Acute overt lower gastrointestinal bleeding (LGIB) accounts for ~20% of all cases of gastrointestinal (GI) bleeding, usually leads to hospital admission with invasive diagnostic evaluations, and consumes significant medical resources (1,2, 3). Although most patients with acute LGIB stop bleeding spontaneously and have favorable outcomes, morbidity and mortality are increased in older patients and those with comorbid medical conditions (4).
An individual with acute LGIB classically presents with the sudden onset of hematochezia (maroon or red blood passed per rectum). However, in rare cases, patients with bleeding from the cecum/right colon can present with melena (black, tarry stools) (5). In addition, hematochezia can be seen in patients with brisk upper gastrointestinal bleeding (UGIB). Approximately 15% of patients with presumed LGIB are ultimately found to have an upper GI source for their bleeding (6). Historically, LGIB was defined as bleeding from a source distal to the Ligament of Treitz. However, bleeding from the small intestine (middle GI bleeding) is distinct from colonic bleeding in terms of presentation, management, and outcomes (7). For the purposes of this guideline, we define LGIB as the onset of hematochezia originating from either the colon or the rectum (8).
In this practice guideline, we discuss the main goals of management of patients with LGIB. First, we discuss the initial evaluation and management of patients with acute LGIB including hemodynamic resuscitation, risk stratification, and management of anticoagulant and antiplatelet agents (antithrombotic agents). We then discuss colonoscopy as a diagnostic and therapeutic tool including preparation, timing, and endoscopic hemostasis. Next, we outline non-colonoscopic diagnostic and therapeutic strategies for LGIB. Finally, we discuss prevention of recurrent LGIB and the role of repeat colonoscopy for recurrent bleeding events.
Each section of this document presents key recommendations followed by a summary of supporting evidence. A summary of the key recommendations is presented in Table 1.


With the assistance of a health sciences librarian, a systematic search of the literature was conducted covering the years 1 January 1968 through 2 March 2015 in the PubMed and EMBASE databases and the Cochrane Library including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effect, and Cochrane Central Register of Controlled Trials (CENTRAL). The PubMed search used a combination of Medical Subject Headings (MeSH), as well as terms appearing in titles and abstracts.
The strategy used to cover the lower gastrointestinal tract included (‘Exp Intestine, Large’[Mesh] OR ‘Exp Lower Gastrointestinal Tract’[Mesh] OR lower gastrointestinal[tiab] OR lower intestinal[tiab]). These terms were combined with terms for gastrointestinal bleeding including ‘Gastrointestinal Hemorrhage’[Mesh:noexp] OR rectal bleeding[tiab] OR colonic hemorrhage[tiab] OR colonic hemorrhages[tiab] OR colonic bleeding[tiab] OR hematochezia[tiab] OR haematochezia[tiab] OR rectal bleed[tiab] OR diverticular bleeding[tiab] OR diverticular bleed[tiab] OR diverticular hemorrhage[tiab] OR severe bleeding[tiab]OR active bleeding[tiab] OR melena[tiab] OR acute bleed[tiab] OR acute bleeding[tiab] OR acute haemorrhage[tiab] OR acute haemorrhage[tiab]) OR (LGIB[tiab] OR LIB[tiab]). The final group was limited to English language and human studies. Citations dealing with children and prostatic neoplasms were excluded. The following website will pull up the PubMed search strategy:http://tinyurl.com/ofnxphu.
Search strategies in EMBASE and the Cochrane Library databases replicated the terms, limits, and features used in the PubMed search strategy.
In addition to the literature search, we reviewed the references of identified articles for additional studies. We also performed targeted searches on topics for which there is relevant literature for UGIB but not LGIB including hemodynamic resuscitation/blood product transfusions and management of anticoagulant and antiplatelet medications.
We used the GRADE system to grade the quality of evidence and rate the strength of each recommendation (9). The quality of evidence, which influences the strength of recommendation, ranges from “high” (further research is very unlikely to change our confidence in the estimate of effect) to “moderate” (further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate) to “low” (further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate) and “very low” (any estimate of effect is very uncertain). The strength of a recommendation is graded as strong when the desirable effects of an intervention clearly outweigh the undesirable effects and is graded as conditional when uncertainty exists about the trade-offs (9). Other factors affecting the strength of recommendation include variability in values and preferences of patients and whether an intervention represents a wise use of resources (9). In the GRADE system, randomized trials are considered high-quality evidence but can be downrated depending on the size, quality, and consistency of studies. Observational studies are generally rated as low-quality studies.

​Initial assessment
 Evaluation and risk stratification
  1. A focused history, physical examination, and laboratory evaluation should be obtained at the time of patient presentation to assess the severity of bleeding and its possible location and etiology. Initial patient assessment and hemodynamic resuscitation should be performed simultaneously (strong recommendation, very-low-quality evidence).
  2. Hematochezia associated with hemodynamic instability may be indicative of an UGIB source, and an upper endoscopy should be performed. A nasogastric aspirate/lavage may be used to assess a possible upper GI source if suspicion of UGIB is moderate (strong recommendation, low-quality evidence).
  3. Risk assessment and stratification should be performed to help distinguish patients at high and low risks of adverse outcomes and assist in patient triage including the timing of colonoscopy and the level of care (conditional recommendation, low-quality evidence).
 Hemodynamic resuscitation
  4. Patients with hemodynamic instability and/or suspected ongoing bleeding should receive intravenous fluid resuscitation with the goal of normalization of blood pressure and heart rate prior to endoscopic evaluation/intervention (strong recommendation, very-low-quality evidence).
  5. Packed red blood cells should be transfused to maintain the hemoglobin above 7 g/dl. A threshold of 9 g/dl should be considered in patients with massive bleeding, significant comorbid illness (especially cardiovascular ischemia), or a possible delay in receiving therapeutic interventions (conditional recommendations, low-quality evidence).
 Management of anticoagulant medications
  6. Endoscopic hemostasis may be considered in patients with an INR of 1.5–2.5 before or concomitant with the administration of reversal agents. Reversal agents should be considered before endoscopy in patients with an INR >2.5 (conditional recommendation, very-low-quality evidence).
  7. Platelet transfusion should be considered to maintain a platelet count of 50 × 10/l in patients with severe bleeding and those requiring endoscopic hemostasis (conditional recommendation, very-low-quality evidence).
  8. Platelet and plasma transfusions should be considered in patients who receive massive red blood cell transfusions (conditional recommendation, very-low-quality evidence).
  9. In patients on anticoagulant agents, a multidisciplinary approach (e.g., hematology, cardiology, neurology, and gastroenterology) should be used when deciding whether to discontinue medications or use reversal agents to balance the risk of ongoing bleeding with the risk of thromboembolic events (strong recommendation, very-low-quality evidence).
Colonoscopy
 Colonoscopy as a diagnostic tool
  10. Colonoscopy should be the initial diagnostic procedure for nearly all patients presenting with acute LGIB (strong recommendation, low-quality evidence).
  11. The colonic mucosa should be carefully inspected during both colonoscope insertion and withdrawal, with aggressive attempts made to wash residual stool and blood in order to identify the bleeding site. The endoscopist should also intubate the terminal ileum to rule out proximal blood suggestive of a small bowel lesion (conditional recommendation, very-low-quality evidence).
 Bowel preparation
  12. Once the patient is hemodynamically stable, colonoscopy should be performed after adequate colon cleansing. Four to six liters of a polyethylene glycol (PEG)-based solution or the equivalent should be administered over 3–4 h until the rectal effluent is clear of blood and stool. Unprepped colonoscopy/sigmoidoscopy is not recommended (strong recommendation, low-quality evidence).
  13. A nasogastric tube can be considered to facilitate colon preparation in high-risk patients with ongoing bleeding who are intolerant to oral intake and are at low risk of aspiration (conditional recommendation, low-quality evidence).
 Timing of colonoscopy
  14. In patients with high-risk clinical features and signs or symptoms of ongoing bleeding, a rapid bowel purge should be initiated following hemodynamic resuscitation and a colonoscopy performed within 24 h of patient presentation after adequate colon preparation to potentially improve diagnostic and therapeutic yield (conditional recommendation, low-quality evidence).
  15. In patients without high-risk clinical features or serious comorbid disease or those with high-risk clinical features without signs or symptoms of ongoing bleeding, colonoscopy should be performed next available after a colon purge (conditional recommendation, low-quality evidence).
 Endoscopic hemostasis therapy
  16. Endoscopic therapy should be provided to patients with high-risk endoscopic stigmata of bleeding: active bleeding (spurting and oozing); non-bleeding visible vessel; or adherent clot (strong recommendation, low-quality evidence).
  17. Diverticular bleeding: through-the-scope endoscopic clips are recommended as clips may be safer in the colon than contact thermal therapy and are generally easier to perform than band ligation, particularly for right-sided colon lesions (conditional recommendation, low-quality evidence).
  18. Angioectasia bleeding: noncontact thermal therapy using argon plasma coagulation is recommended (conditional recommendation, low-quality evidence).
  19. Post-polypectomy bleeding: mechanical (clip) or contact thermal endotherapy, with or without the combined use of dilute epinephrine injection, is recommended (strong recommendation, low-quality evidence).
  20. Epinephrine injection therapy (1:10,000 or 1:20,000 dilution with saline) can be used to gain initial control of an active bleeding lesion and improve visualization but should be used in combination with a second hemostasis modality including mechanical or contact thermal therapy to achieve definitive hemostasis (strong recommendation, very-low-quality evidence).
Role of repeat colonoscopy in the setting of early recurrent bleeding
  21. Repeat colonoscopy, with endoscopic hemostasis if indicated, should be considered for patients with evidence of recurrent bleeding (strong recommendation, very-low-quality evidence).
Non-colonoscopy interventions
  22. A surgical consultation should be requested in patients with high-risk clinical features and ongoing bleeding. In general, surgery for acute LGIB should be considered after other therapeutic options have failed and should take into consideration the extent and success of prior bleeding control measures, severity and source of bleeding, and the level of comorbid disease. It is important to very carefully localize the source of bleeding whenever possible before surgical resection to avoid continued or recurrent bleeding from an unresected culprit lesion (conditional recommendation, very-low-quality evidence).
  23. Radiographic interventions should be considered in patients with high-risk clinical features and ongoing bleeding who have a negative upper endoscopy and do not respond adequately to hemodynamic resuscitation efforts and are therefore unlikely to tolerate bowel preparation and urgent colonoscopy (strong recommendation, very-low-quality evidence).
  24. If a diagnostic test is desired for localization of the bleeding site before angiography, CT angiography should be considered (conditional recommendation, very-low-quality evidence).
Prevention of recurrent lower gastrointestinal bleeding
  25. Non-aspirin NSAID use should be avoided in patients with a history of acute LGIB, particularly if secondary to diverticulosis or angioectasia (strong recommendation, low-quality evidence).
  26. In patients with established high-risk cardiovascular disease and a history of LGIB, aspirin used for secondary prevention should not be discontinued. Aspirin for primary prevention of cardiovascular events should be avoided in most patients with LGIB (strong recommendation, low-quality evidence).
