aace dm2 2013
TRANSCRIPT
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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.
To purchase reprints of this article, please visit: www.aace.com/reprints.Copyright 2013 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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330 AACE Comprehensive Diabetes Management Algorithm,Endocr Pract.2013;19(No. 2)
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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AACE Comprehensive Diabetes Management Algorithm,Endocr Pract.2013;19(No. 2) 331
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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332 AACE Comprehensive Diabetes Management Algorithm,Endocr Pract.2013;19(No. 2)
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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AACE Comprehensive Diabetes Management Algorithm,Endocr Pract.2013;19(No. 2) 333
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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334 AACE Comprehensive Diabetes Management Algorithm,Endocr Pract.2013;19(No. 2)
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)