Refinements based on new clinical information fill out the particulars of a newly updated comprehensive algorithm.
A newly updated comprehensive algorithm continues to guide physicians in the management of patients who have type 2 diabetes mellitus (DM).
The American Association of Clinical Endocrinologists and American College of Endocrinology’s 2016 algorithm takes into account new treatments, disease management, and key clinical data. Included are the following:
• A new lifestyle therapy optimization section.
• A complications-centric model for overweight/obese patients with an analysis of currently available obesity treatments.
• Further stratification of therapy choices based on the patient’s initial A1C level.
• A detailed overview of all the medical treatments for hyperglycemia, hypertension, and hypercholesterolemia that were approved by the FDA through December 2015.
“In addition to advocating glycemic control to reduce microvascular complications, this document highlights obesity and prediabetes as underlying risk factors for the development of (type 2 DM) and associated macrovascular complications,” stated the authors of the new guidelines, led by Alan J. Garber, MD, PhD, Chair, Professor, Departments of Medicine, Biochemistry, and Molecular Biology and Molecular and Cellular Biology, Baylor College of Medicine, Houston. “In addition, the algorithm provides recommendations for blood pressure and lipid control, the two most important risk factors for cardiovascular disease.”
The algorithm emphasizes the importance of making safe therapy choices to minimize or avoid hypoglycemia and its serious complications. In addition, it provides clinical guidance on establishing and maintaining optimal hemoglobin A1C and glycemic targets; minimizing weight gain and its related complications; and managing type 2 DM comorbidities, such as insulin resistance, macro- and microvascular complications, hypertension, cardiovascular disease, and lipid disorders.
The new guidelines suggest no major changes from the 2015 guidelines but offer refinements based on new clinical information.
Color-coded graphic algorithms include those for lifestyle therapy, overweight/obesity, prediabetes, glycemic control, insulin therapy, cardiovascular risk-factor modification, medication profiles, and guiding principles.
A summary chart on the attributes of each class of hyperglycemic treatment and the algorithm principles follow at the end.
The founding principles of the guidelines include the following:
• Lifestyle optimization is essential for all patients with DM.
• The hemoglobin A1C target should be individualized based on numerous factors, such as age, life expectancy, comorbid conditions, duration of DM, risk of hypoglycemia or adverse consequences from hypoglycemia, patient motivation, and patient adherence.
• Glycemic control targets include fasting and postprandial glucose levels as determined by self-monitoring of blood glucose levels.
• The choice of DM therapies should be individualized based on attributes specific to both patients and the medications themselves.
• Minimizing risk of both severe and nonsevere hypoglycemia and of weight gain is a priority.
• The initial acquisition cost of medications is only a part of the total cost of care, which includes monitoring requirements and risks of hypoglycemia and weight gain.
• Combination therapy usually is required and should involve agents that have complementary mechanisms of action.
• Therapy should be evaluated frequently (eg, every 3 months) using multiple criteria until the patient is stable.
• The therapeutic regimen should be as simple as possible to optimize adherence.