  27. In patients on dual antiplatelet therapy or monotherapy with non-aspirin antiplatelet agents (thienopyridine), non-aspirin antiplatelet therapy should be resumed as soon as possible and at least within 7 days based on multidisciplinary assessment of cardiovascular and GI risk and the adequacy of endoscopic therapy (as above, aspirin use should not be discontinued). However, dual antiplatelet therapy should not be discontinued in patients with an acute coronary syndrome within the past 90 days or coronary stenting within the past 30 days (strong recommendation, low-quality evidence).

In this guideline, we sought to evaluate and summarize the literature on major issues in the management of patients with acute LGIB. In general, we found the quality of the existing evidence to be low. There are only a few small, randomized trials of patients with acute LGIB, and therefore we relied heavily on case–control or cohort studies, case series, systematic reviews, or indirect evidence from trials of UGIB. Despite these limitations, we strongly endorse some of the recommendations because the potential benefits appear to outweigh the risk of harm. An approach to patients presenting with acute LGIB is outlined in Figure 1. To summarize, patients presenting with acute severe hematochezia should undergo a focused evaluation simultaneous with hemodynamic resuscitation. An upper GI bleeding source needs to be excluded in patients with hematochezia and hemodynamic instability. Colonoscopy following a colon purge is the initial test of choice in most patients presenting with acute hematochezia. In patients with high-risk features and ongoing bleeding, colonoscopy should be performed within 24 h of presentation following a colon purge. Urgent colonoscopy (<12 h from presentations) may improve diagnostic and therapeutic yield but has not been shown to reduce rates of rebleeding or surgery. Radiographic interventions should be reserved for the small group of patients with brisk bleeding who cannot be adequately stabilized for colonoscopy. Stigmata of hemorrhage can be safely and effectively treated endoscopically. The management of antiplatelet and anticoagulant medications in patients with acute LGIB requires a multidisciplinary, individualized approach that balances the risk of bleeding with the risk of a thrombotic event. However, aspirin should not be discontinued when used as secondary cardiovascular prophylaxis, and dual antiplatelet therapy should not be stopped in patients within 90 days of an acute coronary syndrome or 30 days of coronary stenting.

​84 ENDOCRINE PRACTICE Vol 22 No. 1 January 2016
AACE/ACE Consensus Statement
CONSENSUS STATEMENT BY THE AMERICAN ASSOCIATION OF
CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF
ENDOCRINOLOGY ON THE COMPREHENSIVE TYPE 2 DIABETES
MANAGEMENT ALGORITHM – 2016 EXECUTIVE SUMMARY
Alan J. Garber, MD, PhD, FACE1; Martin J. Abrahamson, MD2;
Joshua I. Barzilay, MD, FACE3; Lawrence Blonde, MD, FACP, FACE4;
Zachary T. Bloomgarden, MD, MACE5; Michael A. Bush, MD6;
Samuel Dagogo-Jack, MD, DM, FRCP, FACE7; Ralph A. DeFronzo, MD, BMS, MS, BS8;
Daniel Einhorn, MD, FACP, FACE9; Vivian A. Fonseca, MD, FACE10;
Jeffrey R. Garber, MD, FACP, FACE11; W. Timothy Garvey, MD, FACE12;
George Grunberger, MD, FACP, FACE13; Yehuda Handelsman, MD, FACP, FNLA, FACE14;
Robert R. Henry, MD, FACE15; Irl B. Hirsch, MD16;
Paul S. Jellinger, MD, MACE17; Janet B. McGill, MD, FACE18;
Jeffrey I. Mechanick, MD, FACN, FACP, FACE, ECNU19;
Paul D. Rosenblit, MD, PhD, FNLA, FACE20; Guillermo E. Umpierrez, MD, FACP, FACE21
From the 1Chair, Professor, Departments of Medicine, Biochemistry
and Molecular Biology, and Molecular and Cellular Biology, Baylor
College of Medicine, Houston, Texas, 2Beth Israel Deaconess Medical
Center, Department of Medicine and Harvard Medical School, Boston,
Massachusetts, 3Division of Endocrinology, Kaiser Permanente of Georgia
and the Division of Endocrinology, Emory University School of Medicine,
Atlanta, Georgia, 4Director, Ochsner Diabetes Clinical Research Unit,
Department of Endocrinology, Diabetes and Metabolism, Ochsner Medical
Center, New Orleans, Louisiana, 5Clinical Professor, Mount Sinai School of
Medicine, Editor, Journal of Diabetes, New York, New York, 6Clinical Chief,
Division of Endocrinology, Cedars-Sinai Medical Center, Associate Clinical
Professor of Medicine, Geffen School of Medicine, UCLA, Los Angeles,
California, 7A.C. Mullins Professor & Director, Division of Endocrinology,
Diabetes and Metabolism, University of Tennessee Health Science Center,
Memphis, Tennessee, 8Professor of Medicine, Chief, Diabetes Division,
University of Texas Health Science Center at San Antonio, San Antonio,
Texas, 9Immediate Past President, American College of Endocrinology,
Past-President, American Association of Clinical Endocrinologists,
Medical Director, Scripps Whittier Diabetes Institute, Clinical Professor
of Medicine, UCSD, Associate Editor, Journal of Diabetes, Diabetes and
Endocrine Associates, La Jolla, California, 10Professor of Medicine and
Pharmacology, Tullis Tulane Alumni Chair in Diabetes, Chief, Section of
Endocrinology, Tulane University Health Sciences Center, New Orleans,
Louisiana, 11Endocrine Division, Harvard Vanguard Medical Associates,
Boston, Massachusetts, Division of Endocrinology, Beth Israel Deaconess
Medical Center, Boston, Massachusetts, 12Professor and Chair, Department
of Nutrition Sciences, University of Alabama at Birmingham, Director, UAB
This document represents the official position of the American Association of Clinical Endocrinologists and American
College of Endocrinology. Where there were no randomized controlled trials or specific U.S. FDA labeling for issues in
clinical practice, the participating clinical experts utilized their judgment and experience. Every effort was made to achieve
consensus among the committee members. Position statements are meant to provide guidance, but they are not to be considered
prescriptive for any individual patient and cannot replace the judgment of a clinician.
Diabetes Research Center, Mountain Brook, Alabama, 13Grunberger Diabetes
Institute, Clinical Professor, Internal Medicine and Molecular Medicine &
Genetics, Wayne State University School of Medicine, Bloomfield Hills,
Michigan, 14Medical Director & Principal Investigator, Metabolic Institute of
America, President, American College of Endocrinology, Tarzana, California,
15Professor of Medicine, University of California San Diego, Chief, Section of
Diabetes, Endocrinology & Metabolism, VA San Diego Healthcare System,
San Diego, California, 16Professor of Medicine, University of Washington
School of Medicine, Seattle, Washington, 17Professor of Clinical Medicine,
University of Miami, Miller School of Medicine, Miami, Florida, The Center
for Diabetes & Endocrine Care, Hollywood, Florida, 18Professor of Medicine,
Division of Endocrinology, Metabolism & Lipid Research, Washington
University, St. Louis, Missouri, 19Clinical Professor of Medicine, Director,
Metabolic Support, Division of Endocrinology, Diabetes, and Bone Disease,
Icahn School of Medicine at Mount Sinai, New York, New York, 20Clinical
Professor, Medicine, Division of Endocrinology, Diabetes, Metabolism,
University California Irvine School of Medicine, Irvine, California,
Co-Director, Diabetes Out-Patient Clinic, UCI Medical Center, Orange,
California, Director & Principal Investigator, Diabetes/Lipid Management
& Research Center, Huntington Beach, California, and 21Professor of
Medicine, Emory University School of Medicine, Director, Endocrinology
Section, Grady Health System, Atlanta, Georgia.
Address correspondence to American Association of Clinical
Endocrinologists, 245 Riverside Avenue, Suite 200, Jacksonville, FL 32202.
E-mail: [email protected]. DOI: 10.4158/EP151126.CS
To purchase reprints of this article, please visit: www.aace.com/reprints.
Copyright © 2016 AACE.
85
Abbreviations:
A1C = hemoglobin A1C; AACE = American
Association of Clinical Endocrinologists; ACCORD
= Action to Control Cardiovascular Risk in Diabetes;
ACCORD BP = Action to Control Cardiovascular
Risk in Diabetes Blood Pressure; ACEI = angiotensinconverting
enzyme inhibitor; AGI = alpha-glucosidase
inhibitor; apo B = apolipoprotein B; ARB = angiotensin
II receptor blocker; ASCVD = atherosclerotic cardiovascular
disease; BAS = bile acid sequestrant; BMI =
body mass index; BP = blood pressure; CHD = coronary
heart disease; CKD = chronic kidney disease;
CVD = cardiovascular disease; DKA = diabetic ketoacidosis;
DPP-4 = dipeptidyl peptidase 4; EPA = eicosapentaenoic
acid; FDA = Food and Drug Administration;
GLP-1 = glucagon-like peptide 1; HDL-C = highdensity-
lipoprotein cholesterol; LDL-C = low-densitylipoprotein
cholesterol; LDL-P = low-density-lipoprotein
particle; Look AHEAD = Look Action for Health
in Diabetes; NPH = neutral protamine Hagedorn; OSA
= obstructive sleep apnea; SFU = sulfonylurea; SGLT-2
= sodium glucose cotransporter-2; SMBG = self-monitoring
of blood glucose; T2D = type 2 diabetes; TZD =
thiazolidinedione
EXECUTIVE SUMMARY
This algorithm for the comprehensive management
of persons with type 2 diabetes (T2D) was developed to
provide clinicians with a practical guide that considers
the whole patient, their spectrum of risks and complications,
and evidence-based approaches to treatment. It is
now clear that the progressive pancreatic beta-cell defect
that drives the deterioration of metabolic control over time
begins early and may be present before the diagnosis of
diabetes (1). In addition to advocating glycemic control to
reduce microvascular complications, this document highlights
obesity and prediabetes as underlying risk factors
for the development of T2D and associated macrovascular
complications. In addition, the algorithm provides recommendations
for blood pressure (BP) and lipid control, the
two most important risk factors for cardiovascular disease
(CVD).
Since originally drafted in 2013, the algorithm has
been updated as new therapies, management approaches,
and important clinical data have emerged. The 2016
edition includes a new section on lifestyle therapy as well
as discussion of all classes of obesity, antihyperglycemic,
lipid-lowering, and antihypertensive medications approved
by the U.S. Food and Drug Administration (FDA) through
December 2015.
This algorithm supplements the American Association
of Clinical Endocrinologists (AACE) and American College
of Endocrinology (ACE) 2015 Clinical Practice Guidelines
for Developing a Diabetes Mellitus Comprehensive Care
Plan (2) and is organized into discrete sections that address
the following topics: the founding principles of the algorithm,
lifestyle therapy, obesity, prediabetes, glucose
control with noninsulin antihyperglycemic agents and
insulin, management of hypertension, and management
of dyslipidemia. In the accompanying algorithm, a chart
summarizing the attributes of each antihyperglycemic
class and the principles of the algorithm appear at the end.
