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ENDOCRINE PRACTICE Vol 19 No. 2 March/April 2013 327

George Grunberger, MD, FACP, FACEYehuda Handelsman, MD, FACP, FACE, FNLA

Irl B. Hirsch, MD

Paul S. Jellinger, MD, MACE

Janet B. McGill, MD, FACE

Jeffrey I. Mechanick, MD, FACE, ECNU, FACN, FACP

Paul D. Rosenblit, MD, FACE

Guillermo Umpierrez, MD, FACE

Michael H. Davidson, MD,Advisor

Martin J. Abrahamson, MDJoshua I. Barzilay, MD, FACE

Lawrence Blonde, MD, FACP, FACE

Zachary T. Bloomgarden, MD, MACE

Michael A. Bush, MD

Samuel Dagogo-Jack, MD, FACE

Michael B. Davidson, DO, FACE

Daniel Einhorn, MD, FACP, FACE

W. Timothy Garvey, MD

TASK FORCE

Alan J. Garber, MD, PhD, FACE, Chair

AACE COMPREHENSIVE

DIABETES MANAGEMENT

ALGORITHM

2013

Copyright 2013 AACE May not be reproduced in any form without express written permission from AACE.

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328 AACE Comprehensive Diabetes Management Algorithm,Endocr Pract.2013;19(No. 2)

TABLE of CONTENTS

Comprehensive Diabetes

Algorithm

Complications-Centric

Model for Care of the

Overweight/Obese Patient

Prediabetes Algorithm

Goals of Glycemic Control

Algorithm for

Adding/Intensifying Insulin

CVD Risk FactorModifications Algorithm

Profiles of Antidiabetic

Medications

Principles for Treatment

of Type 2 Diabetes

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AACE Comprehensive Diabetes Management Algorithm,Endocr Pract.2013;19(No. 2) 329

CARD

IOMETABOLICDISEAS

E

BIOMECH

ANICALCOMPLICATIONS

STEP1

EVALUATIONF

OR

COMPLICATIO

NS

ANDS

TAGING

STEP3

Iftherapeutictargetsforimpro

vementsincomplicationsnot

met,intensifylifestyleand/orm

edical

and/orsurgicaltreatmentmod

alitiesforgreaterweightloss

BMI27WITHCOMPLICATIONS

StageSeverityofComplications

LOW

MEDIUM

HIGH

STEP2

(i)

Therap

eutictargetsforimprovement

incomplications,

(ii)

Treatm

entmodalityand

(iii)

Treatm

entintensityforweightlossba

sedonstaging

SELECT:

MD/RDcounseling;web/remoteprogram;structuredmultidisciplinaryprog

ram

LifestyleM

odification:

phentermine;orlistat;lorcaserin;phent

ermine/topiramateER

MedicalTherapy:

Lapband;gastric

sleeve;gastricbypass

SurgicalTherapy(BMI35):

Com

plications-CentricModelforCare

oftheOverweight/Obes

ePatient

NO

COMPL

ICATIONS

BMI2526.9,

orBMI27

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Proceedto

Hyperglycemia

Algorithm

LIFESTY

LE

M

ODIFICATI

ON

(IncludingM

edicallyAssistedWeightL

oss)

OTHER

CV

D

RISKF

ACTO

RS

TZD

GLP-1RA

NO

RM

AL

GLY

CEM

IA

O

VERT

DIA

BETES

Ifglycemianotnormalized,

considerwithcaution

ANTIHY

PERGLYCEMIC

THERA

PIES

FPG>100

|2hourPG>140

Hypertension

Dyslipidemia

LowRisk

Medications

Metformin

Acarbose

CVDRiskFactor

ModificationsAlgorithm

ANTIOBESIT

Y

THERAPIES

Intensify

Anti-

Obesity

Efforts

1Pre-D

M

Criterion

MultiplePre-DM

Criteria

Prediabe

tesAlgori

thm

IFG1

00125|IGT1401

99|METABOLICSYN

DROMENCEP2005

P

rogression

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A1

c6.5

%

Forh

ealthypatients

with

outconcurrent

illn

essandatlow

hyp

oglycemicrisk

A1

c>6.5

%

Individualizegoals

forpatientswith

con

currentillness

a

ndatriskfor

h

ypoglycemia

GoalsforGlycemicC

ontrol

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MONOTHERAPY*

IfA1c>6.5%

in3monthsadd

seconddrug

(DualTherapy)

INSULIN

OTHER

A

GENTS

ENTRYA1c9.0

%

ADD

ORINTENSIFYINSULIN

NO

SYMPTOMS

SYMPTOMS

OR

DUAL

THERAPY

TRIPLE

THERAPY

P

R

O

G

R

E

S

S

IO

N

O

F

D

IS

E

A

S

E

G

lycemicC

ontrolAlgorithm

*

Orderofmedications

listedareasuggestedhierarchyofusage

**

Baseduponphase3c

linicaltrialsdata

=U

sewithcaution

Fewadverseevents

orpossiblebenefits

=

LEGEND

Metformin

GLP-1RA

DPP4-i

AG-i

SGLT-2**

TZD

SU/GLN

DUALTHERAPY*

Ifnotatgoalin3

monthsproceed

totripletherapy

GLP-1R

A

DPP4

-i

TZ

D

**SGLT-2

Basalinsulin

Colesevelam

BromocriptineQ

R

AG

-i

SU/GL

N

MET

orother

first-line

agent

TRIPLETHERAPY*

Ifnotatgoalin3

monthsproceed

toorintensify

insulintherapy

GLP-1RA

TZD

**SGLT-2

Basalinsulin

DPP4-i

Colesevelam

BromocriptineQR

AG-i

SU/GLN

MET

orother

first-line

agent

2NDLIN

EAGEN

T

LIFESTYLE

M

ODIFICATION

(IncludingMedicallyAssistedWeight

Loss)

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TDD

0.10.2U

/kg

TDD

0.20.3U/kg

**GlycemicGo

al:

FormostpatientswithT2D,anA1c180m

g/dL

IffastingAM

hypoglycemia,reducebasalinsulin

Ifnighttime

hypoglycemia,reducebasaland/orpre-supper

orpre-eveningsnackshort/rapid-actinginsulin

Ifbetweenm

ealdaytimehypoglycemia,reducepre

vious

premealsho

rt/rapid-actinginsulin

TDD:0.30.5

U/kg

50%BasalAnalog

50%PrandialAnalog

Lessdesirable:N

PH

andregularinsu

linor

premixedinsulin

GlycemicControl

NotatGoal**

Add

GLP1RA

orDPP4-i

Algorithmf

orAd

ding/Intens

ifyingInsulin

A1c8%

STARTB

ASAL(long-actinginsu

lin)

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LIPID

PANEL:Assess

CVDRisk

DYSLIPIDE

M

IA

Ifstatin-intolerant

Intensifytherapiesto

attaingoalsaccording

torisklevels

Stat

inTherapy

IfTG>500mg/dL,fibrates,

omega-3ethylesters,niacin

Tryalternatestat

in,lower

statindoseorfre

quency,

oraddnonstatin

LDL-C-

loweringtherapies

Repeatlipidpanel;

assessadequacy,

toleranceoftherapy

Assessadequacy&toleranceoftherapywithfocusedlabo

ratoryevaluationsandpatientfollow-up

HYPERTEN

SION

RISKLEVEL

S

MODERATE

HIGH

DESIRABLE

LEVELS

DESIRABLE

LEVELS

LDL-C(mg/dL)

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