Table 1 – Principles of the AACE/ACE Comprehensive Type 2 Diabetes Management Algorithm

1. Lifestyle therapy, including medically supervised weight loss, is key to managing T2D
2. Weight loss should be considered as a lifelong goal in all patients with prediabetes and T2D who have overweight or obesity, utilizing behavioral interventions and weight loss medications as required to achieve chronic therapeutic goals
3. The A1C target must be individualized
4. Glycemic control targets include fasting and postprandial glucoses
5. The choice of therapies must be individualized on basis of patient characteristics, impact of net cost to patient, formulary restrictions, personal preferences, etc
6. Minimizing risk of hypoglycemia is a priority
7. Minimizing risk of weight gain is a priority
8. Initial acquisition cost of medications is only a part of the total cost of care, which includes monitoring requirement, risk of hypoglycemia, weight gain, etc
9. The algorithm stratifies choice of therapies based on initial A1C
10. Combination therapy is usually required and should involve agents with complementary actions
11. Comprehensive management includes lipid and blood pressure therapies and related comorbidities
12. Therapy must be evaluated frequently until stable (eg, every 3 months), and then less often
13. The therapeutic regimen should be as simple as possible to optimize adherence
14. The algorithm includes every FDA-approved class of medications for diabetes

Garber AJ, et al. Endocr Pract. 2017 Jan 17. [Epub ahead of print]

Continue Reading

Table 2 – Lifestyle Interventions for Weight Loss
(Intensity stratified by burden of obesity and related complications, going left to right)

Intervention Starting Point Addition 1 Addition 1, 2
Nutrition • Maintain optimal weight primarily through plant-based diet high in polyunsaturated and monounsaturated fatty acids
• Calorie restriction (if BMI is increased)
• Avoidance of trans fats; limited intake of saturated fatty acids • Structured counseling
• Meal replacement programs
Physical activity • at least 150 minutes per week of moderate exertion 
• Strength training
• Increase intensity, duration gradually 
• Structured program to learn proper technique
• Wearable technologies (eg, pedometers, accelerometers)
• Medical evaluation/clearance
• Medically supervised
Sleep • Approx. 7 hours per night
• Basic sleep hygiene should be recommended
• Screen for OSA (most common type of sleep apnea)
• Refer for home sleep study
• Refer to sleep lab/sleep specialist
Behavioral support • Encourage community engagement
• Alcohol moderation, substance abuse counseling
• Assess patient’s mood and psychological well-being • Cognitive behavioral therapy 
Smoking cessation • Avoidance of tobacco products • Nicotine replacement therapy should be considered • Refer to structured program if unable to stop smoking

BMI=body mass index; OSA-obstructive sleep apnea; 
Garber AJ, et al. Endocr Pract. 2017 Jan 17. [Epub ahead of print]

Table 3 – Pharmacotherapy for Weight Loss

Short-Term Use (≤3 months) Long-Term Use
• Diethylproprion
• Phendimetrazine
• Phentermine
• Orlistat
• Phentermine/topiramate extended release (ER)
• Lorcaserin
• Naltrexone ER/bupropion ER
• Liraglutide 3mg

Garber AJ, et al. Endocr Pract. 2017 Jan 17. [Epub ahead of print]

Table 4 – Pharmacotherapy for Prediabetes

Drug Class Advantages Disadvantages
Antihyperglycemics (eg, metformin, acarbose) • Reduce risk of future diabetes by 25% to 30%
• Well-tolerated
• May confer CV benefit
Thiazolidinediones • Prevents future development of diabetes in 60% to 75% of subjects • Associated with adverse outcomes
GLP-1 RAs (eg, liraglutide) • May be effective in preventing diabetes and restoring normoglycemia • Lack of data on long-term safety

CV=cardiovascular; GLP-1 RA- glucagon-like peptide-1 receptor agonist
Garber AJ, et al. Endocr Pract. 2017 Jan 17. [Epub ahead of print]