(Endocr Pract. 2016;22:84-113)
Principles
The founding principles of the Comprehensive Type
2 Diabetes Management Algorithm are as follows (see
Comprehensive Type 2 Diabetes Management Algorithm--
Principles):
1. Lifestyle optimization is essential for all patients
with diabetes. Lifestyle optimization is multifaceted,
ongoing, and should engage the entire diabetes
team. However, such efforts should not delay
needed pharmacotherapy, which can be initiated
simultaneously and adjusted based on patient
response to lifestyle efforts. The need for medical
therapy should not be interpreted as a failure of
lifestyle management, but as an adjunct to it.
2. The hemoglobin A1C (A1C) target should be
individualized based on numerous factors, such as
age, life expectancy, comorbid conditions, duration
of diabetes, risk of hypoglycemia or adverse
consequences from hypoglycemia, patient motivation,
and adherence. An A1C level of ≤6.5% is
considered optimal if it can be achieved in a safe
and affordable manner, but higher targets may
be appropriate for certain individuals and may
change for a given individual over time.
3. Glycemic control targets include fasting and postprandial
glucose as determined by self-monitoring
of blood glucose (SMBG).
4. The choice of diabetes therapies must be individualized
based on attributes specific to both patients
and the medications themselves. Medication attributes
that affect this choice include antihyperglycemic
efficacy, mechanism of action, risk of
inducing hypoglycemia, risk of weight gain, other
adverse effects, tolerability, ease of use, likely
adherence, cost, and safety in heart, kidney, or
liver disease.
5. Minimizing risk of both severe and nonsevere
hypoglycemia is a priority. It is a matter of safety,
adherence, and cost.
6. Minimizing risk of weight gain is also a priority.
It too is a matter of safety, adherence, and cost.
7. The initial acquisition cost of medications is only
a part of the total cost of care, which includes
monitoring requirements and risks of hypoglyce86
mia and weight gain. Safety and efficacy should
be given higher priority than medication cost.
8. This algorithm stratifies choice of therapies based
on initial A1C level. It provides guidance as to
what therapies to initiate and add but respects
individual circumstances that could lead to different
choices.
9. Combination therapy is usually required and
should involve agents with complementary mechanisms
of action.
10. Comprehensive management includes lipid and
BP therapies and treatment of related comorbidities.
11. Therapy must be evaluated frequently (e.g., every
3 months) until stable using multiple criteria,
including A1C, SMBG records (fasting and postprandial),
documented and suspected hypoglycemia
events, lipid and BP values, adverse events
(weight gain, fluid retention, hepatic or renal
impairment, or CVD), comorbidities, other relevant
laboratory data, concomitant drug administration,
diabetic complications, and psychosocial
factors affecting patient care. Less frequent monitoring
is acceptable once targets are achieved.
12. The therapeutic regimen should be as simple as
possible to optimize adherence.
13. This algorithm includes every FDA-approved class
of medications for T2D (as of December 2015).
Lifestyle Therapy
The key components of lifestyle therapy include
medical nutrition therapy, regular physical activity, sufficient
amounts of sleep, behavioral support, and smoking
cessation and avoidance of all tobacco products (see
Comprehensive Type 2 Diabetes Management Algorithm--
Lifestyle Therapy). In the algorithm, recommendations
appearing on the left apply to all patients. Patients with
increasing burden of obesity or related comorbidities may
also require the additional interventions listed in the middle
and right side of the figure.
Lifestyle therapy begins with nutrition counseling and
education. All patients should strive to attain and maintain
an optimal weight through a primarily plant-based diet
high in polyunsaturated and monounsaturated fatty acids,
with limited intake of saturated fatty acids and avoidance
of trans fats. Patients who are overweight (body mass
index [BMI] of 25 to 29.9 kg/m2) or obese (BMI ≥30 kg/
m2) should also restrict their caloric intake with the goal
of reducing body weight by at least 5 to 10%. As shown
in the Look AHEAD (Action for Health in Diabetes) and
Diabetes Prevention Program studies, lowering caloric
intake is the main driver for weight loss (3-6). The clinician
or a registered dietitian (or nutritionist) should discuss
recommendations in plain language at the initial visit and
periodically during follow-up office visits. Discussion
should focus on foods that promote health versus those
that promote metabolic disease or complications and
should include information on specific foods, meal planning,
grocery shopping, and dining-out strategies. In addition,
education on medical nutrition therapy for patients
with diabetes should also address the need for consistency
in day-to-day carbohydrate intake, limiting sucrosecontaining
or high-glycemic-index foods, and adjusting
insulin doses to match carbohydrate intake (e.g., use of
carbohydrate counting with glucose monitoring) (2,7).
Structured counseling (e.g., weekly or monthly sessions
with a specific weight-loss curriculum) and meal replacement
programs have been shown to be more effective than
standard in-office counseling (3,6,8-15). Additional nutrition
recommendations can be found in the 2013 Clinical
Practice Guidelines for Healthy Eating for the Prevention
and Treatment of Metabolic and Endocrine Diseases in
Adults from AACE/ACE and The Obesity Society (16).
After nutrition, physical activity is the main component
in weight loss and maintenance programs. Regular
physical exercise—both aerobic exercise and strength
training—improves glucose control, lipid levels, and BP;
decreases the risk of falls and fractures; and improves
functional capacity and sense of well-being (17-24). In
Look AHEAD, which had a weekly goal of ≥175 minutes
per week of moderately intense activity, minutes of physical
activity were significantly associated with weight loss,
suggesting that those who were more active lost more
weight (3). The physical activity regimen should involve
at least 150 minutes per week of moderate-intensity exercise
such as brisk walking (e.g., 15- to 20-minute mile)
and strength training; patients should start any new activity
slowly and increase intensity and duration gradually as they
become accustomed to the exercise. Structured programs
can help patients learn proper technique, establish goals,
and stay motivated. Patients with diabetes and/or severe
obesity or complications should be evaluated for contraindications
and/or limitations to increased physical activity,
and an exercise prescription should be developed for each
patient according to both goals and limitations. More detail
on the benefits and risks of physical activity and the practical
aspects of implementing a training program in people
with T2D can be found in a joint position statement from
the American College of Sports Medicine and American
Diabetes Association (25).
Adequate rest is important for maintaining energy
levels and well-being, and all patients should be advised to
sleep approximately 7 hours per night. Evidence supports
an association of 6 to 9 hours of sleep per night with a
reduction in cardiometabolic risk factors, whereas sleep
deprivation aggravates insulin resistance, hypertension,
hyperglycemia, and dyslipidemia and increases inflammatory
cytokines (26-31). Daytime drowsiness—a frequent
symptom of sleep disorders such as sleep apnea—is associated
with increased risk of accidents, errors in judgment,
87
and diminished performance (32). The most common type
of sleep apnea, obstructive sleep apnea (OSA), is caused
by physical obstruction of the airway during sleep. The
resulting lack of oxygen causes the patient to awaken and
snore, snort, and grunt throughout the night. The awakenings
may happen hundreds of times per night, often without
the patient’s awareness. OSA is more common in men,
the elderly, and persons with obesity (33,34). Individuals
with suspected OSA should be referred to a sleep specialist
for evaluation and treatment (2).
Behavioral support for lifestyle therapy includes the
structured weight loss and physical activity programs
mentioned above as well as support from family and
friends. Patients should be encouraged to join community
groups dedicated to a healthy lifestyle for emotional
support and motivation. In addition, obesity and diabetes
are associated with high rates of anxiety and depression,
which can adversely affect outcomes (35,36). Healthcare
professionals should assess patients’ mood and psychological
well-being and refer patients with mood disorders
to mental healthcare professionals. Cognitive behavioral
therapy may be beneficial. A recent meta-analysis of
psychosocial interventions provides insight into successful
approaches (37).
Smoking cessation is the final component of lifestyle
therapy and involves avoidance of all tobacco products.
Structured programs should be recommended for patients
unable to stop smoking on their own (2).
Obesity
Obesity is a disease with genetic, environmental, and
behavioral determinants that confers increased morbidity
and mortality (38,39). An evidence-based approach to the
treatment of obesity incorporates lifestyle, medical, and
surgical options, balances risks and benefits, and emphasizes
medical outcomes that address the complications
of obesity rather than cosmetic goals. Weight loss should
be considered in all overweight and obese patients with
prediabetes or T2D, given the known therapeutic effects
of weight loss to lower glycemia, improve the lipid profile,
reduce BP, and decrease mechanical strain on the lower
extremities (hips and knees) (2,38).
The AACE Obesity Treatment Algorithm emphasizes
a complications-centric model as opposed to a BMI-centric
approach for the treatment of patients who have obesity
or are overweight (see Comprehensive Type 2 Diabetes
Management Algorithm—Complications-Centric Model
for Care of the Overweight/Obese Patient). The patients
who will benefit most from medical and surgical intervention
have obesity-related comorbidities that can be classified
into 2 general categories: insulin resistance/cardiometabolic
disease and biomechanical consequences of
excess body weight (40). Clinicians should evaluate and
stage patients for each category. The presence and severity
of complications, regardless of patient BMI, should guide
treatment planning and evaluation (41,42). Once these
factors are assessed, clinicians can set therapeutic goals and
select appropriate types and intensities of treatment that
will help patients achieve their weight-loss goals. Patients
should be periodically reassessed (ideally every 3 months)
to determine if targets for improvement have been reached;
if not, weight loss therapy should be changed or intensified.
Lifestyle therapy can be recommended for all patients
with overweight or obesity, and more intensive options can
be prescribed for patients with comorbidities. For example,
weight-loss medications can be used in combination
with lifestyle therapy for all patients with a BMI ≥27 kg/
m2 and comorbidities. As of 2015, the FDA has approved 8
drugs as adjuncts to lifestyle therapy in patients with overweight
or obesity. Diethylproprion, phendimetrazine, and
phentermine are approved for short-term (a few weeks) use,
whereas orlistat, phentermine/topiramate extended release
(ER), lorcaserin, naltrexone/bupropion, and liraglutide 3
mg may be used for long-term weight-reduction therapy. In
clinical trials, the 5 drugs approved for long-term use were
associated with statistically significant weight loss (placeboadjusted
decreases ranged from 2.9% with orlistat to 9.7%
with phentermine/topiramate ER) after 1 year of treatment.
These agents improve BP and lipids, prevent progression to
diabetes during trial periods, and improve glycemic control
and lipids in patients with T2D (43-60). Bariatric surgery
should be considered for adult patients with a BMI ≥35 kg/
m2 and comorbidities, especially if therapeutic goals have
not been reached using other modalities (2,61).
Prediabetes
Prediabetes reflects failing pancreatic islet beta-cell
compensation for an underlying state of insulin resistance,
most commonly caused by excess body weight or obesity.
Current criteria for the diagnosis of prediabetes include
impaired glucose tolerance, impaired fasting glucose, or
metabolic syndrome (see Comprehensive Type 2 Diabetes
Management Algorithm—Prediabetes Algorithm). Any
one of these factors is associated with a 5-fold increase in
future T2D risk (62).
