The American Association of Clinical Endocrinologists (AACE) released an online version of the organization’s new Consensus Statement and Algorithm on the treatment of Type 2 diabetes mellitus (T2DM).1
The statement, which is designed to replace the 2009 AACE/American College of Endocrinology (ACE)’s glycemic control algorithm,2 expands the focus from management of blood glucose and glycemic control to encompass treatment of obesity, cardiovascular disease, and prediabetes as underlying risk factors for diabetes and associated complications.
The new consensus statement emphasizes broad-based strategies for risk and complication reduction, including management of diabetes and coexisting diseases during prediabetes and T1DM; management of hyperglycemia, taking into account age and comorbidities; a complications-centric model of care of overweight or obese patients that incorporates several factors beyond body mass index (BMI); and management of cardiovascular disease (CVD) risk factors (ie, hypertension and hyperlipidemia) in patients with prediabetes or T1DM.
Basic Principles of Diabetes Management
Lifestyle optimization, which the authors describe as a “multifaceted and ongoing approach, which can be introduced concurrently and adjunctively with pharmacotherapy.”
Optimal hemoglobin A1C Target, which is based on factors such as age, comorbid conditions, duration of diabetes, risk of hypoglycemia, patient motivation, adherence, and life expectancy.
Glycemic Control Targets, which include fasting and post-prandial glucose, as determined by self-monitoring of blood glucose (SMBG).
Diabetes therapies that are stratified and based on initial A1C levels. Therapies must be individualized and based on a interface between the attributes specific to patients, and the medications themselves—ie, hypoglycemia risk (which is described as a “priority”), risk of weight gain (also a “priority”), ease of use, cost, and safety impact for heart, kidney, or liver disease. Ideally, therapies with complementary mechanisms of action should be prescribed in combination.
Frequent evaluation of therapeutic effectiveness should take place regularly until stability has been achieved, using multiple criteria, including A1C, SMBG records, (fasting and postprandial), documented and suspected hypoglycemic events, adverse events (weight gain, fluid retention, and hepatic, renal, or cardiac disease), comorbidities, other relevant laboratory data, concomitant drug administration, diabetic complications, and psychosocial factors affecting patient care.
Cost considerations are important, but safety and efficacy should be prioritized over cost of initial acquisition of medications, and consideration should be given to monitoring requirement, hypoglycemia risk, and weight gain.
Rapid-acting insulin analogs are superior to regular insulin because they are more predictable.