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AACE Releases Updated Algorithm for Managing Persons with Type 2 Diabetes


The 2023 algorithm emphasizes a complication-centric approach, beyond glucose levels, for determining first-line pharmacotherapy.



Clinicians who manage patients with type 2 diabetes (T2D) should take a complication-centric approach for determining first-line pharmacotherapy, according to an updated algorithm from the American Association of Clinical Endocrinology (AACE).

The AACE’s 2023 Comprehensive Type 2 Diabetes Management Algorithm was published in the journal Endocrine Practice and unveiled at the AACE Annual Meeting held May 4-6, 2023, in Seattle, Washington.

The 2023 algorithm supplements AACE’s 2022 Clinical Practice Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan and emphasizes the need to assess other health concerns, including cardiovascular disease and chronic kidney disease, to frame pharmacologic decisions for the treatment of T2D.

"Over the last several years, the paradigm of diabetes treatment has changed from a strict focus on glucose control and a one-size-fits-all approach, to a personalized assessment that considers a person's existing risks for cardiac events or kidney failure, so we can choose the right medication to decrease those risks," said first author and president-elect of AACE Susan L. Samson, MD, PhD, in an AACE press release. "Therefore, the latest algorithm provides a road map to easily navigate care and treatment based on both glycemic control and other conditions to improve a person's health and quality of life."

The complications-centric algorithm focuses on patients with T2D who also have atherosclerotic cardiovascular disease (ASCVD), heart failure, stroke, or chronic kidney disease. For persons with ASCVD, clinicians should start treatment with a GLP-1 receptor agonist or SGLT2 inhibitor. Patients with heart failure should receive an SGLT2, whereas those with stroke should receive a GLP-1 or pioglitazone, and adults with CKD should begin therapy with an SGLT2 or GLP-1.

Like the 2022 AACE diabetes guideline, the updated algorithm also emphasizes lifestyle modification and treatment of overweight/obesity as key pillars in the management of prediabetes and T2D.

In addition, the algorithm includes access and cost of medications as factors related to health equity to consider in clinical decision-making.

"We know that by focusing on the individual person's characteristics, preferences and environment to inform decisions for diabetes treatment, care teams can improve outcomes," added Samson. "We at AACE are pleased to share this comprehensive guide to promote better outcomes for our patients."

Another new section in the 2023 algorithm is immunization recommendations for patients with T2D, which recommends patients should receive vaccinations according to the Centers for Disease Control and Prevention’s recommended immunization schedule. The paper also details each recommended vaccination and when it should be received.

“Having a properly trained staff and a culture of vaccine confidence in the entire clinical practice are important in ensuring that all health care team members are engaged in efforts to improve patient vaccinations,” wrote Samson and colleagues. “Other measures recommended to improve vaccination rates include making vaccinations more convenient, coadministration of compatible vaccines, and making use of vaccination champions in the clinical setting.”

Reference: Samson SL, Vellanki P, Blonde L, et al. American Association of Clinical Endocrinology consensus statement: Comprehensive type 2 diabetes management algorithm - 2023 update. Endocr Pract. 2023;29:305-340.

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