The primary goal of prediabetes management is weight
loss. Whether achieved through lifestyle therapy, pharmacotherapy,
surgery, or some combination thereof, weight
loss reduces insulin resistance and can effectively prevent
progression to diabetes as well as improve plasma lipid
profile and BP (44,48,49,51,53,60,63). However, weight
loss may not directly address the pathogenesis of declining
beta-cell function. When indicated, bariatric surgery can be
highly effective in preventing progression from prediabetes
to T2D (62).
No medications (either weight loss drugs or antihyperglycemic
agents) are approved by the FDA solely for
the management of prediabetes and/or the prevention of
T2D. However, antihyperglycemic medications such as
metformin and acarbose reduce the risk of future diabetes
88
in prediabetic patients by 25 to 30%. Both medications are
relatively well-tolerated and safe, and they may confer a
cardiovascular risk benefit (63-66). In clinical trials, thiazolidinediones
(TZDs) prevented future development of
diabetes in 60 to 75% of subjects with prediabetes, but
this class of drugs has been associated with a number of
adverse outcomes (67-69). Glucagon-like peptide 1 (GLP-
1) receptor agonists may be equally effective, as demonstrated
by the profound effect of liraglutide 3 mg in safely
preventing diabetes and restoring normoglycemia in the
vast majority of subjects with prediabetes (59,60,70,71).
However, owing to the lack of long-term safety data on
the GLP-1 receptor agonists and the known adverse effects
of the TZDs, these agents should be considered only for
patients at the greatest risk of developing future diabetes
and those failing more conventional therapies.
As with diabetes, prediabetes increases the risk for
atherosclerotic cardiovascular disease (ASCVD). Patients
with prediabetes should be offered lifestyle therapy and
pharmacotherapy to achieve lipid and BP targets that will
reduce ASCVD risk.
T2D Pharmacotherapy
In patients with T2D, achieving the glucose target
and A1C goal requires a nuanced approach that balances
age, comorbidities, and hypoglycemia risk (2). The AACE
supports an A1C goal of ≤6.5% for most patients and a goal
of >6.5% (up to 8%; see below) if the lower target cannot
be achieved without adverse outcomes (see Comprehensive
Type 2 Diabetes Management Algorithm—Goals for
Glycemic Control). Significant reductions in the risk or
progression of nephropathy were seen in the Action in
Diabetes and Vascular Disease: Preterax and Diamicron
MR Controlled Evaluation (ADVANCE) study, which
targeted an A1C <6.5% in the intensive therapy group
versus standard approaches (72). In the Action to Control
Cardiovascular Risk in Diabetes (ACCORD) trial, intensive
glycemic control significantly reduced the risk and/
or progression of retinopathy, nephropathy, and neuropathy
(73,74). However, in ACCORD, which involved older and
middle-aged patients with longstanding T2D who were at
high risk for or had established CVD and a baseline A1C
>8.5%, patients randomized to intensive glucose-lowering
therapy (A1C target of <6.0%) had increased mortality
(75). The excess mortality occurred only in patients whose
A1C remained >7% despite intensive therapy, whereas in
the standard therapy group (A1C target 7 to 8%), mortality
followed a U-shaped curve with increasing death rates at
both low (<7%) and high (>8%) A1C levels (76). In contrast,
in the Veterans Affairs Diabetes Trial (VADT), which had
a higher A1C target for intensively treated patients (1.5%
lower than the standard treatment group), there were no
between-group differences in CVD endpoints, cardiovascular
death, or overall death during the 5.6-year study
period (75,77). After approximately 10 years, however,
VADT patients participating in an observational follow-up
study were 17% less likely to have a major cardiovascular
event if they received intensive therapy during the trial
(P<.04; 8.6 fewer cardiovascular events per 1,000 personyears),
whereas mortality risk remained the same between
treatment groups (78). Severe hypoglycemia occurs more
frequently with intensive glycemic control (72,75,77,79).
In ACCORD, severe hypoglycemia may have accounted
for a substantial portion of excess mortality among
patients receiving intensive therapy, although the hazard
ratio for hypoglycemia-associated deaths was higher in
the standard treatment group (80). Cardiovascular autonomic
neuropathy may be another useful predictor of
cardiovascular risk, and a combination of cardiovascular
autonomic neuropathy (81) and symptoms of peripheral
neuropathy increase the odds ratio to 4.55 for CVD and
mortality (82).
Taken together, this evidence supports individualization
of glycemic goals (2). In adults with recent onset of T2D
and no clinically significant CVD, an A1C between 6.0 and
6.5%, if achieved without substantial hypoglycemia or other
unacceptable consequences, may reduce lifetime risk of
microvascular and macrovascular complications. A broader
A1C range may be suitable for older patients and those at
risk for hypoglycemia. A less stringent A1C of 7.0 to 8.0% is
appropriate for patients with history of severe hypoglycemia,
limited life expectancy, advanced renal disease or macrovascular
complications, extensive comorbid conditions, or
long-standing T2D in which the A1C goal has been difficult
to attain despite intensive efforts, so long as the patient
remains free of polydipsia, polyuria, polyphagia, or other
hyperglycemia-associated symptoms. Therefore, selection
of glucose-lowering agents should consider a patient’s therapeutic
goal, age, and other factors that impose limitations
on treatment, as well as the attributes and adverse effects of
each regimen. Regardless of the treatment selected, patients
must be followed regularly and closely to ensure that glycemic
goals are met and maintained.
The order of agents in each column of the Glucose
Control Algorithm suggests a hierarchy of recommended
usage, and the length of each line reflects the strength of
the expert consensus recommendation (see Comprehensive
Type 2 Diabetes Management Algorithm—Glycemic
Control Algorithm). Each medication’s properties should
be considered when selecting a therapy for individual
patients (see Comprehensive Type 2 Diabetes Management
Algorithm—Profiles of Antidiabetic Medications), and
healthcare professionals should consult the FDA prescribing
information for each agent.
• Metformin has a low risk of hypoglycemia, can
promote modest weight loss, and has good antihyperglycemic
efficacy at doses of 2,000 to 2,500 mg/day.
Its effects are quite durable compared to sulfonylureas
(SFUs), and it also has robust cardiovascular safety
relative to SFUs (83-85). Owing to risk of lactic acido89
sis, the U.S. prescribing information states that metformin
is contraindicated if serum creatinine is >1.5 mg/
dL in men or >1.4 mg/dL in women, or if creatinine
clearance is “abnormal” (86). However, the risk for
lactic acidosis in patients on metformin is extremely
low (87), and the FDA guidelines prevent many
individuals from benefiting from metformin. Newer
chronic kidney disease (CKD) guidelines reflect this
concern, and some authorities recommend stopping
metformin at an estimated glomerular filtration rate
(eGFR) <30 mL/min/1.73 m2 (88,89). AACE recommends
metformin not be used in patients with stage
3B, 4, or 5 CKD (2). In up to 16% of users, metformin
is responsible for vitamin B12 malabsorption and/or
deficiency (90,91), a causal factor in the development
of anemia and peripheral neuropathy (92). Vitamin
B12 levels should be monitored in all patients taking
metformin, and vitamin B12 supplements should be
given to affected patients.
• GLP-1 receptor agonists have robust A1C-lowering
properties, are usually associated with weight loss
and BP reductions (93), and are available in several
formulations. The risk of hypoglycemia with GLP-1
receptor agonists is low (94), and they reduce fluctuations
in both fasting and postprandial glucose levels.
GLP-1 receptor agonists should not be used in patients
with personal or family history of medullary thyroid
carcinoma or those with multiple endocrine neoplasia
syndrome type 2. Exenatide should not be used
if creatinine clearance is <30 mL/min. No studies
have confirmed that incretin agents cause pancreatitis
(95); however, GLP-1 receptor agonists should be
used cautiously—if at all—in patients with a history
of pancreatitis and discontinued if acute pancreatitis
develops. Some GLP-1 receptor agonists may
retard gastric emptying, especially with initial use.
Therefore, use in patients with gastroparesis or severe
gastroesophageal reflux disease requires careful monitoring
and dose adjustment.
• Sodium glucose cotransporter 2 (SGLT-2) inhibitors
have a glucosuric effect that results in decreased A1C,
weight, and systolic BP. In the only SGLT-2 inhibitor
cardiovascular outcomes trial reported to date, empagliflozin
was associated with significantly lower rates
of all-cause and cardiovascular death and lower risk
of hospitalization for heart failure (96). Heart failure–
related endpoints appeared to account for most
of the observed benefits in this study. SGLT-2 inhibitors
are associated with increased risk of mycotic
genital infections and slightly increased low-densitylipoprotein
cholesterol (LDL-C) levels, and because
of their mechanism of action, they have limited efficacy
in patients with an eGFR <45 mL/min/1.73 m2.
Dehydration due to increased diuresis may lead to
hypotension (97-99). The incidence of bone fractures
in patients taking canagliflozin and dapagliflozin was
increased in clinical trials (99). Investigations into
postmarketing reports of SGLT-2 inhibitor–associated
diabetic ketoacidosis (DKA), which has been reported
to occur in type 1 diabetes and T2D patients with
less than expected hyperglycemia (euglycemic DKA)
(98), are ongoing. After a thorough review of the
evidence during an October 2015 meeting, an AACE/
ACE Scientific and Clinical Review expert consensus
group found that the incidence of DKA is infrequent
and recommended no changes in SGLT-2 inhibitor
labeling (100).
• Dipeptidyl peptidase 4 (DPP-4) inhibitors exert
antihyperglycemic effects by inhibiting DPP-4 and
thereby enhancing levels of GLP-1 and other incretin
hormones. This action stimulates glucose-dependent
insulin synthesis and secretion and suppresses
glucagon secretion. DPP-4 inhibitors have modest
A1C-lowering properties, are weight neutral, and are
available in combination tablets with metformin, an
SGLT-2 inhibitor, and a TZD. The risk of hypoglycemia
with DPP-4 inhibitors is low (101,102). The
DPP-4 inhibitors, except linagliptin, are excreted by
the kidneys; therefore, dose adjustments are advisable
for patients with renal dysfunction. These agents
should be used with caution in patients with a history
of pancreatitis, although a causative association has
not been established (95).
• The TZDs, the only antihyperglycemic agents to
directly reduce insulin resistance, have relatively
potent A1C-lowering properties, a low risk of hypoglycemia,
and durable glycemic effects (84,103,104).
Pioglitazone may confer CVD benefits (103,105),
whereas rosiglitazone has a neutral effect on CVD
risk (106,107). Side effects that have limited TZD use
include weight gain, increased bone fracture risk in
postmenopausal women and elderly men, and elevated
risk for chronic edema or heart failure (108-111). A
possible association with bladder cancer has largely
been refuted (112). Side effects may be mitigated by
using a moderate dose (e.g., ≤30 mg) of pioglitazone.
• In general, alpha-glucosidase inhibitors (AGIs) have
modest A1C-lowering effects and low risk for hypoglycemia
(113). Clinical trials have shown CVD
benefit in patients with impaired glucose tolerance and
diabetes (64,114). Side effects (e.g., bloating, flatulence,
diarrhea) have limited their use in the United
States. These agents should be used with caution in
patients with CKD.
