AACE Releases New Algorithm for Treatment of Type 2 Diabetes

A simple flowchart can be used as a resource in treating type 2 diabetes.

| Nov 7, 2009

The American Association of Clinical Endocrinologists (AACE) and the College of Endocrinology (ACE) released online a one-page resource for physicians and healthcare providers for the management of glycemic control in type 2 diabetes.

"Depending on a patient's current A1C level, a physician will use the algorithm to determine whether a mono-, dual-, or triple combination therapy should be considered," Dr. Helena Rodbard, former AACE president and Co-Chair of the Algorithm Task Force said in a press release. "To minimize the risk of diabetic complications, the algorithm will help achieve a hemoglobin A1C value of 6.5 or less when appropriate."

The algorithm (a simple flowchart) starts with lifestyle modification, such as exercise and diet, as the primary impacting factor on a patient's health. Then depending on hemoglobin A1c levels, physicians can use the flow chart to determine if a single medication, dual medications, or a triple-combination therapy should be prescribed.

The algorithm, which was developed by a group of leading endocrinologists, prioritizes medications according to a number of factors. These factors include risk of hypoglycemia, efficacy, simplicity, and anticipated degree of patient adherence. It is based on the AACE/ACE Diabetes Guidelines and recent medical literature.  

The algorithm goes something like this:

If A1c levels were between 6.5 - 7.5% at diagnosis, you would probably be started on a monotherapy (single medicine): either metformin, a thiazolinedione, a DPP-4 inhibitor, or an alpha-glucosidase inhibitor. If that didn't do the trick in maintaining glycemic control after two or three months, you might be moved on to dual therapy. Dual therapy means metformin would be prescribed in addition to a thiazolinedione, a DPP-4 inhibitor, or an alpha-glucosidase inhibitor.

If A1c levels were between 7.6 - 9.0% at diagnosis, you would be started on dual therapy of metformin plus one of the above monotherapies. If blood glucose control were not achieved in two or three months, triple combination therapy would be next. An example of a triple combination therapy would be metformin plus a DPP-4 inhibitor plus a thiazolidinedione.

If A1c levels were above 9.0% at diagnosis and you had symptoms, you would be started on insulin. If you had no symptoms, you would be prescribed a triple combination therapy as described above.

You can view the AACE Glycemic Control Algorithm here.

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Consensus statement




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Categories: A1c Test, Blood Glucose, Diabetes, Diabetes, Health, Insulin, Low Blood Sugar, Research, Type 2 Issues

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Posted by Anonymous on 8 November 2009

Our family physician who diagnosed me as a type 2 diabetic based on a fasting sugar reading of 468 mg/dl (roughly equivalent to 15.5% A1c) in July 1991 was a cardiologist. His prescription was that I take diabetes oral pills oral away. I begged him to allow me to use diet and exercise because a neighbor who was diagnosed ahead of me and had been been taking pharma diabetes drugs was having bad hypo episodes more often than not.

I was required to pass a stress test first before I got the go-signal to exercise and to temporarily delay my use of any diabetes drugs or insulin.

Long story short, for more than 18 years (since my diagnosis), my only diabetes medication has been exercise. I have been eating only heart-healthy foods (mostly carbohydrates like fresh fruits, vegetables, grains, beans, nuts, roots, seeds, and some fish, lean pork, lean beef). Strictly speaking, I don't consider my foods to be a part of my diabetes control because all my after-meal sugars are unacceptably high. But I don't worry about these sugar highs because they have never adversely affected my A1c's which were from a low of 5.3% to a high of 6.3%. Amazingly, I have no diabetes complications yet.

Would I have done better if an endocrinologist required me to be on insulin or triple combination therapy? I doubt it very much because I have yet to see or hear about a type 2 on insulin or triple combination therapy who has done better than I have in a period of 18+ years.


Posted by lraynes on 9 November 2009

The proposed algorithm is a valuable step towards standardization in treatment to goal. However, I do have a concern with the use of the A1c for patients with renal impairment. Is there any thought to the use of glycated albumin for a more accurate picture of diabetic control in the patients with renal insufficiency?

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