® A AACE/ACE COMPREHENSIVE TYPE 2 DIABETES MANAGEMENT ALGORITHM = TASK FORCE Alan J. Garber, MD, PhD, FACE, Chair Cee) Eee ees Ces and reed Vivian A. Fonseca, MD, FACE cond re eae Sea ed Sea ea pene ed Pano aes es aed Michael A.Bush, MD Cornea eed Sora ned Serer ted Ce ete eee oem)Lifestyle therapy. including medically supervised weight los, key to managing type 2 diabetes. Wilght oss should be considered a 2 elong goal inal patients with predlabetes and T20 who aso hae overweight or ‘obesity, utizing behaviralinterventions and weight los medications as required to achieve chronic therapeutic goals ‘The AIC target ust be individualized “lycemic conto targets include fasting and postprandial glucose ‘The choice of therapies must be individualized on bas of patent characteristics, impact of net cost to patient, formulary resictions, personal preferences et. Minimizing rsk of hyposlycemia sa prionty. Minisizing risk of weight gin sa prion Intl acquisition cost of medications is only par ofthe toa cost of care which ncides monitoring requirements, ‘skofhypooiyema, weight gain, safely ee ‘This algarthm sratifes choice oftherapes based on inital AIG Combination therapy usually required and should involve agents with complementary actions. Comprehensive management includes lipid and blood pressure therapies and related comorbidities, ‘Therapy must be evaluated frequently untl stable (eg, every 3 months) and then les often, The therapeutic regimen shoul be as simple as possible to optimize adherence ‘This algothm includes every FOR approved as of medications for dabetes.Behavioral Ered Sor) eer) Maintain optimal weight Calorie restriction (if MI Isincreased) Plant-based die; high polyunsaturated and monounsaturated fatty acids 150 min/week moderate exertion (eg. walking stair climbing) Strength training Increase as tolerated About 7 hours per night Basic sleep hygiene Community engagement Alcohol maderation No tobacco products Avoid trans fatty acids; mit saturated fatty acids Structured program Wearable technologies Screen OSA Home slep study Discuss mood with HCP Nicotine replace ment therapy, structured ‘counseling Meal replacement Medical evaluation’ clearance Mecical supervision Referral to sleep lab Formal behavior therapy Referral to structured programG r EVALUATION FOR COMPLICATIONS AND STAGING eM <25 fe ee Pee BMI 225 BMI = 25 Ce — > — t t t ‘Therapeutic targets for Treatment “Treatment intensity based Improvement in complications modality onstaging ad ~~ Peres eeu) Pn 5h If therapeutic target for complications not met, intensify lifestyle, medical, and/or surgical treatment modalities ter weight loss. Obesity is a chronic progressive disease and requires commitment to long-term therapyFG (100-125) | 1GT (140-199) | METABOLIC SYNDROME (NCEP 2001) 7 iss Seal eon ete) Ae aD) WEIGHT Loss Maan cea Cazares THERAPIES FPG > 100 | 2-hour PG> 140 ASCVD RISK FACTOR er 1 PRE-DM. MULTIPLE PRE-DM MODIFICATIONS ALGORITHM GLYCEMIA CRITERION CRITERIA DYSLIPIDEMIA HYPERTENSION ieee mien LIPIDE a Tae a Progression s or eo Acarbose Clon yr Prieta acd falreonelbupropionlagitise 3g, Piast nein lf alycemia fr barr surgery indented for ent not normalizedArkona Pee ea Per g Tiy alternate statin tower stain fepeatlipié pane Intensify therapies to dose or requency or add nonstatin assessadequacy, atan goals according LDL-C towering therapies tolerance of therapy Tors levels Pert DLC git ‘ato 70 <5 Nom HOU ima) <0 100 <0 Teimalat) 0 150 150 reigns p08 maid * oy a In mesen) and glycemic control consider additonal therapy eres ene ST te eA cee eee on yee ror Erteed eee) Assess adequacy & tolerance of therapy wth focused laboratory evaluations an patient follow-upINDIVIDL A1C < 6.5% A1C > 6.5% For patients without For patients with concurrent serious concurrent serious illness and at low illness and at risk hypoglycemic risk for hypoglycemiaLGORITHM aia S See oor ted Weight L = fect EE ERT EE iy Y Metormin v SLPARA v SUPRA sera v sour = «| TR fern = a er vy OPP-4 MET ¥ i i SGLT-21 Lied TzD a 2D 1D A ercther - 7 = ES] Tisine Sara ns v i sie f, Sealinsin 4, SUN ¥ Selesevelam v Depa AP| 7 semceentn Aciocaas =. > v3 V Sromocptine OR Somer ADD OR INTENSIFY L_ 4 swan va INSULIN sot mao rte fetes. stn lori prsendtb hea i L_ 4 swcw ae i a a eeea ae ae Add lary oan Be eek s Been) Ger Conary Plus 3 Begin prandia Begin rand eee inal before Insulin before erent largest meal each meal ees not at goal Sos Basal / per erierac progres to 50% Prandil Injections before Topa3-05 Uikg Zora meals eee een fora age, duration of diabetes, presence of comorbditiPROFILES OF ANTIDIABETIC MEDICATIONS A PP. . c BCROR INSULIN. 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