• The insulin-secretagogue SFUs have relatively
potent A1C-lowering effects but lack durability and
are associated with weight gain and hypoglycemia
(84,115). SFUs have the highest risk of serious hypoglycemia
of any noninsulin therapy, and analyses
of large datasets have raised concerns regarding the
90
cardiovascular safety of this class when the comparator
is metformin, which may itself have cardioprotective
properties (85,116). The secretagogue glinides
have somewhat lower A1C-lowering effects, have a
shorter half-life, and carry a lower risk of hypoglycemia
risk than SFUs.
• Colesevelam, which is a bile acid sequestrant (BAS),
lowers glucose modestly, does not cause hypoglycemia,
and decreases LDL-C. A perceived modest efficacy
for both A1C and LDL-C lowering as well as
gastrointestinal intolerance (constipation and dyspepsia),
which occurs in 10% of users, may contribute
to limited use. In addition, colesevelam can increase
triglyceride levels in individuals with pre-existing
triglyceride elevations (117).
• The quick-release dopamine receptor agonist
bromocriptine mesylate has slight glucose-lowering
properties (118) and does not cause hypoglycemia. It
can cause nausea and orthostasis and should not be used
in patients taking antipsychotic drugs. Bromocriptine
mesylate may be associated with reduced cardiovascular
event rates (119,120).
For patients with recent-onset T2D or mild hyperglycemia
(A1C <7.5%), lifestyle therapy plus antihyperglycemic
monotherapy (preferably with metformin) is recommended
(see Comprehensive Type 2 Diabetes Management
Algorithm—Glycemic Control Algorithm). Acceptable
alternatives to metformin as initial therapy include GLP-1
receptor agonists, SGLT-2 inhibitors, DPP-4 inhibitors,
and TZDs. AGIs, SFUs, and glinides may also be appropriate
as monotherapy for select patients.
Metformin should be continued as background therapy
and used in combination with other agents, including
insulin, in patients who do not reach their glycemic target
on monotherapy. Patients who present with an A1C >7.5%
should be started on metformin plus another agent in addition
to lifestyle therapy (115) (see Comprehensive Type
2 Diabetes Management Algorithm—Glycemic Control
Algorithm). In metformin-intolerant patients, 2 drugs with
complementary mechanisms of action from other classes
should be considered.
The addition of a third agent may safely enhance
treatment efficacy (see Comprehensive Type 2 Diabetes
Management Algorithm—Glycemic Control Algorithm),
although any given third-line agent is likely to have somewhat
less efficacy than when the same medication is used
as first- or second-line therapy. Patients with A1C >9.0%
who are symptomatic would derive greater benefit from
the addition of insulin, but if presenting without significant
symptoms, these patients may initiate therapy with maximum
doses of 2 other medications. Doses may then be
decreased to maintain control as the glucose falls. Therapy
intensification should include intensified lifestyle therapy
and anti-obesity treatment (where indicated).
Certain patient populations are at higher risk for
adverse treatment-related outcomes, underscoring the
need for individualized therapy. Although several antihyperglycemic
classes carry a low risk of hypoglycemia
(e.g., metformin, GLP-1 receptor agonists, SGLT-2 inhibitors,
DPP-4 inhibitors, and TZDs), significant hypoglycemia
can occur when these agents are used in combination
with an insulin secretagogue or exogenous insulin.
When such combinations are used, one should consider
lowering the dose of the insulin secretagogue or insulin
to reduce the risk of hypoglycemia. Many antihyperglycemic
agents (e.g., metformin, GLP-1 receptor agonists,
SGLT-2 inhibitors, some DPP-4 inhibitors, AGIs, SFUs)
have limitations in patients with impaired renal function
and may require dose adjustments or special precautions
(see Comprehensive Type 2 Diabetes Management
Algorithm—Profiles of Antidiabetic Medications). In
general, diabetes therapy does not require modification for
mild to moderate liver disease, but the risk of hypoglycemia
increases in severe cases.
Insulin
Insulin is the most potent glucose-lowering agent.
However, many factors come into play when deciding to
start insulin therapy and choosing the initial insulin formulation
(see Comprehensive Type 2 Diabetes Management
Algorithm—Algorithm for Adding/Intensifying Insulin).
These decisions, made in collaboration with the patient,
depend greatly on each patient’s motivation, cardiovascular
and end-organ complications, age, general well-being,
risk of hypoglycemia, and overall health status, as well as
cost considerations. Patients taking 2 oral antihyperglycemic
agents who have an A1C >8.0% and/or long-standing
T2D are unlikely to reach their target A1C with a third
oral antihyperglycemic agent. Although adding a GLP-1
receptor agonist as the third agent may successfully lower
glycemia, eventually many patients will still require insulin
(121,122). In such cases, a single daily dose of basal
insulin should be added to the regimen. The dosage should
be adjusted at regular and fairly short intervals to achieve
the glucose target while avoiding hypoglycemia. Recent
studies (123,124) have shown that titration is equally effective
whether it is guided by the healthcare professional or a
patient who has been instructed in SMBG.
Basal insulin analogs are preferred over neutral protamine
Hagedorn (NPH) insulin because a single basal dose
provides a relatively flat serum insulin concentration for up
to 24 hours. Although insulin analogs and NPH have been
shown to be equally effective in reducing A1C in clinical
trials, insulin analogs caused significantly less hypoglycemia
(123-127).
Premixed insulins provide less dosing flexibility and
have been associated with a higher frequency of hypoglycemic
events compared to basal and basal-bolus regimens
(128-130). Nevertheless, there are some patients for
91
whom a simpler regimen using these agents is a reasonable
compromise.
Patients whose basal insulin regimens fail to provide
glucose control may benefit from the addition of a GLP-1
receptor agonist, SGLT-2 inhibitor, or DPP-4 inhibitor (if
not already taking one of these agents; see Comprehensive
Type 2 Diabetes Management Algorithm—Algorithm for
Adding/Intensifying Insulin). When added to insulin therapy,
the incretins and SGLT-2 inhibitors enhance glucose
reductions and may minimize weight gain without increasing
the risk of hypoglycemia, and the incretins also increase
endogenous insulin secretion in response to meals, reducing
postprandial hyperglycemia (121,131-136). Depending
on patient response, basal insulin dose may need to be
reduced to avoid hypoglycemia.
Patients whose glycemia remains uncontrolled while
receiving basal insulin and those with symptomatic hyperglycemia
may require combined basal and mealtime bolus
insulin. Rapid-acting analogs (lispro, aspart, or glulisine)
or inhaled insulin are preferred over regular human insulin
because the former have a more rapid onset and offset
of action and are associated with less hypoglycemia (137).
The simplest approach is to cover the largest meal with
a prandial injection of a rapid-acting insulin analog or
inhaled insulin and then add additional mealtime insulin
later, if needed. Several randomized controlled trials have
shown that the stepwise addition of prandial insulin to basal
insulin is safe and effective in achieving target A1C with
a low rate of hypoglycemia (138-140). A full basal-bolus
program is the most effective insulin regimen and provides
greater flexibility for patients with variable mealtimes and
meal carbohydrate content (140).
Pramlintide is indicated for use with basal-bolus insulin
regimens. Pioglitazone is indicated for use with insulin at
doses of 15 and 30 mg, but this approach may aggravate
weight gain. There are no specific approvals for the use of
SFUs with insulin, but when they are used together the risks
of both weight gain and hypoglycemia increase (141,142).
It is important to avoid hypoglycemia. Approximately
7 to 15% of insulin-treated patients experience at least one
annual episode of hypoglycemia (143), and 1 to 2% have
severe hypoglycemia (144,145). Several large randomized
trials found that T2D patients with a history of one or more
severe hypoglycemic events have an approximately 2- to
4-fold higher death rate (82,146). It has been proposed that
hypoglycemia may be a marker for persons at higher risk
of death, rather than the proximate cause of death (145).
Patients receiving insulin also gain about 1 to 3 kg more
weight than those receiving other agents.
BP
Elevated BP in patients with T2D is associated with an
increased risk of cardiovascular events (see Comprehensive
Type 2 Diabetes Management Algorithm—ASCVD Risk
Factor Modifications Algorithm). AACE recommends that
BP control be individualized, but that a target of <130/80
mm Hg is appropriate for most patients. Less stringent
goals may be considered for frail patients with complicated
comorbidities or those who have adverse medication
effects, whereas a more intensive goal (e.g., <120/80 mm
Hg) should be considered for some patients if this target
can be reached safely without adverse effects from medication.
Lower BP targets have been shown to be beneficial
for patients at high risk for stroke (147-149). Among
participants in the Action to Control Cardiovascular Risk
in Diabetes Blood Pressure (ACCORD BP) trial, there
were no significant differences in primary cardiovascular
outcomes or all-cause mortality between standard therapy
(which achieved a mean BP of 133/71 mm Hg) and
intensive therapy (mean BP of 119/64 mm Hg). Intensive
therapy did produce a comparatively significant reduction
in stroke and microalbuminuria, but these reductions came
at the cost of requiring more antihypertensive medications
and produced a significantly higher number of serious
adverse events (SAEs) (150). A meta-analysis of antihypertensive
therapy in patients with T2D or impaired fasting
glucose demonstrated similar findings. Systolic BP ≤135
mm Hg was associated with decreased nephropathy and a
significant reduction in all-cause mortality compared with
systolic BP ≤140 mm Hg. Below 130 mm Hg, stroke and
nephropathy, but not cardiac events, declined further, but
SAEs increased by 40% (147).
Lifestyle therapy can help T2D patients reach their
BP goal:
• Weight loss can improve BP in patients with T2D.
Compared with standard intervention, the results of
the Look AHEAD trial found that significant weight
loss is associated with significant reduction in BP,
without the need for increased use of antihypertensive
medications (4).
• Sodium restriction is recommended for all patients
with hypertension. Clinical trials indicate that potassium
chloride supplementation is associated with
BP reduction in people without diabetes (151). The
Dietary Approaches to Stop Hypertension (DASH)
diet, which is low in sodium and high in dietary potassium,
can be recommended for all patients with T2D
without renal insufficiency (152-157).
• Numerous studies have shown that moderate alcohol
intake is associated with a lower incidence of heart
disease and cardiovascular mortality (158,159).
• The effect of exercise in lowering BP in people without
diabetes has been well-established. In hypertensive
patients with T2D, however, exercise appears to
have a more modest effect (25,160); still, it is reasonable
to recommend a regimen of moderately intense
physical activity in this population.
Most patients with T2D and hypertension will require
medications to achieve their BP goal. Angiotensin92
converting enzyme inhibitors (ACEIs), angiotensin II
receptor blockers (ARBs), beta blockers, calcium-channel
blockers (CCBs), and thiazide diuretics are favored choices
for first-line treatment (161-165). The selection of medications
should be based on factors such as the presence
of albuminuria, CVD, heart failure, or post–myocardial
infarction status as well as patient race/ethnicity, possible
metabolic side effects, pill burden, and cost. Because
ACEIs and ARBs can slow progression of nephropathy
and retinopathy, they are preferred for patients with T2D
(162,166-168). Patients with heart failure could benefit
from beta blockers, those with prostatism from alpha
blockers, and those with coronary artery disease (CAD)
from beta blockers or CCBs. In patients with BP >150/100
mm Hg, 2 agents should be given initially because it is
unlikely any single agent would be sufficient to achieve the
BP target. An ARB/ACEI combination more than doubles
the risk of renal failure and hyperkalemia and is therefore
not recommended (169,170).
Lipids
Compared to those without diabetes, patients with
T2D have a significantly increased risk of ASCVD (171).
Whereas blood glucose control is fundamental to prevention
of microvascular complications, controlling atherogenic
cholesterol particle concentrations is fundamental
to prevention of macrovascular disease (i.e., ASCVD).
To reduce the significant risk of ASCVD, including
coronary heart disease (CHD), in T2D patients, early
intensive management of dyslipidemia is warranted (see
Comprehensive Type 2 Diabetes Management Algorithm--
ASCVD Risk Factor Modifications Algorithm).
The classic major risk factors that modify the LDL-C
goal for all individuals include cigarette smoking, hypertension
(BP ≥140/90 mm Hg or use of antihypertensive
medications), high-density-lipoprotein cholesterol (HDLC)
<40 mg/dL, family history of CHD, and age ≥45 years
for men or ≥55 years for women (172). Recognizing that
T2D carries a high lifetime risk for developing ASCVD,
risk should be stratified for primary prevention as “high”
(patients <40 years of age; ≤1 major risk factor) or “very
high” (≥2 major risk factors). Patients with T2D and a prior
ASCVD event (i.e., recognized “clinical ASCVD”) are also
stratified as “very high” or “extreme” risk in this setting for
secondary or recurrent events prevention. Risk stratification
in this manner can guide management strategies.
In addition to hyperglycemia, the majority of T2D
patients have a syndrome of insulin resistance, which is
characterized by a number of ASCVD risk factors, including
hypertension; hypertriglyceridemia; low HDL-C;
elevated apolipoprotein (apo) B and small, dense LDL; and
a procoagulant and proinflammatory milieu. The presence
of these factors justifies classifying these patients as being
at either high or very high risk (173,174); as such, AACE
recommends LDL-C targets of <100 mg/dL or <70 mg/dL
and non-HDL-C targets of <130 mg/dL or <100 mg/dL,
respectively, with additional lipid targets shown in Table
1 (see also Comprehensive Type 2 Diabetes Management
Algorithm—ASCVD Risk Factor Modifications
Algorithm). The atherogenic cholesterol goals appear
identical for very high risk primary prevention and for
very high risk secondary (or recurrent events) prevention.
However, AACE does not define how low the goal should
be and recognizes that even more intensive therapy, aimed
at lipid levels far lower than an LDL-C <70 mg/dL or non-
HDL-C <100 mg/dL, might be warranted for the secondary
prevention group. A meta-analysis of 8 major statin trials
demonstrated that those individuals achieving an LDL-C
<50 mg/dL, a non-HDL-C <75 mg/dL, and apo B <50 mg/
dL have the lowest ASCVD events (175). Furthermore,
the primary outcome and subanalyses of the Improved
Reduction of Outcomes: Vytorin Efficacy International
Trial (IMPROVE-IT), a study involving 18,144 patients,
provided evidence that lower LDL-C is better in patients
after acute coronary syndromes (176).
Many patients with T2D can achieve lipid profile
improvements using lifestyle therapy (smoking cessation,
physical activity, weight management, and healthy eating)
(172). However, most patients will require pharmacotherapy
to reach their target lipid levels and reduce their cardiovascular
risk.
A statin should be used as first-line cholesterol-lowering
drug therapy, unless contraindicated; current evidence
supports a moderate- to high-intensity statin (177-180).
Numerous randomized clinical trials and meta-analyses
conducted in primary and secondary prevention populations
have demonstrated that statins significantly reduce
the risk of cardiovascular events and death in patients
with T2D (177,179-183). However, considerable residual
risk persists even after aggressive statin monotherapy
in primary prevention patients with multiple cardiovascular
risk factors and in secondary prevention patients
with stable clinical ASCVD or acute coronary syndrome
(ACS) (180,184,185). Although intensification of statin
therapy (e.g., through use of higher dose or higher potency
agents) can further reduce atherogenic cholesterol particles
(primarily LDL-C) and the risk of ASCVD events (186),
some residual risk will remain (187). Data from several
studies have shown that even when LDL-C reaches an
optimal level (20th percentile), non-HDL-C, apo B, and
low-density-lipoprotein particle (LDL-P) number can
remain suboptimal (188). Furthermore, statin intolerance
(usually muscle-related adverse effects) can limit the use
of intensive statin therapy in some patients (189).
Other lipid-modifying agents should be utilized in
combination with maximally tolerated statins when therapeutic
levels of LDL-C, non-HDL-C, apo B, or LDL-P
have not been reached:
• Ezetimibe inhibits intestinal absorption of cholesterol,
reduces chylomicron production, decreases hepatic
93
cholesterol stores, upregulates LDL receptors, and
lowers apo B, non-HDL-C, LDL-C, and triglycerides
(190). In IMPROVE-IT, the relative risk of ASCVD
was reduced by 6.4% (P = .016) in patients taking
simvastatin plus ezetimibe for 7 years (mean LDL-C,
54 mg/dL) compared to simvastatin alone (LDL-C, 70
mg/dL). The ezetimibe benefit was almost exclusively
noted in the prespecified diabetes subgroup, which
comprised 27% of the study population and in which
the relative risk of ASCVD was reduced by 14.4%
(P = .023) (176).
• Monoclonal antibody inhibitors of proprotein convertase
subtilisin–kexin type 9 (PCSK9) serine protease,
a protein that regulates the recycling of LDL receptors,
have recently been approved by the FDA for primary
prevention in patients with hetero- and homozygous
familial hypercholesterolemia or as secondary prevention
in patients with clinical ASCVD who require
additional LDL-C–lowering therapy. This class of
drugs meets a large unmet need for more aggressive
lipid-lowering therapy beyond statins in an attempt to
further reduce residual ASCVD risk in many persons
with clinical ASCVD and diabetes. When added to
maximal statin therapy, these once- or twice-monthly
injectable agents reduce LDL-C by approximately
50%, raise HDL-C, and have favorable effects on
other lipids (191-197). In post hoc cardiovascular safety
analyses of alirocumab and evolocumab added to
statins with or without other lipid-lowering therapies,
mean LDL-C levels of 48 mg/dL were associated with
statistically significant relative risk reductions of 48 to
53% in major ASCVD events (192,193). Furthermore,
a subgroup analysis of patients with diabetes taking
alirocumab demonstrated that a 59% LDL-C reduction
was associated with an ASCVD event relative risk
reduction trend of 42% (198).
• The highly selective BAS colesevelam, by increasing
elimination of bile acids, increases hepatic bile acid
production, thereby decreasing hepatic cholesterol
stores. This leads to an upregulation of LDL receptors
and reduces LDL-C, non-HDL-C, apo B, and
LDL-P and improves glycemic status. There is a small
compensatory increase in de novo cholesterol biosynthesis,
which can be suppressed by the addition of
statin therapies (199-201).
• Fibrates have only small effects on lowering atherogenic
cholesterol (5%) and are used mainly for lowering
triglycerides. By lowering triglycerides, fibrates
unmask residual atherogenic cholesterol in triglyceride-
rich remnants (i.e., very-low-density-lipoprotein
cholesterol). In progressively higher triglyceride
settings, as triglycerides decrease, LDL-C increases,
thus exposing the need for additional lipid therapies.
As monotherapy, fibrates have demonstrated significantly
favorable outcomes in populations with high
non-HDL-C (202) and low HDL-C (203). The addition
of fenofibrate to statins in the ACCORD study
showed no benefit in the overall cohort in which
mean baseline triglycerides and HDL-C were within
normal limits (204). Subgroup analyses and metaanalyses,
however, have shown a relative risk reduction
for CVD events of 26 to 35% among patients with
moderate dyslipidemia (triglycerides >200 mg/dL and
HDL-C <40 mg/dL) (204-209).
• Niacin lowers apo B, LDL-C, and triglycerides in a
dose-dependent fashion and is the most powerful lipidmodifying
agent for raising HDL-C on the market
(210). It may reduce cardiovascular events through
a mechanism other than an increase in HDL-C (211).
Two trials designed to test the HDL-C–raising hypothesis
(Atherothrombosis Intervention in Metabolic
Syndrome with Low HDL/High Triglycerides: Impact
Table 1
AACE Lipid Targets for Patients With Type 2 Diabetes
High-risk patients
(T2D but no other major risk and/or
age <40 years)
Very-high-risk patients
(T2D plus ≥1 major ASCVD riska or
established ASCVD)
LDL-C (mg/dL) <100 <70
Non-HDL-C (mg/dL) <130 <100
Triglycerides (mg/dL) <150 <150
TC/HDL-C <3.5 <3.0
Apo B (mg/dL) <90 <80
LDL-P (nmol/L) <1,200 <1,000
Abbreviations: AACE = American Association of Clinical Endocrinologists; Apo B = apolipoprotein B;
ASCVD = atherosclerotic cardiovascular disease; HDL-C = high-density-lipoprotein cholesterol;
LDL-C = low-density-lipoprotein cholesterol; LDL-P = low-density-lipoprotein particle; TC = total
cholesterol; T2D = type 2 diabetes.
a Hypertension, family history of ASCVD, low HDL-C, smoking.
94
on Global Health Outcomes [AIM-HIGH] and Heart
Protection Study 2—Treatment of HDL to Reduce the
Incidence of Vascular Events [HPS2-THRIVE]) failed
to show CVD protection during the 3- and 4-year trial
periods, respectively (212,213); by design, betweengroup
differences in LDL-C were nominal at 5 mg/
dL and 10 mg/dL, respectively. Previous trials with
niacin that showed CVD benefits utilized higher doses
of niacin, which were associated with much greater
between-group differences in LDL-C, suggesting niacin
benefits may result solely from its LDL-C–lowering
properties (214). Although niacin may increase blood
glucose, its beneficial effects appear to be greatest
among patients with the highest baseline glucose levels
and those with metabolic syndrome (215).
• Dietary intake of fish and omega-3 fish oil is associated
with reductions in the risks of total mortality, sudden
death, and CAD through various mechanisms of action
other than lowering of LDL-C. In a large clinical trial,
highly purified, prescription-grade, moderate-dose
(1.8 grams) eicosapentaenoic acid (EPA) added to a
statin regimen was associated with a significant 19%
reduction in risk of any major coronary event among
Japanese patients with elevated total cholesterol (216)
and a 22% reduction in CHD in patients with impaired
fasting glucose or T2D (217). Among those with
triglycerides >150 mg/dL and HDL-C <40 mg/dL,
EPA treatment reduced the risk of coronary events by
53% (218). Other studies of lower doses (1 gram) of
omega-3 fatty acids (combined EPA and docosahexaenoic
acid) in patients with baseline triglycerides <200
mg/dL have not demonstrated cardiovascular benefits
(219,220). Studies evaluating high-dose (4 grams)
prescription-grade omega-3 fatty acids in the setting
of triglyceride levels >200 mg/dL are ongoing.
Relative to statin efficacy (30 to >50% LDL-C
lowering), drugs such as ezetimibe, BASs, fibrates, and
niacin have lesser LDL-C–lowering effects (7 to 20%)
and ASCVD reduction (221). However, these agents can
significantly lower LDL-C when utilized in various combinations,
either in statin-intolerant patients or as add-on to
maximally tolerated statins. Triglyceride-lowering agents
such as prescription-grade omega-3 fatty acids, fibrates,
and niacin are important agents that expose the atherogenic
cholesterol within triglyceride-rich remnants that require
additional cholesterol lowering.
If triglyceride levels are severely elevated (>500 mg/
dL), begin treatment with a very-low-fat diet and reduced
intake of simple carbohydrates and initiate combinations
of a fibrate, prescription-grade omega-3-fatty acid, and/or
niacin to reduce triglyceride levels and to prevent pancreatitis.
Although no large clinical trials have been designed
to test this objective, observational data and retrospective
analyses support long-term dietary and lipid management
of hypertriglyceridemia for prophylaxis against or treatment
of acute pancreatitis (222,223).
ACKNOWLEDGMENT
Amanda M. Justice, BA, provided editorial support
and medical writing assistance in the preparation of this
document.
DISCLOSURE
Dr. Alan J. Garber reports that he is on the Advisory
Board for Novo Nordisk, Vivus, Janssen, Merck, Kowa,
Lexicon, Viking Therapeutics, and Takeda. He is also
a consultant for Novo Nordisk, Vivus, Janssen, Merck,
Kowa, Lexicon, Viking Therapeutics, and Takeda.
Dr. Martin J. Abrahamson has received consulting
fees from Novo Nordisk.
Dr. Joshua I. Barzilay reports that he does not have
any relevant financial relationships with any commercial
interests.
Dr. Lawrence Blonde reports that he is a consultant
for AstraZeneca, GlaxoSmithKline, Intarcia, Janssen
Pharmaceutical Companies, Merck & Co., Inc, Novo
Nordisk, Quest Diagnostics, and Sanofi. He is a speaker for
AstraZeneca, Janssen Pharmaceutical Companies, Merck
& Co, Inc, and Novo Nordisk.
Dr. Zachary Bloomgarden reports that he is a consultant
for Novo Nordisk, Merck, and AstraZeneca. He is also
a speaker for Novo Nordisk, Merck, and AstraZeneca. He
is a stock shareholder for Baxter Medical, CVS Caremark,
Roche Holdings, St. Jude Medical, and Novartis.
Dr. Michael A. Bush reports that he is an Advisory
Board Consultant for Janssen and Eli Lilly. He is on the
speaker’s bureau for Takeda, Eli Lilly, Novo Nordisk,
AstraZeneca, and Boehringer Ingelheim.
Dr. Samuel Dagogo-Jack reports that he is a consultant
for Merck, Novo Nordisk, Janssen, and Boehringer
Ingelheim. He has received research grants from
AstraZeneca, Novo Nordisk, and Boehringer Ingelheim.
He has clinical trial contacts with the University of
Tennessee for studies in which he serves as the Investigator
or Co-investigator.
Dr. Ralph A. DeFronzo reports that he is a consultant
for Boehringer Ingelheim, AstraZeneca, Novo Nordisk, and
Janssen. He is a speaker for Novo Nordisk, AstraZeneca,
and Janssen. He has received speaker honoraria from BMS,
Boehringer Ingelheim, Janssen, and AstraZeneca.
Dr. Daniel Einhorn reports that he is a shareholder for
Halozyme. He is a consultant for Novo Nordisk, Eli Lilly,
Sanofi, AstraZeneca, Takeda, Merck, and Janssen. He is a
speaker for Janssen and has received research grants from
all of the companies listed, plus Freedom-Meditech.
Dr. Vivian A. Fonseca reports that he is a consultant
for Takeda, Novo Nordisk, Sanofi, Eli Lily, Pamlabs,
95
AstraZeneca, Abbott, Boehringer Ingelheim, Janssen and
Intarcia. He is a speaker for Janssen, Takeda, and Sanofi.
He has received research grants from Novo Nordisk, Asahi,
Eli Lilly, Abbott, Endo Barrier, and Gilead.
Dr. Jeffrey R. Garber reports that he does not have
any relevant financial relationships with any commercial
interests.
Dr. W. Timothy Garvey reports that he is a consultant
for AstraZeneca, Vivus, Liposcience, Daiichi-Sankyo,
Janssen, Eisai, Takeda, Boehringer Ingelheim, and Novo
Nordisk. He is a speaker for AstraZeneca and shareholder
with ISIS, Novartis, BristolMyersSquibb, Pfizer, Merck,
and Lilly. He has received research grants from Merck,
Weight Watchers, Sanofi, Eisai, AstraZeneca, Pfizer, Novo
Nordisk, and Glaxo.
Dr. George Grunberger reports that he has received
speaker honoraria from Eli Lilly, BI-Lilly, Novo Nordisk,
Sanofi, Janssen, AstraZeneca, and GSK. He has received
research funding from Novo Nordisk, AstraZeneca, Merck,
and Medtronic.
Dr. Yehuda Handelsman reports that he received
research grant support from Amgen, BI, Grifols, Gilead,
Himni, Intarcia, Lexicon, Merck, Novo Nordisk, Sanofi,
and Takeda. He is a consultant for Amarin, Amgen, Dia
Deux, Eisai, Gilead, Halozyme, LipoScience, Merck,
Novo Nordisk, Sanofi, Vivus, and Janssen. He is a speaker
for Amarin, Amgen, AstraZeneca, BI-Lily, Janssen, Novo
Nordisk, Vivus, and Regeneron.
Dr. Robert R. Henry reports that he is a consultant
for Alere, Amgen, AstraZeneca, Boehringer Ingelheim,
Bristol Myers Squibb, Clin Met, Eisea, Elcelyx, Gilead,
Hitachi, Intarcia, Isis, Johnson and Johnson, Janssen,
Merck, Novo Nordisk, Sanofi-Aventis, and Vivus. He has
received research grants from Hitachi, Eli Lilly, Sanofi,
and Viacyte.
Dr. Irl B. Hirsch reports that he has received research
support from Novo Nordisk. He is also a consultant for
Abbott, Roche, and BD.
Dr. Paul S. Jellinger reports that he has received
speaker honoraria from Amarin Corp, Boehringer
Ingelheim GmbH, Bristol-Myers Squibb Co/AstraZeneca,
Janssen Pharmaceuticals, Inc, and Novo Nordisk A/S.
Dr. Janet B. McGill reports that she has received
research grants from Novartis, Sanofi, Intarcia, Novo
Nordisk, Pfizer, and Dexcom. She is a consultant for
Abbott, AstraZeneca, Boehringer Ingelheim, Janssen,
Mannkind, Merck, Novo Nordisk, and Sanofi.
Dr. Jeffrey I. Mechanick reports that he is a consultant
and speaker for Abbott Nutrition International.
Dr. Paul D. Rosenblit reports that he has received
consulting fees from Amarin, AstraZeneca, Lilly, Merck,
and Sanofi-Regeneron. He is a speaker for AbbVie,
AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline,
Janssen, Kowa, Merck, Sanofi, and Takeda. He has also
received research grants from Amgen, Bristol-Myers
Squibb, Dexcom, Lilly, MannKind, Merck, Novo Nordisk,
Orexigen, Pfizer, and Sanofi.
Dr. Guillermo E. Umpierrez reports that he is
a consultant for Sanofi, Novo Nordisk, Boehringer
Ingelheim, Regeneron, Glytec, and Merck. He also received
research grants from Merck, Novo Nordisk, AstraZeneca,
Regeneron, and Boehringer Ingelheim.
Amanda M. Justice (medical writer) has received
fees for medical writing from Asahi Kasei and Lexicom.
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194. Ramasamy I. Recent advances in physiological lipoprotein
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196. Verbeek R, Stoekenbroek RM, Hovingh GK. PCSK9
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to atorvastatin versus other lipid treatment strategies:
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198. Colhoun HM, Ginsberg HN, Leiter LA, et al. Efficacy
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200. Handelsman Y. Role of bile acid sequestrants in the treatment
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201. Rosenson RS, Abby SL, Jones MR. Colesevelam HCl
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202. Frick MH, Elo O, Haapa K, et al. Helsinki Heart Study:
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203. Rubins HB, Robins SJ, Collins D, et al. Gemfibrozil for the
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103
TASK FORCE
Alan J. Garber, MD, PhD, FACE, Chair
AACE/ACE COMPREHENSIVE TYPE 2
DIABETES MANAGEMENT ALGORITHM
2016
Irl B. Hirsch, MD
Paul S. Jellinger, MD, MACE
Janet B. McGill, MD, FACE
Jerey I. Mechanick, MD, FACP, FACE, FACN, ECNU
Paul D. Rosenblit, MD, PhD, FNLA, FACE
Guillermo Umpierrez, MD, FACP, FACE
Martin J. Abrahamson, MD
Joshua I. Barzilay, MD, FACE
Lawrence Blonde, MD, FACP, FACE
Zachary T. Bloomgarden, MD, MACE
Michael A. Bush, MD
Samuel Dagogo-Jack, MD, DM, FRCP, FACE
Ralph A. DeFronzo, MD
Daniel Einhorn, MD, FACP, FACE
Vivian A. Fonseca, MD, FACE
Jerey R. Garber, MD, FACP, FACE
W. Timothy Garvey, MD, FACE
George Grunberger, MD, FACP, FACE
Yehuda Handelsman, MD, FACP, FNLA, FACE
Robert R. Henry, MD, FACE
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104
TABLE OF CONTENTS
Comprehensive Type 2 Diabetes Algorithm
I. Lifestyle Therapy
II. Complications-Centric Model for Care
of the Overweight/Obese Patient
III. Prediabetes Algorithm
IV. Goals for Glycemic Control
V. Glycemic Control Algorithm
VI. Algorithm for Adding/Intensifying Insulin
VII. ASCVD Risk Factor Modifications Algorithm
VIII. Profiles of Antidiabetic Medications
IX. Principles for Treatment of Type 2 Diabetes
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105
LIFESTYLE THERAPY
RISK STRATIFICATION FOR DIABETES COMPLICATIONS
Nutrition
Physical
Activity
Sleep
Behavioral
Support
Smoking
Cessation
• Maintain optimal weight
• Calorie restriction
• Plant-based diet; high polyunsaturated
and monounsaturated fatty acids
• Avoid trans fatty acids;
limit saturated fatty acids
• Structured counseling
• Meal replacement +
• 150 min/week moderate exertion
(eg. walking, stair climbing)
• Strength training
• Increase as tolerated
• Medical evaluation/
clearance
• Medical supervision
• About 7 hours per night • Screen for obstructive sleep apnea
• Community engagement
• Screen for mood disorders
• Refer to mental healthcare professional
• Behavioral therapy
• No tobacco products • Structured programs
+
+++
• Structured +
program
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INTENSITY STRATIFIED BY BURDEN OF OBESITY AND RELATED COMPLICATIONS
106
COMPLICATIONSCENTRIC MODEL FOR CARE
OF THE OVERWEIGHT/OBESE PATIENT
STEP 1
COMPLICATIONS
E VA LUAT I O N F O R CO M P L I CAT I O N S A N D S TAG I N G
Lifestyle Therapy: Physician/RD counseling, web/remote program, structured multidisciplinary program
Phentermine, orlistat, lorcaserin, phentermine/topiramate ER,
naltrexone/bupropion, liraglutide 3 mg
Medical Therapy
(BMI  27):
Surgical Therapy (BMI  35): Gastric banding, sleeve, or bypass
STEP 3 If therapeutic targets for complications not met, intensify lifestyle, medical, and/or surgical treatment
modalities for greater weight loss.
