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AACE - New Diabetes Guidelines Based on Tailored Approach

Posted: Sunday, May 12, 2013

Alan Garber, MD, PhD, of Baylor College of Medicine in Houston, and colleagues reported in Endocrine Practice and at the AACE meeting that, the new recommendations from the American Association of Clinical Endocrinologists (AACE) offer an algorithm that involves every FDA approved class of medications for managing hyperglycemia while still suggesting consideration of individual patient characteristics such as age and comorbidities.

Garber added that, "The majority of patients aren't reaching goal." "We think a more assertive recommendation of treatments will help physicians get patients to goal and avoid the pitfalls of certain medications."

Last year, the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) relinquished the use of an algorithm in its updated guidelines for managing type 2 diabetes. But Garber said the AACE's step-wise approach is not all that different from the ADA/EASD guidance.

"I don't think they gave it up completely," he said. "They use broad guidelines ... and we agree that you have to consider [multiple factors], but we also evaluate and recommend agents within categories."

The guidance is highly graphical, published in a form more representative of a slide presentation than a guideline update. It is color-coded to represent evidence on risks and benefits, and the style enables a more intuitive understanding of the concepts of the guidance, Garber said.

For managing hyperglycemia, the guidelines recommend mono-, dual-, or triple therapy based on initial hemoglobin A1c, and recommended drug therapies are given green or yellow ratings to signal the potential for adverse effects.

For instance, recommendations for monotherapy include metformin, glucagon-like peptide-1 (GLP-1) agonists and dipeptidyl peptidase-4 (DPP4) inhibitors as well as alpha-glucosidase inhibitors (AGi) as first-line therapies of minimal risk, while they urge caution for sodium glucose cotransporter 2 (SGLT-2) drugs, thiazolidinediones (TZDs), and sulfonylureas in this setting.

For dual therapy, they recommend metformin or another first-line agent plus any of the three other greenlighted agents from the monotherapy list in addition to colesevelam (Welchol) or bromocriptine (Cycloset). Again, they urge caution for TZDs, SGLT-2s, basal insulin, and sulfonylureas in this setting.

The recommendations are similar for triple therapy.

Incretins received a positive recommendation in this guidance, despite previous concerns about adverse effects, particularly pancreatitis and pancreatic tumors.

Garber added, "The evidence regarding pancreatic disease with GLP-1 agonists or DPP4 inhibitors is unpersuasive, anecdotal evidence so far." "The evidence is just not there."

The AACE guidance also recommends individualization of glycemic targets based on several factors, although 6.5% remains the optimal goal. Garber also noted that the guidance is "comprehensive" in that it includes management of cardiovascular risk reduction, excess weight and obesity, and prediabetes.

Obesity is now an integral part of diabetes management, Garber said, particularly with the advent of new anti-obesity medications lorcaserin (Belviq) and phentermine/topiramate (Qsymia).

Practice Pearls:

  • A new guideline calls for a tailored approach to treating type 2 diabetes while maintaining the use of an algorithm-based model.
  • Note that for managing hyperglycemia, the guidelines recommend mono-, dual-, or triple therapy based on initial hemoglobin A1c, and recommended drug therapies are given green or yellow ratings to signal the potential for adverse effects.

Source: http://www.diabetesincontrol.com/index.php?option=com_content&view=article&id=14596&catid=53&Itemid=8, Garber AJ, et al "AACE comprehensive diabetes management algorithm 2013" Endocrine Practice 2013; 19: 327-336 .

 
 
 
 
 
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