The New AACE Algorithm: What does it mean?
James Yang, PharmD Candidate 2014
Tiffaney Threat, PharmD
The Comprehensive Diabetes Management Algorithm released by the American Association of Clinical Endocrinologists (AACE) goes beyond just managing blood glucose. It is intended to address the whole patient and includes management of obesity, prediabetes, and cardiovascular risk. The updated algorithm was published online April 22, 2013 and the document utilizes 7 separate color-coded algorithms. Each of these algorithms offers treatment recommendations based upon the individualized patient. The layout of the document consists of the following:
1.Complications-centric model for care of the overweight/obese patient
a.Recommendations for treatment of obesity depend on a patient’s BMI and complications. The therapy ranges from lifestyle modifications and weight loss medications to surgical therapy. If targets for improvement of complications are not met, it is recommended to intensify the lifestyle modification and/or medical and/or surgical modalities for greater weight loss.
2.Prediabetes algorithm
a.This algorithm focuses on modifying cardiovascular risk factors and intensifying antiobesity efforts. Initiating low risk antihyperglycemic therapy may also be recommended.
3.Goals of glycemic control
a.The A1c goals for patients with diabetes, without concurrent illness and at low risk for hypoglycemia are 6.5% or lower. Individualized A1c goals above 6.5% may be established for patients with concurrent illness and who are at risk for hypoglycemia.
4.Glycemic-control algorithm
a.Lifestyle modifications, including medically assisted weight loss if necessary, are emphasized for all of the treatments.
b.Pharmacologic treatment is based on A1c level. Entry A1c < 7.5% yields monotherapy, entry A1c ≥7.5% yields dual therapy, and entry A1c > 9.0% yields dual/triple therapy if no symptoms or insulin plus other agents if symptoms are present. A menu of treatment options is listed for each type of therapy.
c.Those medications that are considered safer and preferred are color coded with green and displayed in order of preference. Yellow color-coding indicates caution in use.
d.If patients are not at goal within 3 months, the algorithm recommends stepping up the therapy.
5.Algorithm for adding/intensifying insulin
a.Initiation of basal insulin and titration every 2-3 days to reach glycemic goals is recommended.
i.0.1-0.2 units/kg/day if A1c < 8%
ii.0.2-0.3 units/kg/day if A1c > 8%
b.Insulin therapy should be intensified if glycemic control is not met.
c.The addition of a GLP-1 RA (receptor agonist) or DPP4-i or prandial insulin is an option that can be considered.
6.Cardiovascular disease (CVD) risk factor modifications algorithm
a.Lifestyle modifications, including medically assisted weight loss, are emphasized for all of the treatments.
b.Dyslipidemia and hypertension are to be managed to achieve desirable lipid and blood pressure goals.
7.Profiles of antidiabetic medications
a.This algorithm profiles each medication with regard to hypoglycemia, weight gain/loss, renal/genitourinary risks, gastrointestinal symptoms, congestive heart failure, cardiovascular disease, and bone loss.
These AACE guidelines are much broader in scope than previous guidelines and take an individualized approach to treating patients with diabetes, especially those with type 2 diabetes. I want to highlight a few important and/or novel features of the algorithm.
•Lifestyle modifications, including obesity management, are given clear emphasis in the treatment guides as evidence shows that weight loss reduces blood glucose. Perhaps this document will encourage providers in their efforts to help patients achieve weight loss goals.
•Metformin is still considered the preferred agent to be utilized in the management of type 2 diabetes unless contraindicated or intolerable. It is uncertain which agent should be initiated next if glycemic control is not obtained and a menu of options is available. These options even include the new class of medication, SGLT-2 inhibitors. The color coding and order of preference features may help make choosing the next step a bit easier. But it is important to remember that treatment should be individualized based on patient attributes and after consideration of the risks (hypoglycemia, weight gain, renal/genitourinary risks, etc.) and benefits (weight loss, lipid control, etc.) associated with that agent.
•Although the AACE guidelines still prefer and recommend an A1c of 6.5% or lower in order to limit microvascular damage, the goals may be relaxed a bit in consideration of the individual patient.
•The insulin algorithm offers guidance for basal insulin titration and intensification of therapy when goal is not met. A new option is provided for including a GLP-1 RA or DPP-4 inhibitor as the next step rather than adding prandial insulin; however, either may be a suitable treatment option. Risks for hypoglycemia or weight gain should be considered when individualizing intensification therapy after basal insulin has not achieved goal.
I am not sure that at first glance this algorithm seems as simple as it was intended, but after you focus a little deeper, the message becomes clearer. I should mention though that the psychological state of the patient isn’t considered in this comprehensive approach; this is certainly one area of patient care that should not be overlooked. Even so, this document does serve to educate the clinician as well as guide therapy at the point of care in a mostly comprehensive, patient-individualized manner.
Reference:
Endocrine Practice. 2013; 19 (2):327-336.