CARDIOMETABOLIC DISEASE | BIOMECHANICAL COMPLICATIONS
BMI  27: Stage Severity of Complications
MILD TO MODERATE SEVERE
BMI 25–26.9
NO COMPLICATIONS
BMI 25
Therapeutic targets for
STEP 2 improvement in complications Treatment
modality
Treatment intensity based
on staging SELECT: + +
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107
NORMAL
GLYCEMIA
Intensify
Weight
Loss
Therapies
TZD
GLP-1 RA
Progression
OVERT
DIABETES
Consider with
Caution
TREAT HYPERGLYCEMIA
FPG > 100 | 2-hour PG > 140
TREAT ASCVD
RISK FACTORS
Orlistat, lorcaserin,
phentermine/topiramate ER,
naltrexone/bupropion, liraglutide 3 mg,
or bariatric surgery as indicated for
obesity treatment
PREDIABETES ALGORITHM
IFG 100125 | IGT 140199 | METABOLIC SYNDROME NCEP 2001
LEGEND
MULTIPLE PREDM
CRITERIA
If glycemia
not normalized
Low-risk
Medications
Metformin
Acarbose
WEIGHT LOSS
THERAPIES
ASCVD RISK FACTOR
MODIFICATIONS ALGORITHM
1 PREDM
CRITERION
L I F E S T YL E T H E R A PY
(Including Medically Assisted Weight Loss)
PROCEED TO
HYPERGLYCEMIA
ALGORITHM
HYPERTENSION
ROUTE
DYSLIPIDEMIA
ROUTE
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108
GOALS FOR GLYCEMIC CONTROL
A1C  6.5%
For patients without
concurrent serious
illness and at low
hypoglycemic risk
A1C > 6.5%
For patients with
concurrent serious
illness and at risk
for hypoglycemia
INDIVIDUALIZE GOALS
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109
Metformin
GLP-1 RA
SGLT-2i
DPP-4i
TZD
AGi
SU/GLN
GLP-1 RA
SGLT-2i
DPP-4i
TZD
Basal Insulin
Colesevelam
Bromocriptine QR
AGi
SU/GLN
MONOTHERAPY*
If not at goal
in 3 months
proceed to
Triple Therapy
MET
or other
1st-line
agent +
DUAL THERAPY*
MET
or other
1st-line
agent +
2nd-line
agent
+
TRIPLE THERAPY*
GLP-1 RA
SGLT-2i
TZD
Basal insulin
DPP-4i
Colesevelam
Bromocriptine QR
AGi
SU/GLN
If not at goal in
3 months proceed
to or intensify
insulin therapy
SYMPTOMS
DUAL
Therapy
TRIPLE
Therapy
OR
INSULIN
±
Other
Agents
ADD OR INTENSIFY
INSULIN
Refer to Insulin Algorithm
L I F E S T YL E T H E R A PY
(Including Medically Assisted Weight Loss)
GLYCEMIC CONTROL ALGORITHM
* Order of medications represents a suggested hierarchy of usage;
length of line reects strength of recommendation
If not at goal in 3 months
proceed to Dual Therapy
LEGEND
Few adverse events and/or
possible benets
Use with caution
Entry A1C < 7.5% Entry A1C  7.5% Entry A1C > 9.0%
NO YES
P R O G R E S S I O N O F D I S E A S E
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110
• <7% for most patients with T2D; fasting and premeal
BG < 110 mg/dL; absence of hypoglycemia
• A1C and FBG targets may be adjusted based on patient’s
age, duration of diabetes, presence of comorbidities,
diabetic complications, and hypoglycemia risk
• Fixed regimen: Increase TDD by 2 U
• Adjustable regimen:
• FBG > 180 mg/dL: add 20% of TDD
• FBG 140–180 mg/dL: add 10% of TDD
• FBG 110–139 mg/dL: add 1 unit
• If hypoglycemia, reduce TDD by:
• BG < 70 mg/dL: 10% – 20%
• BG < 40 mg/dL: 20% – 40%
ALGORITHM FOR ADDING/INTENSIFYING INSULIN
*Glycemic Goal:
A1C < 8% A1C > 8%
S TAR T BA S A L (Long-Acting Insulin)
Consider discontinuing or reducing sulfonylurea after
starting basal insulin (basal analogs preferred to NPH)
TDD TDD
Add
GLP1 RA
0.10.2 U/kg 0.20.3 U/kg
Insulin titration every 2–3 days
to reach glycemic goal:
Glycemic
Control Not
at Goal*
Basal Plus 1, Plus 2,
Plus 3
Basal Bolus
Or SGLT-2i
Or DPP-4i
Add Prandial Insulin
• Begin prandial
insulin before
largest meal
• If not at goal,
progress to
injections before
2 or 3 meals
• Start: 10% of basal
dose or 5 units
• Start: 50% of TDD
in three doses
before meals
• Begin prandial
insulin before
each meal
• 50% Basal /
50% Prandial
TDD 0.3–0.5 U/kg
Insulin titration every 2–3 days to reach glycemic goal:
• Increase prandial dose by 10% or 1-2 units if 2-h postprandial
or next premeal glucose consistently > 140 mg/dL
• If hypoglycemia, reduce TDD basal and/or prandial insulin by:
• BG consistently < 70 mg/dL: 10% - 20%
• Severe hypoglycemia (requiring assistance from another
person) or BG < 40 mg/dL: 20% - 40%
I N T E N S I F Y (Prandial Control)
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111
DYS L I P I D E M I A
If statin-intolerant
Intensify therapies to
attain goals according
to risk levels
Try alternate statin, lower statin
dose or frequency, or add nonstatin
LDL-C- lowering therapies
Repeat lipid panel;
assess adequacy,
tolerance of therapy
Assess adequacy & tolerance of therapy with focused laboratory evaluations and patient follow-up
HYP E R T E N S I O N
Intensify lifestyle therapy (weight loss, physical activity, dietary changes)
and glycemic control; consider additional therapy
IF NOT AT DESIRABLE LEVELS:
TO LOWER LDL-C: Intensify statin, add ezetimibe, PCSK9i, colesevelam, or niacin
TO LOWER Non-HDL-C, TG: Intensify statin and/or add Rx-grade OM3 fatty acid, brate, and/or niacin
TO LOWER Apo B, LDL-P: Intensify statin and/or add ezetimibe, PCSK9i, colesevelam, and/or niacin
TO LOWER LDL-C in FH:** Statin + PCSK9i
Additional choices (-blockers,
central agents, vasodilators,
aldosterone antagonist)
GOAL: SYSTOLIC <130,
DIASTOLIC <80 mm Hg
For initial blood pressure
>150/100 mm Hg:
DUAL THERAPY
ACEi
or
ARB
ASCVD RISK FACTOR MODIFICATIONS ALGORITHM
L I F E S T YL E T H E R A PY (Including Medically Assisted Weight Loss)
Calcium
Channel
Blocker
ß-blocker
Thiazide
ACEi
or
ARB
If not at goal (2–3 months)
If not at goal (2–3 months)
If not at goal (2–3 months)
Add calcium channel blocker, ß-blocker or thiazide diuretic
RISK LEVELS HIGH VERY HIGH
D E S I R A B L E L E V E L S D E S I R A B L E L E V E L S
LDL-C (mg/dL) <100 <70
Non-HDL-C (mg/dL) <130 <100
TG (mg/dL) <150 <150
TC/HDL-C <3.5 <3.0
Apo B (mg/dL) <90 <80
LDL-P (nmol/L) <1200 <1000
STATIN THERAPY
If TG > 500 mg/dL, brates, Rx-grade omega-3 fatty acids, niacin
* EVEN MORE INTENSIVE THERAPY MIGHT BE WARRANTED ** FAMILIAL HYPERCHOLESTEROLEMIA
DM + major ASCVD risk(s) (HTN, Fam Hx,
low HDL-C, smoking) or ASCVD*
DM but no other major risk
and/or age <40
LIPID PANEL: Assess ASCVD Risk
Achievement of target blood
pressure is critical
Add next agent from the above
group, repeat
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112
MET GLP-1 RA SGLT-2i DPP-4i AGi
TZD
(moderate
dose)
COLSVL BCR-QR INSULIN PRAML
HYPO Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Moderate
to Severe Neutral
WEIGHT Slight
Loss Loss Loss Neutral Neutral Gain Gain Neutral Neutral Gain Loss
RENAL/
GU
Contraindicated
CKD
Stage
3B,4,5
Exenatide
Not
Indicated
CrCl < 30
Not
Effective
with
eGFR < 45
Genital
Mycotic
Infections
Dose
Adjustment
Necessary
(Except
Linagliptin)
Neutral Neutral
More
Hypo
Risk
Neutral Neutral More
Hypo Risk Neutral
GI Sx Moderate Moderate Neutral Neutral Moderate Neutral Neutral Mild Moderate Neutral Moderate
CHF
CARDIAC
ASCVD
Neutral
Neutral Possible
Benefit Neutral Neutral
Moderate Neutral
Neutral
Neutral
Neutral Neutral
Benefit Neutral ? Safe
BONE Neutral Neutral Neutral Neutral Neutral
Moderate
Fracture
Risk
Neutral Neutral Neutral Neutral Neutral
SU
Mild
PROFILES OF ANTIDIABETIC MEDICATIONS
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GLN
Moderate/
Severe
Few adverse events or possible benefits Use with caution Likelihood of adverse effects ? Uncertain effect
113
PRINCIPLES OF THE AACE/ACE COMPREHENSIVE
TYPE 2 DIABETES MANAGEMENT ALGORITHM
1. Lifestyle therapy, including medically supervised weight loss, is key to managing type 2 diabetes.
2. The A1C target must be individualized.
3. Glycemic control targets include fasting and postprandial glucoses.
4. The choice of therapies must be individualized on basis of patient characteristics, impact of net cost
to patient, formulary restrictions, personal preferences, etc.
5. Minimizing risk of hypoglycemia is a priority.
6. Minimizing risk of weight gain is a priority.
7. Initial acquisition cost of medications is only a part of the total cost of care which includes
monitoring requirements, risk of hypoglycemia, weight gain, safety, etc.
8. This algorithm stratifies choice of therapies based on initial A1C.
9. Combination therapy is usually required and should involve agents with complementary actions.
10. Comprehensive management includes lipid and blood pressure therapies and related comorbidities.
11. Therapy must be evaluated frequently until stable (e.g., every 3 months) and then less often.
12. The therapeutic regimen should be as simple as possible to optimize adherence.
13. This algorithm includes every FDA-approved class of medications for diabetes.
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