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Updated Diabetes Clinical Guidelines

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An updated algorithm for type 2 diabetes management from the American Association of Clinical Endocrinologists (AACE) has been recently released. It includes new sections on lifestyle therapy, guiding principles, and incorporates all medications approved by the Food and Drug Administration through December 2015 for managing hyperglycemia, weight, blood pressure, and dyslipidemia.

Lifestyle therapy (previously “modification”) is now given its own section, focusing on nutrition counseling and education, physical activity, adequate rest, and behavioral support.

It begins with a new list of “founding principles”

1. Lifestyle optimization is essential for all patients with diabetes. Lifestyle optimization is multifac- eted, ongoing, and should engage the entire diabe- tes team. However, such efforts should not delay needed pharmacotherapy, which can be initiated simultaneously and adjusted based on patient response to lifestyle efforts. The need for medical therapy should not be interpreted as a failure of lifestyle management, but as an adjunct to it.

2. The hemoglobin A1C (A1C) target should be individualized based on numerous factors, such as age, life expectancy, comorbid conditions, dura- tion of diabetes, risk of hypoglycemia or adverse consequences from hypoglycemia, patient moti- vation, and adherence. An A1C level of ≤6.5% is considered optimal if it can be achieved in a safe and affordable manner, but higher targets may be appropriate for certain individuals and may change for a given individual over time.

3. Glycemic control targets include fasting and post- prandial glucose as determined by self-monitor- ing of blood glucose (SMBG).

4. The choice of diabetes therapies must be individu- alized based on attributes specific to both patients and the medications themselves. Medication attri- butes that affect this choice include antihyper- glycemic efficacy, mechanism of action, risk of inducing hypoglycemia, risk of weight gain, other adverse effects, tolerability, ease of use, likely adherence, cost, and safety in heart, kidney, or liver disease.

5. Minimizing risk of both severe and nonsevere hypoglycemia is a priority. It is a matter of safety, adherence, and cost.

6. Minimizing risk of weight gain is also a priority. It too is a matter of safety, adherence, and cost.

7. 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. Safety and efficacy should be given higher priority than medication cost.

8. This algorithm stratifies choice of therapies based on initial A1C level. It provides guidance as to what therapies to initiate and add but respects individual circumstances that could lead to different choices.

9. Combination therapy is usually required and should involve agents with complementary mechanisms of action.

10. Comprehensive management includes lipid and BP therapies and treatment of related comorbidities.

11. Therapy must be evaluated frequently (e.g., every 3 months) until stable using multiple criteria, including A1C, SMBG records (fasting and post- prandial), documented and suspected hypoglyce- mia events, lipid and BP values, adverse events (weight gain, fluid retention, hepatic or renal impairment, or CVD), comorbidities, other rele- vant laboratory data, concomitant drug adminis- tration, diabetic complications, and psychosocial factors affecting patient care. Less frequent moni- toring is acceptable once targets are achieved.

12. The therapeutic regimen should be as simple as possible to optimize adherence.

13. This algorithm includes every FDA-approved class of medications for T2D (as of December 2015).

Here are the algorithms provided by the American Association of Clinical Endocrinologists:

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