The American Association of Clinical Endocrinologists (AACE) has released new, comprehensive clinical practice guidelines and an updated diabetes algorithm to aid clinicians in the medical management of patients with diabetes mellitus (DM). The 2015 guidelines have been substantially modified since the previous guidelines with the focus going beyond glycemic control to address multiple DM risk factors.
Clinical recommendations for the management of obesity, lipid disorders, hypertension, kidney disease, cardiovascular disease, hypoglycemia, and anti-hyperglycemic therapy to prevent complications are also included. The guidelines also address important information regarding vaccination, cancer risks, sleep disorders, depression, and management of prediabetes.
The diabetes management algorithm is presented as an illustrated treatment pathway and includes all FDA-approved medication classes for diabetes. The treatment algorithm is based on initial A1c, with medications listed in a suggested hierarchy of usage. For example, recommendations for type 2 diabetes include the following:
For patients with entry A1C of <7.5%:
- Initial therapy can include: metformin, GLP-1 receptor agonist, DPP-4 inhibitor, SGLT2 inhibitor, or α-glucosidase inhibitor (Grade C)
- Thiazolidinediones, sulfonylurea or glinide may be considered as alternative treatment but should be used with caution (Grade C)
For patients with entry A1C of >7.5%:
- Initiate with metformin (unless contraindicated) plus a second agent (preference for agents with low hypoglycemia potential, those that are weight neutral or are associated with weight loss) (Grade C)
- Preferred second agents: GLP-1 receptor agonists, SGLT2 inhibitors, DPP-4 inhibitors; thiazolidinediones and basal insulin may be considered alternatives
- In some situations, colesevelam, bromocriptine, or an α-glucosidase inhibitor may be useful for glycemic control (Grade C)
- Due to risk of hypoglycemia, sulfonylureas and glinides are considered least desirable alternatives. (Grade B)
For patients with entry A1C >9.0% who have symptoms of hyperglycemia:
- Insulin alone or in combination with metformin or other oral agents is recommended (Grade A)
- To reduce postprandial hyperglycemia, A1C, and weight, pramlintide and GLP-1 receptor agonists can be used as adjuncts to prandial insulin therapy (Grade B)
To view the complete guidelines and algorithm visit AACE.com.