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On January 10, 2017, the American Association of Clinical Endocrinologists and the American College of Endocrinology (AACE/ACE) announced the publication of an update to its Comprehensive Type 2 Diabetes (T2D) Management Algorithm.1,2
Building on previous algorithms, the 2017 edition includes an updated section on lifestyle therapy as well as a discussion of all classes of obesity, antihyperglycemic, lipid-lowering, and hypertensive medications approved by the US Food and Drug Administration (FDA) through December 2016.
Principles of the algorithm are listed in Table 1.
Lifestyle Therapy
Lifestyle optimization is “multifaceted” and “ongoing” and “essential for all patients with diabetes.” It should include not only one provider but also the whole diabetes team. The authors emphasize that “such efforts should not delay needed pharmacotherapy, which can be initiated simultaneously and adjusted based on patient response to lifestyle efforts.” They caution providers not to regard the need of medical therapy as a “failure” of lifestyle management but as an “adjunct” to it.
Key components of lifestyle therapy include medical nutrition therapy, regular physical activity, sufficient sleep, behavioral support, and smoking cessation.
Obesity
Weight loss is a crucial component of overweight/obese patients with T2D. It should consist of lifestyle changes that include a reduced-calorie health meal plan, physical activity, and behavioral interventions. (Table 2) Lifestyle interventions are appropriate for all patients with overweight/obesity and more intensive options can be prescribed for those with complications. For example, weight loss medications can be used to augment lifestyle therapy in patients with BMI ≥27 kg/m2 who have complications, and patients with body mass index (BMI) ≥30 kg/m2, regardless of the presence or absence of complications. FDA-approved drugs for weight loss are listed in Table 3. Bariatric surgery should be considered for adult patients with BMI ≥35 kg/m2 and comorbidities, especially if other modalities have been unsuccessful.
The algorithm is a “complications-centric model, as opposed to a BMI-centric approach,” and classifies overweight/obese patients who will benefit from medical or surgical interventions into two categories: those with insulin resistance/cardiometabolic disease and those who have biomechanical consequences of excess body weight. Patients should be evaluated for the “risk, presence, and severity of complications” and, once these factors have been assessed, therapeutic goals can be set, and appropriate types and intensities of treatment can be selected.
Prediabetes
Diagnostic criteria for prediabetes include impaired glucose tolerance, impaired fasting glucose, or metabolic syndrome. Weight loss, whether achieved through lifestyle interventions, pharmacotherapy, surgery, or some combination, is the primary goal of prediabetes, as it reduces insulin resistance, effectively prevents progression to diabetes, and improves plasma lipid profile and blood pressure (BP). No medications are FDA-approved solely and specifically for management of prediabetes. However, certain medications have been shown effective in managing prediabetes and/or prevention progression to T2D. (Table 4)
T2D Pharmacotherapy
The authors state that in patients with T2D, “achieving the glucose target and A1C goal requires a nuanced approach that balances age, comorbidities, and hypoglycemia risk.” The A1C goal is ≤6.5 for most patients, and >6.5% to 8% if the lower target cannot be achieved without adverse outcomes. General principles for individualization can be found in Table 5. Some properties of specific medication classes can be found in Table 6.
