Continuing to refine how diabetes is treated, the American Association of Clinical Endocrinologists have released a new series of algorithms for the medical management of type 2 diabetes, pre-diabetes metabolic syndrome, and obesity.
The guidelines are written for practitioners, both other endocrinologists and primary care physicians. Most people with diabetes are cared for by their primary care physicians. If all patients with diabetes desired treatment by a specialist, the number of practicing endocrinologist would be woefully inadequate to meet the need. Many primary care physicians do not have the time to devote to an in-depth knowledge of diabetes so treatment algorithms and guidelines provide a much needed paradigm for care delivery.
The new algorithms are a change from previous recommendations. They stress obesity management through lifestyle, medications and surgical procedures as part of the treatment of diabetes and its cardiac co-morbidities. They also place greater emphasis on the use of medication early in the pre-diabetes stage of the disease. Including medications as a concomitant part of treatment from the beginning, acknowledges both the difficulty of lifestyle therapy and the progressive nature of the disease.
The algorithm for type 2 diabetes recommends the quick intensification of therapy at 3 month intervals when target glycemic goals are not reached. This is important as the longer patients continue to have glucose levels out of target range, the higher the risk of developing complications.
Sulfonuyreas, which were the standard bearer treatment in addition to metformin for the last twenty-five years, have lost their favored status. They are now considered drugs to be used only if other medications aren’t tolerated or fail, due to their risk of causing hypoglycemia and weight gain. Thiazolidinediones (Actos® and Avandia®) are also relegated to second-tier status.
For newly diagnosed patients, the algorithm lays out treatment decisions based on starting A1C levels. Medication management is recommended for all patients in addition to lifestyle modification. Metformin, incretins, DPP4-inhibitors and alpha-glucosidase inhibitors are the drugs of choice, in the order listed, for initial therapy.
It also advocates the use of fast acting insulin analogs, Novolog®, Humalog®, Apidra® over regular insulin and flat basal insulins, Lantus® and Levemir,® over the use of NPH due to the decreased risk of hypoglycemia and the improved consistency of action throughout their duration.
The AACE suggests a target of 6.5 percent for A1C. This is lower than the 7 percent advised by the American Diabetes Association or the Joslin Diabetes Center. However, they recognize that this target will need to be modified based on individual risk factors and circumstances. Prevention of hypoglycemia is paramount when developing a treatment strategy for patients.