AACE/ACE algorithm: In type 2 diabetes, address multifactorial risk management

Alan J. Garber

PHILADELPHIA — In treating adults with prediabetes or type 2 diabetes, clinicians must consider and work to treat all risk factors for conversion to overt type 2 diabetes and its related macrovascular and microvascular complications, according to a speaker here.

Lifestyle modification underlies all therapies for a person with type 2 diabetes, and it must remain the central focus of any management effort, Alan J. Garber, MD, PhD, MACE, professor in the departments of medicine, biochemistry and molecular biology, and molecular and cellular biology at Baylor College of Medicine in Houston, and chief medical editor of Endocrine Today, said during a presentation at the second annual Heart in Diabetes continuing education conference. In addressing risk management, clinicians must take care to work with a patient to avoid hypoglycemia, avoid weight gain, individualize all glycemic targets — including HbA1c, fasting plasma glucose and postprandial glucose — and chose therapies that reflect a patient’s cardiac, cerebrovascular and renal status.

“This business of creating rules for hundreds of millions of people and expecting it to be relevant, let alone optimal care, is laughable,” Garber said. “It’s the clinician’s job to make his or her treatment recommendations appropriate for the patient at hand.”

R ole of overweight, obesity

In patients with type 2 diabetes and overweight or obesity, the intensity of the intervention should be based on the underlying degree of complications produced by the patient’s obesity, Garber said.

“For so long, we’ve made avoidance of obesity an independent goal, but a goal that reflects an underlying character flaw of the patient,” Garber said. “Patients rarely want to discuss it, and usually, do not engage in adequate therapies. Yet, the literature is filled with data showing lifestyle modification with weight loss will produce a better outcome for such patients.”

Rather than a BMI-centric approach for the treatment of patients who have obesity or overweight, the 2018 AACE/ACE Comprehensive Type 2 Diabetes Management Algorithm emphasizes a complications-centric model that incorporates three disease stages: stage 0 (elevated BMI with no obesity complications), stage 1 (1 or 2 mild to moderate obesity complications) and stage 3 (at least two mild to moderate obesity complications or at least one severe complication). The patients who will benefit most from medical and surgical intervention have obesity-related complications that can be classified into two general categories: insulin resistance/cardiometabolic disease and biomechanical consequences of excess body weight, according to the algorithm.

“If [the patient] has clinically apparent, relevant cardiovascular illness, get them to lose some weight,” Garber said. “It’s part of their problem, and they need to deal with it. They need to go through the routine of systematic lifestyle, exercise, nutritional therapy and prescriptive therapies for weight loss, not just up to and including nutrition, but including those therapies, which may be medications or surgical. Whatever is necessary to try and give the patient a future.”

Garber also noted that interventions should begin as early in the course of the disease as possible, during the prediabetes phase.

“We recognize that diabetes is not an open and shut disease,” Garber said. “It’s a gradation of dysglycemia through which each patient travels at his or her own course. We propose that patients, early in the course, what we now call prediabetes, be interrupted in that course as soon as we can with adequate treatments for the drivers of the prediabetic state.”

Consider other risk factors

Two recently-approved agents — SGLT2 inhibitors and GLP-1 receptor agonists—seem to influence CV outcomes in diabetes, but the therapies are “not the only game in town” when it comes to risk reduction, Garber cautioned. The 2018 AACE/ACE algorithm includes updates on lipid-lowering and antihypertensive medications for the prevention of CVD, and Garber noted it is important to consider patient targets in those areas as well.

“The standard drivers of complications include lipids and blood pressure, and not to go on immediately to ‘magic medicines’ that have proved positive in a clinical trial,” Garber said. “Let’s also deal with established risk factors, such as dyslipidemia, and a recognition of a category of ‘extreme risk,’ where LDL [cholesterol] levels are high relative to what is going on in the patient.”

The glycemic control algorithm, Garber said, should proceed along the same lines. When a provider finds a specific agent is no longer effective for a patient, the provider should consider adding a second drug, without hesitation, he said.

“When you’re 3 months [on a new agent] are up — and you should have already titrated your drug — you’ll find out that this is not going to get the patient to goal,” Garber said. “Get them on a second drug, or a third drug. If they’re still having symptoms, frankly, I think the only treatment is insulin, at least initially, to relieve the glucotoxicity.”

New agents, patient benefits

One can argue about the fine points of each medication and what each study suggested; however, today, patients have a remarkable number of options to manage their diabetes, Garber said.

“I wanted to remind you of something,” Garber said. “Most of the superior drugs for addition to metformin — for second- and third-line therapy — are already those approved for cardiovascular benefit because they don’t cause hypoglycemia and they have no or minimal risk for weight gain. Those agents, irrespective of whether they’re actually producing benefit with respect to cardiovascular risk, surely help your patient benefit from better glucose control without difficulties. And it’s the difficulties which result in so much of our compliance disorders.” – by Regina Schaffer

Reference:

Garber A. AACE management recommendations for the high-risk CV patient with DM. Presented at: Heart in Diabetes Clinical Education Conference; July 13-15, 2018; Philadelphia.

AACE/ACE Comprehensive Type 2 Diabetes Algorithm. Available at: https://www.aace.com/sites/all/files/diabetes-algorithm-executive-summary.pdf.

Disclosure: Garber is chief medical editor of Endocrine Today. He reports he is a consultant for Novo Nordisk and Intarcia.