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AACE comprehensive diabetes algorithm addresses 'broad nature' of disease
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PHOENIX — Integration of obesity management in the treatment of patients with diabetes is one of the key recommendations highlighted in the newly published American Association of Clinical Endocrinologists comprehensive diabetes management algorithm, experts said here.
“What makes this algorithm different from others is it does not just focus on hyperglycemia but it does address obesity, prediabetes, goals of glycemic control, a new aspect looking at insulins and cardiovascular risks,” Yehuda Handelsman MD, FACP, FACE, FNLA, medical director and principal investigator of the Metabolic Institute of America in Tarzana, Calif., said during a presentation here.
Yehuda Handelsman
Obesity management, prevention
AACE President-Elect Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU, said that obesity is a major driver in the metabolic model of type 2 diabetes and that obesity is indeed a disease.
“Management for obesity includes prevention and treatment. This is a salient point highlighted in this algorithm — it is not just a treatment algorithm of management, it incorporates prevention as well,” Mechanick said. “[The algorithm also] includes lifestyle, pharmacotherapy and surgery. Weight loss is the main clinical endpoint.. It is a complications-centric risk stratification strategy. Complications of obesity are insulin resistance, cardiometabolic and then we include approved medications.”
Moreover, Mechanick said that lifestyle modifications are an emerging specialty and are critical in the care of patients with diabetes.
“Nutritional care of patients with diabetes includes traditional medical nutrition therapy, as well ashealthy eating strategies,” Mechanick said.
Cardiovascular assessment
Task force member, George Grunberger, MD, FACP, FACE, addressed the cardiovascular points of the new algorithm.
George Grunberger
“If you look at dyslipidemia, therapeutic lifestyle changes are critical because we’re dealing with patients at higher risk, and if they are obese and overweight, we need to pay attention to that. For dyslipidemia we need to assess risk for CVD. A lipid panel is required to find out what to do for these patients,” Grunberger said. “We reached a consensus that if patients with type 2 diabetes can tolerate it, they should be on a statin. However, there’s an exception if the triglycerides at the first lipid panel are over 500 mg/dL; we thought it wise to first address that.”
Grunberger said to use fibrate or omega-3 fatty acids to reduce triglycerides before turning to a statin. However, if patients cannot use statins, he said alternative medications can be attempted, lower statin dosages can be prescribed in less frequency, or non-statins can be added for LDL therapy.
Once this is done, Grunberger said a repeat lipid panel and assessment is warranted to adequately address tolerance of therapy.
In addition to lipids, Grunberger addressed the issue of hypertension in this patient population. He said that ACE-i or ARBs should be the first choice whenever possible; that the target in most patients should be about130/80 mmHg.
According to Grunberger, reaching the target is more important than the order of addition of different agents. Furthermore, he said the avoidance of clinical inertia and the addition of different drugs every 2-3 months is essential. Individulized care is key, he said.
Prediabetes, insulin and glycemic control
Prediabetes, insulin and glycemic control
Alan J. Garber, MD, PhD, Endocrine Today chief medical editor and past-president of AACE, said that the task force decided to emphasize the broad nature of the issues that confront the patient with diabetes.
“Our prediabetes algorithm is based essentially on the 2008 prediabetes consensus statement which recognizes three prediabetic states: impaired fasting glucose, impaired glucose tolerance and the metabolic syndrome using the expanded glucose criteria of the NCDP 2005 update,” Garber said. “What’s new in this prediabetes algorithm is the recognition that weight management and obesity reduction is an effective solution to the dysglycemia of prediabetes, as is the previously used antihyperglycemic treatments that are the hallmark of all other strategies for prediabetes management.”
Alan J. Garber
Garber reported that there are two different alternative pathways for dealing with dysglycemia.
“We suspect that anti-obesity therapies – whether surgically or medically assisted weight loss– are as effective as or more effective than any antihyperglycemic therapy in restoring apparent normal glycemia in patients with prediabetes,” he said.
Formerly, the task force recommended that patients with only 1 criterion for prediabetes only have about a fivefold increase for developing future diabetes.
“Low intensity medications that would lower risk and are relatively well-tolerated, such as metformin or alpha-glycosidase, would be sufficient,” he added.
Regarding glucose control in patients with established diabetes, Garber said that for patients with concurrent illness and at risk for hypoglycemia, an HbA1c target of >6.5% is suggested. For healthy patients without concurrent illness with a low risk for hypoglycemia, the algorithm suggests an HbA1c target of ≤6.5%.
Garber suggests it is probable that basal insulin therapy may be a third line drug as beta-cell function digresses and relative insulin resistance progresses in these patients. In almost every circumstance, the task force advises against the use of sulfonylureas.
For patients with very high HbA1c levels presenting with symptoms, Garber suggests exogenous insulin.
Additionally, the task force has provided guidance for the use of insulin in those in whom control with insulin is not attempted until after monotherapy and dual therapy failures.
“We usually have two different titration intervals depending on entrance HbA1c, again using HbA1c as the guide for residual pancreatic dysfunction or insulin resistance. For HbA1c less than 8%, a lower dose or titration can be given. For those with greater than 8%, a higher dose is likely due to a higher beta-cell dysfunction and pancreatic deficiency,” Garber said.
Once a patient has reached a goal, he suggests stopping titration. If not, prandial control by either incretin addition or rapid acting prandial insulin analogs is recommended. – by Samantha Costa
For more information:
Garber AJ. SGS4: Panel discussion: AACE Comprehensive Algorithm for the Management of Diabetes. Presented at: the AACE Annual Scientific and Clinical Congress; May 1-5, 2013; Phoenix.
Disclosure: Garber is a speaker/consultant for Janssen Pharmaceuticals. Grunberger reports research grants from Lilly, Novo Nordisk, Bristol Myers Squibb and speaker’s bureaus for Lilly, Novo Nordisk, Valeritas, Amarin, Takeda, Sanofi, and Merck. Handelsman reports various financial ties with AstraZeneca, Boehringer Ingelheim, Bristol-Myers Squibb, Daiichi Sankyo, Genentech, Gilead, GlaxoSmithKline, Merck & Co, Novo Nordisk, Sanofi-Aventis, Takeda, Tolerx and Xoma. Mechanick reports that he has received speaker and program development honoraria from Abbott Nutrition.