AACE standards were published in January 2019. They are a continual update of the original 2013 guidelines. Unlike ADA which recommends a general A1c target ≤7.0%, AACE promotes a tighter A1c goal of ≤6.5% for most patients with type 2 diabetes.
Recommendations also address lifestyle interventions, obesity, prediabetes, hypoglycemia, hypertension and dyslipidemia. Oral and injectable medications including insulin are discussed. A key priority is the avoidance of hypoglycemia — do no harm!
The 12 Principles
- 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.
- Minimizing the risk of both severe and nonsevere hypoglycemia is a priority. It is a matter of safety, adherence, and cost.
- Minimizing risk of weight gain is also a priority. This is important for long-term health, in addition to safety, adherence, and cost. Weight loss should be considered in all patients with prediabetes and T2D, who also have overweight or obesity.
- Weight-loss therapy should consist of a specific lifestyle prescription that includes a reduced-calorie healthy meal plan, physical activity, and behavioral interventions.
- Weight-loss medications approved for the chronic management of obesity should also be considered if needed to obtain the degree of weight loss required to achieve therapeutic goals in prediabetes and T2D.
- Obesity is a chronic disease, and a long-term commitment to therapy is necessary.
- 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.
- Glycemic control targets include fasting and postprandial glucose as determined by self-monitoring of blood glucose (SMBG).
- In recent years, continuous glucose monitoring (CGM) has become more available for people with T2D and has added a considerable degree of clarity for the patient’s and clinician’s understanding of the glycemic pattern.
- A1C ≤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.
- 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 initial A1C, duration of T2D, and obesity status.
- Other considerations 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 or risk reduction in heart, kidney, or liver disease.
- The choice of therapy depends on the individual patient’s cardiac, cerebrovascular, and renal status. Combination therapy is usually required and should involve agents with complementary mechanisms of action.
- Comorbidities must be managed for comprehensive care, including management of lipid and BP abnormalities with appropriate therapies and treatment of other related conditions.
- Targets should be achieved as soon as possible. Therapy must be evaluated frequently (e.g., every 3 months) until stable using multiple criteria, including A1C, SMBG records (fasting and postprandial) or CGM tracings, documented and suspected hypoglycemia events, lipid and BP values, adverse events (weight gain, fluid retention, hepatic or renal impairment, or ASCVD), comorbidities, other relevant laboratory data, concomitant drug administration, complications of diabetes, and psychosocial factors affecting patient care. With CGM, initial therapy adjustments can be made much more frequently until stable. Less frequent monitoring is acceptable once targets are achieved.
- The choice of therapy includes ease of use and affordability. The therapeutic regimen should be as simple as possible to optimize adherence. The initial acquisition cost of medications is only a part of the total cost of care, which includes monitoring requirements and risks of hypoglycemia and weight gain. Safety and efficacy should be given higher priority than medication acquisition cost.
- Insulin therapy does not preclude an A1C target of ≤6.5%; however, such patients should be on CGM for safety monitoring.
- This algorithm includes every FDA-approved class of medications for T2D (as of December 2018).