Table 1
Principles of the AACE/ACE Recommendations
  • Lifestyle therapy, including medically supervised weight loss, is key
  • The A1C target must be individualized
  • Glycemic control targets include fasting and postprandial glucose
  • Choice of therapies must be individualized, based on patient characteristics that include cost to patient, formulary restrictions, and personal preferences
  • Minimizing hypoglycemic risk is a priority
  • Minimizing risk of weight gain is a priority
  • Initial acquisition cost of medications is only part of the total cost of care, which also includes monitoring requirements, risk of hypoglycemia, weight gain, and safety
  • The algorithm stratifies choice of therapies based on initial A1C
  • Combination therapy is usually required and should involve agents with complementary actions
  • Comprehensive management includes lipid and blood pressure therapies, when applicable, and treatment of related comorbidities
  • Therapy must be evaluated frequently until stable (eg, every 3 months), and then less often
  • The therapeutic regimen should be as simple as possible to optimize adherence
  • The algorithm includes every FDA-approved class of medication for diabetes

Garber AJ, et al. Endocr Pract. 2016;22(1):84-113.

Table 2
Comparison of AACE/ACE 2013 and 2016 Recommendations
2013 2016

Medical therapy for obese patients includes only phentermine, orlistat, lorcaserin, and phentermine/topiramate ER


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Liraglutide and naltrexone/bupropion added as medical therapies

SGLT-2 inhibitors should be used with caution, ranked as fifth option for monotherapy

SGLT-2 inhibitors no longer regarded as “to be used with caution” and ranked as third option for monotherapy

Add GLP-1 RA or DPP-4 inhibitor to intensify prandial control

Add GLP-1 RA, or SGLT-2 inhibitor or DPP4-inhibitor to intensify prandial control

GLP-1 RA =glucagon-like peptide-1 (GLP-1) receptor agonists; SGLT2=sodium glucose cotransporter 2 inhibitors; DPP-4i=dipeptidyl peptidase 4 inhibitors

Garber AJ, et al. Endocr Pract. 2016;22(1):84-113.

Table 3

Lifestyle Therapy: Risk Stratification for Diabetes Complications

(Intensity stratified by burden of obesity and related complications, going left to right)

Intervention Starting Point Addition 1 Additions 1, 2
Nutrition
  • Maintain optimal weight
  • Calorie restriction
  • Plant-based diet; high polyunsaturated and monounsaturated fatty acids
  • Avoid trans fatty acids; limit saturated fatty acids
  • Structured counseling
  • Meal replacement
  • Structured counseling
  • Meal replacement
Physical activity
  • 150 min/week moderate exertion (eg, walking, stair climbing)
  • Strength training
  • Increase as tolerated
  • Structured program
  • Structured program
  • Medical evaluation/clearance
  • Medical supervision
Sleep
  • About 7 hours/night
  • Screen for obstructive sleep apnea
  • Screen for obstructive sleep apnea
Behavioral support
  • Community engagement
  • Screen for mood disorders
  • Refer to mental health professional
  • Behavioral therapy
  • Refer to mental health professional
  • Behavioral therapy
Smoking cessation
  • No tobacco products
  • Structured programs
  • Structured programs
Garber AJ, et al. Endocr Pract. 2016;22(1):84-113.

Table 4
FDA-Approved Weight Loss Medications
Short-Term (a few weeks) Long-Term
  • Diethylpropion
  • Phendimetrazine
  • Phentermine
  • Orlistat
  • Phentermine/topiramate extended release (ER)
  • Lorcaserin
  • Naltrexone/bupropion
  • Liraglutide 3mg
Garber AJ, et al. Endocr Pract. 2016;22(1):84-113.

Table 5
Glycemic Control Pharmacotherapy
(Intensity stratified by burden of obesity and related complications, going left to right)
Entry A1C <7.5% Entry A1C ≥7.5% Entry A1C ≥7.5% Entry A1C >9.0%
Monotherapy

  • Metformin
  • GLP1-RA
  • SGLT-2i
  • DPP-4i
  • TZD*
  • AGi
  • SU/GLN*

Proceed to dual therapy if not at goal in 3 months

Dual Therapy Metformin or other 1st-line agent, plus–

  • GLP-1RA
  • SGLT-2i
  • DPP-4i
  • TZD*
  • Basal insulin*
  • Colesevelam
  • Bromocriptine QR
  • AGi
  • SU/GLN*

Proceed to triple therapy if not at goal in 3 months

Triple Therapy Metformin or other 1st-line agent, + 2nd-line agent, plus–

  • GLP-1 RA
  • SGLT-2i
  • TZD*
  • Basal insulin*
  • CPP-4i
  • Colesevelam
  • Bromocriptine QR
  • AGi
  • SU/GLN*

Proceed to or intensify insulin therapy if not at goal in 3 months

Asymptomatic:

  • Dual therapy or
  • Triple therapy

Symptomatic:

  • Insulin ±
  • Other agents

Add to/intensify insulin

*Use with caution
GLP-1 RA =glucagon-like peptide-1 (GLP-1) receptor agonists; SGLT2=sodium glucose cotransporter 2 inhibitors; DPP-4i=dipeptidyl peptidase 4 inhibitors; TZD= thiazolidinediones; AGi=alpha-glucosidase inhibitors; SU= sulfonylureas
Garber AJ, et al. Endocr Pract. 2016;22(1):84-113.