1 2 0. AM E RI C A N A S S O CI A TI O N O F CL I NICAL ENDOCRINOLOGIST S. AM E RI C A N CO L L EG E O F E ND O CR INOLOGY. AA C E/A C E C O M P R E H E N S I V E. 1 9. TY P E 2 DI A BE T E S. MAN AG E M E N T A L G O R I T H M. COPYRIGHT 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI TABLE OF CONTENTS. COMPREHENSIVE TYPE 2 DIABETES MANAGEMENT ALGORITHM. I. Principles for Treatment of Type 2 Diabetes II. Lifestyle Therapy III. Complications-Centric Model for Care of the Patient with Overweight/Obesity IV. Prediabetes Algorithm V. ASCVD Risk Factor Modifications Algorithm VI. Glycemic Control Algorithm VII.
2 Algorithm for Adding/Intensifying Insulin VIII. Profiles of Antidiabetic Medications COPYRIGHT 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI PRINCIPLES OF THE AACE/ACE COMPREHENSIVE. TYPE 2 DIABETES MANAGEMENT ALGORITHM. 1. Lifestyle modification underlies all therapy ( , weight control, physical activity, sleep, etc.). 2. Avoid hypoglycemia 3. Avoid weight gain 4. Individualize all glycemic targets (A1C, FPG, PPG). 5. Optimal A1C is , or as close to normal as is safe and achievable 6. Therapy choices are affected by initial A1C, duration of diabetes, and obesity status 7. Choice of therapy reflects cardiac, cerebrovascular, and renal status 8.
3 Comorbidities must be managed for comprehensive care 9. Get to goal as soon as possible adjust at 3 months until at goal 10. Choice of therapy includes ease of use and affordability 11. A1C for those on any insulin regimen as long as CGM is being used COPYRIGHT 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI LIFESTYLE THERAPY. RISK STRATIFICATION FOR DIABETES COMPLICATIONS. INTENSITY STRATIFIED BY BURDEN OF OBESITY AND RELATED COMPLICATIONS. Maintain optimal weight + +. Calorie restriction Avoid trans fatty Structured (if BMI is increased) acids; limit Nutrition counseling Plant-based diet; saturated fatty Meal replacement high polyunsaturated and acids monounsaturated fatty acids + +.
4 150 min/week moderate exertion Structured Medical evaluation/. Physical ( , walking, stair climbing) program clearance Activity Strength training Wearable Medical supervision Increase as tolerated technologies Sleep About 7 hours per night Basic sleep hygiene + Screen OSA. Home sleep study + Referral to sleep lab Behavioral Support Community engagement Alcohol moderation + Discuss mood with HCP + Formal behavioral therapy Smoking Cessation No tobacco products + Nicotine replacement therapy + Referral to structured program COPYRIGHT 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI COMPLICATIONS-CENTRIC MODEL FOR CARE OF.
5 THE PATIENT WITH OVERWEIGHT/OBESITY. S T EP 1 EVA LU AT I ON FOR COMPLI CAT I ONS AND STAGING. CARDIOMETABOLIC DISEASE | BIOMECHANICAL COMPLICATIONS. BMI <25 NO COMPLICATIONS COMPLICATIONS. NO OVERWEIGHT BMI 25 BMI 25. OR OBESITY OVERWEIGHT OR OBESITY MILD TO MODERATE SEVERE. STAGE 0 STAGE 1 STAGE 2. S T EP 2 S E LE CT: Therapeutic targets for improvement in complications + Treatment modality + Treatment intensity based on staging Lifestyle Therapy: Physician/RD counseling, web/remote program, structured multidisciplinary program Medical Individualize care by selecting one of the following based on e cacy, safety, Therapy and patients' CLINICAL pro le: phentermine, orlistat, lorcaserin, (BMI 27): phentermine/topiramate ER, naltrexone/bupropion, liraglutide 3 mg Surgical Therapy (BMI 35).
