2 0

AM E RI C A N A S S O CI A TI O N O F CL I NICAL ENDOCRINOLOGIST S
AM E RI C A N CO L L EG E O F E ND O CR INOLOGY

AA C E/A C E C O M P R E H E N S I V E

1 9
TY P E 2 DI A BE T E S
MAN AG E M E N T A L G O R I T H M

COPYRIGHT © 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI 10.4158/CS-2018-0535
 TABLE OF CONTENTS
COMPREHENSIVE TYPE 2 DIABETES MANAGEMENT ALGORITHM

I. Principles for Treatment of Type 2 Diabetes

II. Lifestyle Therapy

III. Complications-Centric Model for Care of the Patient with Overweight/Obesity

IV. Prediabetes Algorithm

V. ASCVD Risk Factor Modifications Algorithm

VI. Glycemic Control Algorithm

VII. Algorithm for Adding/Intensifying Insulin

VIII. Profiles of Antidiabetic Medications

COPYRIGHT © 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI 10.4158/CS-2018-0535
 PRINCIPLES OF THE AACE/ACE COMPREHENSIVE
TYPE 2 DIABETES MANAGEMENT ALGORITHM

1. Lifestyle modification underlies all therapy (e.g., weight control, physical activity, sleep, etc.)

2. Avoid hypoglycemia

3. Avoid weight gain

4. Individualize all glycemic targets (A1C, FPG, PPG)

5. Optimal A1C is ≤6.5%, or as close to normal as is safe and achievable

6. Therapy choices are affected by initial A1C, duration of diabetes, and obesity status

7. Choice of therapy reflects cardiac, cerebrovascular, and renal status

8. Comorbidities must be managed for comprehensive care

9. Get to goal as soon as possible—adjust at ≤3 months until at goal

10. Choice of therapy includes ease of use and affordability

11. A1C ≤6.5% for those on any insulin regimen as long as CGM is being used

COPYRIGHT © 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI 10.4158/CS-2018-0535
 LIFESTYLE THERAPY
RISK STRATIFICATION FOR DIABETES COMPLICATIONS

INTENSITY STRATIFIED BY BURDEN OF OBESITY AND RELATED COMPLICATIONS

• Maintain optimal weight

+ +
• Calorie restriction • Avoid trans fatty • Structured
(if BMI is increased) acids; limit
Nutrition counseling
• Plant-based diet; saturated fatty
• Meal replacement
high polyunsaturated and acids
monounsaturated fatty acids

+ +
• 150 min/week moderate exertion • Structured
• Medical evaluation/
Physical (e.g., walking, stair climbing) program
clearance
Activity • Strength training • Wearable
• Medical supervision
• Increase as tolerated technologies

Sleep
• About 7 hours per night
• Basic sleep hygiene + • Screen OSA
• Home sleep study + • Referral to sleep lab

Behavioral
Support
• Community engagement
• Alcohol moderation + • Discuss mood
with HCP + • Formal behavioral
therapy

Smoking
Cessation
• No tobacco products
+ • Nicotine
replacement
therapy + • Referral to
structured program

COPYRIGHT © 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI 10.4158/CS-2018-0535
 COMPLICATIONS-CENTRIC MODEL FOR CARE OF
THE PATIENT WITH OVERWEIGHT/OBESITY

S T EP 1 EVA LU AT I ON FOR COMPLI CAT I ONS AND STAGING

CARDIOMETABOLIC DISEASE | BIOMECHANICAL COMPLICATIONS

BMI <25 NO COMPLICATIONS COMPLICATIONS

NO OVERWEIGHT BMI ≥25 BMI ≥25

OR OBESITY OVERWEIGHT OR OBESITY MILD TO MODERATE SEVERE

STAGE 0 STAGE 1 STAGE 2

S T EP 2 S E LE CT:
Therapeutic targets for
improvement in complications + Treatment
modality + Treatment intensity based
on staging

Lifestyle Therapy: Physician/RD counseling, web/remote program, structured multidisciplinary program

Medical Individualize care by selecting one of the following based on efficacy, safety,
Therapy and patients’ clinical profile: phentermine, orlistat, lorcaserin,
(BMI ≥27): phentermine/topiramate ER, naltrexone/bupropion, liraglutide 3 mg

Surgical Therapy (BMI ≥35): Gastric banding, sleeve, or bypass

If therapeutic targets for complications not met, intensify lifestyle, medical, and/or surgical treatment
S TE P 3 modalities for greater weight loss. Obesity is a chronic progressive disease and requires commitment to
long-term therapy and follow-up.

