AACE Updates Type 2 Diabetes Algorithm for First Time Since 2023, Adding New Classification Tool and Expanded Comorbidity Guidance

The American Association of Clinical Endocrinology (AACE) has released its 2026 updated consensus statement on the management of adults with type 2 diabetes, emphasizing a shift toward weight-centered care and comorbidity-driven treatment strategies rather than glucose control alone.¹

On March 17, 2026, the AACE published the 2026 update to its type 2 diabetes algorithm in Endocrine Practice. It is the first update of the algorithm since 2023 and was conducted in part due to the rapid evolution of medications for cardiometabolic disorders. It was developed by a multidisciplinary task force led by Susan L. Samson, MD, PhD, FRCPC, FACE, professor and chair of diabetes and metabolism at Mayo Clinic in Florida, and Priyathama Vellanki, MD, section chief and medical director at the Grady Endocrinology Clinic at Emory University School of Medicine.¹

The revised algorithm includes 11 sections spanning principles of care, prediabetes, diabetes classification, dyslipidemia, hypertension, complications- and comorbidities-centric glycemic control, glucose-centric glycemic control, insulin initiation and titration, pharmacotherapy profiles for type 2 diabetes and obesity, and vaccine recommendations for adults with type 2 diabetes. Authors state that the 2026 update continues to emphasize lifestyle modification and treatment of overweight and obesity as central pillars of care while further elevating management of atherosclerotic risk factors and comorbid conditions.¹

A key highlight of the consensus statement is the introduction of a diabetes classification algorithm aimed at reducing misdiagnosis, particularly distinguishing type 1 from type 2 diabetes and identifying less common etiologies. After confirming a diagnosis of diabetes using standard criteria, clinicians are guided to assess for a type 2 diabetes phenotype by reviewing for overweight or obesity, family history, history of gestational diabetes, and signs of insulin resistance. Those who do not clearly fit the type 2 diabetes profile are directed toward further evaluation for type 1 diabetes or latent autoimmune diabetes in adults, pancreatic disease, monogenic diabetes, or medication-induced hyperglycemia. The task force noted that in one UK cohort study, nearly 40% of adults meeting criteria for type 1 diabetes had initially been treated as though they had type 2 diabetes.¹

In addition, within this framework, the guidelines newly prioritize screening for hypercortisolism, informed by findings from the CATALYST clinical trial, which demonstrated a higher-than-expected prevalence among patients with difficult-to-control diabetes.^1,2

The algorithm also sharpens its complications-first approach to pharmacotherapy. In adults with type 2 diabetes and heart failure, chronic kidney disease, established or high-risk atherosclerotic cardiovascular disease, prior stroke or transient ischemic attack, or metabolic dysfunction–associated steatotic liver disease, treatment selection should be driven first by those conditions. The update highlights sodium-glucose cotransporter 2 inhibitors for heart failure and chronic kidney disease, glucagon-like peptide-1 receptor agonists for atherosclerotic cardiovascular disease and stroke risk reduction, and incretin-based therapies and pioglitazone as options in selected patients with metabolic dysfunction–associated steatotic liver disease.¹

Weight management receives more explicit attention throughout the document. The guidance states that excess weight contributes to insulin resistance and multiple cardiometabolic complications and notes that meaningful clinical improvement may occur across weight-loss thresholds greater than 5% to greater than 15%. In prediabetes, the algorithm identifies a 7% to 10% reduction in body weight as an important target to delay progression to type 2 diabetes and discusses use of antiobesity pharmacotherapy and bariatric procedures when appropriate.¹

The statement also underscores use of continuous glucose monitoring in adults with diabetes, particularly those using insulin, and recommends broader incorporation of time in range, time below range, glucose management indicator, and glycemic variability into treatment decisions when available. For most adults, the algorithm continues to target an A1C of 6.5% or lower if achievable safely, while stressing that glycemic goals should be individualized based on comorbidity burden, hypoglycemia risk, life expectancy, and cognitive or psychological status.¹

Another practical addition for frontline clinicians is the vaccine recommendations section for adults with diabetes mellitus. The document summarizes current CDC adult immunization recommendations and encourages clinicians to assess vaccination status at every visit, strongly recommend indicated vaccines, administer or refer for vaccination, and document immunizations in the medical record and registry systems.¹

References:

1. Samson SL, Vellanki P, Blonde L, et al. American Association of Clinical Endocrinology Consensus Statement: Algorithm for Management of Adults With Type 2 Diabetes - 2026 Update. Endocr Pract. Published online March 17, 2026. doi:10.1016/j.eprac.2026.01.006
2. Buse JB, Kahn SE, Aroda VR, et al. Prevalence of hypercortisolism in difficultto-control type 2 diabetes. Diabetes Care. 2025;48:2012—2020. doi.org/10.2337/dc24-2841