6 Gastric banding, sleeve, or bypass If therapeutic targets for complications not met, intensify lifestyle, medical, and/or surgical treatment S TE P 3 modalities for greater weight loss. Obesity is a chronic progressive disease and requires commitment to long-term therapy and follow-up. COPYRIGHT 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI PREDIABETES ALGORITHM. IFG (100 125) | IGT (140 199) | METABOLIC SYNDROME (NCEP 2001). LIFESTYLE THERAPY. (Including Medically Assisted Weight Loss). TREAT ASCVD WEIGHT LOSS TREAT HYPERGLYCEMIA. RISK FACTORS THERAPIES FPG >100 | 2-hour PG >140.
7 ASCVD RISK FACTOR NORMAL 1 PRE-DM MULTIPLE PRE-DM. MODIFICATIONS ALGORITHM GLYCEMIA CRITERION CRITERIA. DYSLIPIDEMIA HYPERTENSION. Low-risk Consider with ROUTE ROUTE. Progression Intensify Medications Caution Weight Loss Metformin TZD. Therapies OVERT Acarbose GLP-1RA. DIABETES. LEGEND. Orlistat, lorcaserin, phentermine/topiramate ER, PROCEED TO. naltrexone/bupropion, liraglutide 3 mg, GLYCEMIC CONTROL If glycemia not normalized or bariatric surgery as indicated for obesity treatment ALGORITHM. COPYRIGHT 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI ASCVD RISK FACTOR MODIFICATIONS ALGORITHM.
8 D Y S L I PIDE MIA HYPERTEN SION. L I F E S T Y L E T H E R A P Y (Including Medically Assisted Weight Loss). LI P I D P ANEL: Assess ASCVD Risk GO A L : SY ST O L I C < 1 3 0 , D I A ST O L I C < 8 0 m m H g STATI N T HER A PY ACEi For initial blood pressure If TG >500 mg/dL, brates, Rx-grade omega-3 fatty acids, niacin or >150/100 mm Hg: If statin-intolerant ARB DUAL THERAPY. Calcium Try alternate statin, lower statin Repeat lipid panel; Intensify therapies to Channel dose or frequency, or add nonstatin assess adequacy, attain goals according ACEi Blocker LDL-C- lowering therapies tolerance of therapy to risk levels or ARB -blocker RISK LEVELS HIGH VERY HIGH EXTREME RISK LEVELS: Thiazide HIGH: DESIRABLE LEVELS DESIRABLE LEVELS DESIRABLE LEVELS DM but no other major risk and/or age <40.
9 LDL-C (mg/dL) <100 <70 <55 VERY HIGH: If not at goal (2 3 months). DM + major ASCVD. Non-HDL-C (mg/dL) <130 <100 <80 risk(s) (HTN, Fam Hx, low HDL-C, smoking, Add calcium channel blocker, TG (mg/dL) <150 <150 <150. CKD3,4)*. -blocker or thiazide diuretic EXTREME: DM plus established Apo B (mg/dL) <90 <80 <70 CLINICAL CVD If not at goal (2 3 months). Intensify lifestyle therapy (weight loss, physical activity, dietary Add next agent from the above If not at desirable levels: group, repeat changes) and glycemic control; consider additional therapy If not at goal (2 3 months). To lower LDL-C: Intensify statin, add ezetimibe, PCSK9i, colesevelam, or niacin Additional choices ( -blockers, To lower Non-HDL-C, TG: Intensify statin and/or add Rx-grade OM3 fatty acid, brate, and/or niacin central agents, vasodilators, To lower Apo B, LDL-P: Intensify statin and/or add ezetimibe, PCSK9i, colesevelam, and/or niacin aldosterone antagonist).
10 To lower LDL-C in FH:** Statin + PCSK9i Achievement of target blood Assess adequacy & tolerance of therapy with focused laboratory evaluations and patient follow-up pressure is critical * EV E N MORE INTEN S I V E TH ER A PY M I GH T B E W A R R AN T E D * * F AM IL IAL H YP E R C H OL E S T E R OL E M IA. COPYRIGHT 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI GLYCEMIC CONTROL ALGORITHM. INDIVIDUALIZE For patients without concurrent serious For patients with concurrent serious A1C A1C > COPYRIGHT 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE.