New Diabetes Management Guidelines Consider Concurrent Conditions

In diagnosing a patient with type 2 diabetes, an endocrinologist or primary care physician may struggle with developing healthy treatment targets when comorbid conditions like obesity and hypoglycemia are at play.

To offer more comprehensive guidelines that cover the entire patient spectrum, the American Association of Clinical Endocrinologists (AACE) recently published a new diabetes management algorithm in the March/April 2013 issue of its peer-reviewed Endocrine Practice with recommendations for evidence-based approaches to treating prediabetes and type 2 diabetes mellitus (T2DM) that also consider various risks and complications from other conditions.

“This algorithm is a definitive, point-of-care tool for clinicians engaged in the treatment of those who are at risk for or have developed diabetes,” AACE President Alan Garber, MD, PhD, FACE, says in a press release. “With more than 100 million suffering from diabetes and prediabetes in the United States, there simply are not enough endocrinologists to care for all patients. Thus, this algorithm is essential to assist and educate clinicians who are charged with these patients’ care.”

As obesity continues to exacerbate T2DM, one key recommendation from the new complications-centric AACE algorithm is for endocrinologists, primary care doctors and other health care professionals to consider weight management an integral part of lifestyle optimization plans for obese diabetes patients in order to reduce disability and mortality risk.In terms of a glycated hemoglobin (A1c) target, the algorithm suggests a blood sugar of less than or equal to 6.5 percent for healthy patients without concurrent illness and at low hypoglycemic risk. For patients with a blood sugar above that goal, the algorithm recommends physicians individualize targets based on a patient’s age, comorbid conditions, diabetes duration, hypoglycemia risk, motivation, adherence and life expectancy, as the members of the algorithm task force note “higher targets may be appropriate and may change in a given individual over time.”

To take individualized diabetes treatment a step further, the algorithm differentiates FDA-approved classes of therapies based on patients’ initial A1c, glycemic control targets and the attributes of the medications themselves, which include “risk of inducing hypoglycemia, risk of weight gain, ease of use, cost and safety impact of kidney, heart or liver disease,” the authors write.

However, the authors note minimizing risks of hypoglycemia and weight gain through medications are the top priorities, citing matters of safety, adherence and cost. Still, the authors believe medications’ safety and efficacy have higher priorities than their initial cost, “since cost of medications is only a small part of the total cost of care of diabetes.”

While the authors deem rapid-acting insulin superior to regular insulin and long-acting insulin analogs superior to NPH insulin, they recommend physicians evaluate the effectiveness of their chosen therapy every three months using multiple criteria — including A1c, psycho-social factors, diabetic complications, weight gain, fluid retention, bone loss, hyperlipidemia, cardiac disease and documented and suspected hypoglycemia — until stability is achieved.