COPYRIGHT © 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI 10.4158/CS-2018-0535
 PREDIABETES ALGORITHM
IFG (100–125) | IGT (140–199) | METABOLIC SYNDROME (NCEP 2001)

LIFESTYLE THERAPY
(Including Medically Assisted Weight Loss)

TREAT ASCVD WEIGHT LOSS TREAT HYPERGLYCEMIA

RISK FACTORS THERAPIES FPG >100 | 2-hour PG >140

ASCVD RISK FACTOR NORMAL 1 PRE-DM MULTIPLE PRE-DM

MODIFICATIONS ALGORITHM GLYCEMIA CRITERION CRITERIA

DYSLIPIDEMIA HYPERTENSION
Low-risk Consider with
ROUTE ROUTE
Progression Intensify Medications Caution
Weight
Loss Metformin TZD
Therapies
OVERT Acarbose GLP-1RA
DIABETES
LEGEND

Orlistat, lorcaserin,
phentermine/topiramate ER, PROCEED TO
naltrexone/bupropion, liraglutide 3 mg, GLYCEMIC CONTROL If glycemia not normalized
or bariatric surgery as indicated
for obesity treatment
ALGORITHM

COPYRIGHT © 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI 10.4158/CS-2018-0535
 ASCVD RISK FACTOR MODIFICATIONS ALGORITHM

D Y S L I PIDE MIA HYPERTEN SION

L I F E S T Y L E T H E R A P Y (Including Medically Assisted Weight Loss)

LI P I D P ANEL: Assess ASCVD Risk GO A L : SY ST O L I C < 1 3 0 ,

D I A ST O L I C < 8 0 m m H g

STATI N T HER A PY ACEi For initial blood pressure

If TG >500 mg/dL, fibrates, Rx-grade omega-3 fatty acids, niacin or >150/100 mm Hg:

If statin-intolerant ARB DUAL THERAPY

Calcium
Try alternate statin, lower statin Repeat lipid panel; Intensify therapies to
Channel
dose or frequency, or add nonstatin assess adequacy, attain goals according ACEi
Blocker
LDL-C- lowering therapies tolerance of therapy to risk levels or
ARB ß-blocker
RISK LEVELS HIGH VERY HIGH EXTREME RISK LEVELS:
Thiazide
HIGH:
DESIRABLE LEVELS DESIRABLE LEVELS DESIRABLE LEVELS DM but no other major
risk and/or age <40
LDL-C (mg/dL) <100 <70 <55 VERY HIGH: If not at goal (2–3 months)
DM + major ASCVD
Non-HDL-C (mg/dL) <130 <100 <80 risk(s) (HTN, Fam Hx,
low HDL-C, smoking, Add calcium channel blocker,
TG (mg/dL) <150 <150 <150
CKD3,4)*
ß-blocker or thiazide diuretic
EXTREME:
DM plus established
Apo B (mg/dL) <90 <80 <70 clinical CVD If not at goal (2–3 months)

If not at desirable levels:
To lower LDL-C:
To lower Non-HDL-C, TG:
To lower Apo B, LDL-P:
To lower LDL-C in FH:**
Intensify lifestyle therapy (weight loss, physical activity, dietary Add next agent from the above
group, repeat
changes) and glycemic control; consider additional therapy
If not at goal (2–3 months)
Intensify statin, add ezetimibe, PCSK9i, colesevelam, or niacin
Additional choices (α-blockers,
Intensify statin and/or add Rx-grade OM3 fatty acid, fibrate, and/or niacin central agents, vasodilators,
Intensify statin and/or add ezetimibe, PCSK9i, colesevelam, and/or niacin aldosterone antagonist)
Statin + PCSK9i

Achievement of target blood

Assess adequacy & tolerance of therapy with focused laboratory evaluations and patient follow-up pressure is critical

* EV E N MORE INTEN S I V E TH ER A PY M I GH T B E W A R R AN T E D * * F AM IL IAL H YP E R C H OL E S T E R OL E M IA

COPYRIGHT © 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI 10.4158/CS-2018-0535
 GLYCEMIC CONTROL ALGORITHM

INDIVIDUALIZE For patients without concurrent serious For patients with concurrent serious
A1C ≤6.5% A1C >6.5%

COPYRIGHT © 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI 10.4158/CS-2018-0535
GOALS illness and at low hypoglycemic risk illness and at risk for hypoglycemia

LIFESTYLE THERAPY (Including Medically Assisted Weight Loss)

Entry A1C <7.5% Entry A1C ≥7.5% Entry A1C >9.0%

MONOTHERAPY 1 SYMPTOMS
DUAL T HER A PY 1
Metformin TR IPL E THER A PY 1 NO Y ES
GLP1-RA 2,3

GLP1-RA 2,3
GLP1-RA 2,3 DUAL INSULIN
MET SGLT2i 2,3 Therapy ±
SGLT2i 2,3 or other
1st-line DPP4i
MET SGLT2i 2,3 Other
OR

+
agent or other Agents
DPP4i 1st-line TZD
TZD
agent + TRIPLE
TZD 2nd-line Basal Insulin Therapy

+
Basal Insulin agent
AGi Colesevelam DPP4i

SU/GLN Bromocriptine QR Colesevelam

AGi Bromocriptine QR A D D OR INTE NSIF Y

If not at goal in 3 months INSU L IN
proceed to Dual Therapy SU/GLN AGi
Refer to Insulin Algorithm
SU/GLN
LEGEND
1 Order of medications represents a If not at goal in 3 months
suggested hierarchy of usage; length of proceed to Triple Therapy Few adverse events and/or
line reflects strength of recommendation If not at goal in 3 months possible benefits
2 Certain GLP1-RAs and SGLT2is have shown proceed to or intensify
insulin therapy Use with caution
CVD and CKD benefits—preferred in
patients with those complications

3 Include one of these medications

if CHD present

P R O G R E S S I O N O F D I S E A S E
 ALGORITHM FOR ADDING/INTENSIFYING INSULIN

S T A R T B A S A L (Long-Acting Insulin) INTE NSIF Y (Prandial Control)

A1C <8% A1C >8% Add Add Prandial Insulin

GLP1-RA

TDD 0.1–0.2 U/kg TDD 0.2–0.3 U/kg Or SGLT2i

Or DPP4i

Basal Plus 1, Basal Bolus

Insulin titration every 2–3 days Plus 2, Plus 3
to reach glycemic goal:
• Begin prandial • Begin prandial
• Fixed regimen: Increase TDD by 2 U insulin before insulin before
• Adjustable regimen: largest meal each meal
Glycemic
• FBG >180 mg/dL: add 20% of TDD • If not at goal, • 50% Basal /
Control Not
• FBG 140–180 mg/dL: add 10% of TDD progress to 50% Prandial
• FBG 110–139 mg/dL: add 1 unit
at Goal* injections before TDD 0.3–0.5 U/kg
• If hypoglycemia, reduce TDD by: 2 or 3 meals
• BG <70 mg/dL: 10% – 20%
• BG <40 mg/dL: 20% – 40% • Start: 10% of • Start: 50% of TDD
basal dose or in three doses
5 units before meals
Consider discontinuing or reducing sulfonylurea after
starting basal insulin (basal analogs preferred to NPH)
Insulin titration every 2–3 days to reach glycemic goal:
*Glycemic Goal:
• Increase prandial dose by 10% or 1-2 units if 2-h postprandial
or next premeal glucose consistently >140 mg/dL
• <7% for most patients with T2D; fasting and premeal
BG <110 mg/dL; absence of hypoglycemia • If hypoglycemia, reduce TDD basal and/or prandial insulin by:
• A1C and FBG targets may be adjusted based on patient’s age, • BG consistently <70 mg/dL: 10% - 20%
duration of diabetes, presence of comorbidities, diabetic • Severe hypoglycemia (requiring assistance from another
complications, and hypoglycemia risk person) or BG <40 mg/dL: 20% - 40%

COPYRIGHT © 2019 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE. DOI 10.4158/CS-2018-0535
 PROFILES OF ANTIDIABETIC MEDICATIONS
TZD SU
MET GLP1-RA SGLT2i DPP4i AGi (moderate COLSVL BCR-QR INSULIN PRAML
dose) GLN
Moderate/
Severe Moderate
HYPO Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral
Mild
to Severe

WEIGHT Slight Loss Loss Loss Neutral Neutral Gain Gain Neutral Neutral Gain Loss

Not Indicated for

eGFR <45 mL/ Dose
Exenatide min/1.73 m2
Not Adjustment
Contra- Indicated Necessary
indicated CrCl <30 (Except
Genital Mycotic More More
RENAL / GU if eGFR <30 Linagliptin) Neutral Neutral Neutral Neutral Neutral
Infections Hypo Risk Hypo Risk
mL/min/
1.73 m2 Effective in
Possible Reducing
Possible CKD Albuminuria
Benefit of
Benefit
Liraglutide

GI Sx Moderate Moderate Neutral Neutral Moderate Neutral Neutral Mild Moderate Neutral Moderate

CHF Moderate Neutral Neutral Neutral CHF Risk

CARDIAC Neutral See #1 See #2 See #3 Neutral Neutral

May Possible
ASCVD Reduce ASCVD Benefit Safe Neutral
Stroke Risk Risk

Moderate
BONE Neutral Neutral Neutral Neutral Neutral Fracture Neutral Neutral Neutral Neutral Neutral
Risk

DKA Can Occur

KETOACIDOSIS Neutral Neutral in Various Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral
Stress Settings

Few adverse events or possible benefits COPYRIGHT © 2019 AACE

1. Liraglutide—FDA approved for prevention of MACE events. MAY NOT BE REPRODUCED IN ANY FORM
Use with caution 2. Empagliflozin—FDA approved to reduce CV mortality. Canagliflozin—FDA approved to reduce MACE events. WITHOUT EXPRESS WRITTEN PERMISSION
3. Possible increased hospitalizations for heart failure with alogliptin and saxagliptin. FROM AACE.
Likelihood of adverse effects DOI 10.4158/CS-2018-0535