In January, 2016, the American Association of Clinical Endocrinologists/American College of Endocrinology (AAACE/ACE) released their 2016 Comprehensive Type 2 Diabetes Management Algorithm,1 which serves as an update to the earlier 2013 algorithm.2
The new algorithm takes into account therapies that were not available at the time of the publication of the earlier guideline, as well as disease management approaches and key clinical data, which led to a new section on lifestyle therapy optimization. Other important components include a complications-centric model for approaches to the treatment of overweight/obese patients, including an analysis of currently available anti-obesity drugs; updated choices for stratifying therapies, based on the patient’s initial hemoglobin A1C levels; and a detailed analysis of all of the anti-hyperglycemic, anti-hypertensive, and lipid-lowering medications approved by the US Food and Drug Administration (FDA) through December, 2015. Factors such as patient preference, ease of use, likely adherence, and cost are also taken into account in arriving at a medication regimen.1 Principles of the algorithm are found in Table 1 and comparison of some of the 2013 and 2016 recommendations can be found in Table 2.
The Role of A1C
Although glycemic control targets not only include A1C but also fasting and postprandial glucose, it is entry A1C that is used to determine medication strategy, with monotherapy recommended for patients whose initial A1C is <7.5%, dual therapy or those with an initial A1C of ≥7.5%, and dual or triple therapy in asymptomatic patients with initial A1C of >9.5%, with the addition of insulin in those who are symptomatic.1
The A1C target should be individualized, based on life expectancy, comorbid conditions, diabetes duration, risk of hypoglycemia or other adverse effects, and patient motivation and adherence. And although the target ≤6.5% is “optimal” in patients without concurrent serious illness and at low hypoglycemic risk, higher targets may be appropriate for certain patients.1
Lifestyle therapy (including medically-assisted weight loss) is considered the starting point with obese/overweight patients, those with prediabetes, and those with established diabetes. Recommended lifestyle interventions are found in Table 3.