New guidelines from the American Association of Clinical Endocrinologists cover therapy with all approved classes of diabetes drugs as well as obesity, prediabetes, and cardiovascular risk factor management.

The American Association of Clinical Endocrinologists (AACE) has released new diabetes guidelines that provide algorithms for treatment, but also call for therapy to be tailored to the needs of individual patients. For the first time, the guidelines also incorporate obesity, prediabetes, and cardiovascular health management, in recognition of the ways these factors interact with diabetes. The guidelines were published in the March/April 2013 edition of Endocrine Practice.
The guidelines, which are presented as a series of colorful flow charts, call for a hemoglobin A1c goal of 6.5% or lower for healthy patients and individualized goals above 6.5% for those with other illnesses or at risk of hypoglycemia. (The A1c goal specified in the association’s previous guidelines, released in 2009, was below 6.5% for most patients.)

To address hyperglycemia, the guidelines call for use of 1, 2, or 3 medications depending on the patient’s initial A1c level. Monotherapy is advised for those with initial A1c under 7.5%; dual therapy is advised for those with initial A1c between 7.5% and 9.0%; and dual therapy, triple therapy, or insulin therapy is advised depending on the patient when initial A1c is higher than 9.0%. If sufficient progress is not achieved within 3 months, the guidelines call for therapy to be stepped up.
The guidelines’ recommendations for monotherapy, in order of preference, are metformin, glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 (DD4) inhibitors, and alpha-glucosidase inhibitors (AG-i), which are designated as posing a low risk of adverse effects. According to the guidelines, sodium-glucose cotransporter 2 (SGLT-2) drugs, thiazolidinediones (TZDs), and sulfonylureas are to be used with caution as monotherapy. When dual or triple therapy is warranted, the algorithm advises adding any of the first-line agents or colesevelam or bromocriptine. A separate algorithm addresses the details of insulin treatment.
The guideline authors note that A1c targets should be individualized based on patient factors such as age, comorbid conditions, duration of diabetes, hypoglycemia risk, motivation, adherence level, and life expectancy. They also note that the algorithm includes all FDA-approved classes of diabetes drug, but takes into account each type of drug’s risk of inducing hypoglycemia and causing weight gain, ease of use, cost, and impact on risk of developing comorbid conditions. In addition, they note that when selecting a medication, safety and efficacy should be prioritized over cost, since medications make up a relatively small part of the total cost of diabetes care.
To download a PDF of the new guidelines, click here.