or who fall within one or more additional risk factors for diabetes (a few would include physical inactivity, first-degree relatives with diabetes, high-risk patients due to race or ethnicity, history of cardiovascular disease).
Additional key points include the need to begin testing at 45 years of age regardless of the patient’s weight; if the tests are normal, repeat testing should be carried out at a minimum of three-year intervals. Specifically for the diagnosing of type 1 diabetes patients, the blood glucose rather than the hemoglobin A1C level should be utilized for acute onset of the disease in patients with symptoms related to hyperglycemia. Type 2 diabetes patients should be initiated on metformin unless contraindicated or if they are intolerant to the medication, and insulin therapy initiation (with or without additional agents) should be considered in patients with newly diagnosed type 2 diabetes and elevated blood glucose levels or A1C. Due to new evidence obtained on ASCVD risk amongst women, the recommendation to consider aspirin therapy in women aged 60 years was changed to include women aged greater than 50 years of age. In addition, new evidence stating that Zetia (ezetimibe) added to moderate-intensity statin therapy can theoretically offer cardiovascular benefits for individuals with diabetes and should be considered. Patients who are pregnant with diabetes were also addressed in the most recent update, emphasizing that the A1C target recommendation should be from 6% to 6.5% though dependent on hypoglycemia risk that target might be tightened or relaxed.
One important recommendation that is definitely becoming more and more prevalent as technology continues to advance is the encouragement to use new devices and programs such as applications and text messaging in order to manage and prevent diabetes. Society today is so heavily fixated on the use of multimedia and it is important to realize that it can be used to help maintain an active and healthy lifestyle and definitely help with the management of patients with diabetes.
The guidelines for the standards of medical care in diabetes are updated annually in order to maintain the most optimal recommendations for healthcare providers with all components of diabetes care, treatment goals and even tools to help evaluate the quality of care.
- The AACE/ACE 2016 update algorithm for management of patients with type 2 diabetes was formulated to give physicians a practical guide and to consider the patient as a whole.
- The 2016 version of the guidelines includes a new section on lifestyle therapy and discusses all classes of obesity and medications that are FDA-approved for diabetes management.
- The guidelines are broken down into discrete sections that address the following: principles of the algorithm, lifestyle therapy, obesity, prediabetes, glucose control with noninsulin, hypertension management, and dyslipidemia management.
“Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2016 Executive Summary.” Endocrine Practice 22.1 (2016): 84-102. Web. 18 Jan. 2016.
Researched and prepared by Javeria Fayyaz, Doctor of Pharmacy Candidate FAMU College of Pharmacy, reviewed by Dave Joffe, BSPharm, CDE