Diabetes Roadmap

7/25/2019 Diabetes Roadmap

1/8

Road Maps to Achieve Glycemic Control

In Type 2 Diabetes Mellitus

ACE/AACE Diabetes Road Map Task Force

Chairpersons

Paul S. ellin!er" MD" MAC#" Co$Chair

aime A. Davidson" MD" %AC#" Co$Chair

Tas& %orce Members

'a(rence )londe" MD" %ACP" %AC#

Daniel #inhorn" MD" %ACP" %AC#

Geor!e Grunber!er" MD" %ACP" %AC#

*ehuda +andelsman" MD" %ACP" %AC#

Richard +ellman" MD" %ACP" %AC#

+arold 'ebovit," MD" %AC#

Philip 'evy" MD" %AC#

-ictor '. Roberts" MD" M)A" %ACP" %AC#

2//0 AAC#. All ri!hts reserved. 1o portion o the Roadmap may be altered" reproduced

or distributed in any orm (ithout the e3press permission o AAC#.


2/8

Road Map to Achieve Glycemic Goals4 1a5ve to Therapy6Type 27

Initial

A8C9

Achieve AC#

Glycemic Goals:

6 %PG" PPG" and A8C 7Intervention

Continuous

Titration o R3

6 2 $ ; months 7

I < =.>9 A8C Goal

1ot Achieved

Assess %PG

and PPG

Initial Therapy Monitor ? ad@ust R3 to

ma3imal eective dose

to meet AC# Glycemic

Goals

Intensiy 'iestyle

Modiication

Intensiy or combine R3

includin! incretin mimetic8

Tar!et4 PPG

and %PG

Monitor ? ad@ust R3 to



Goals

Combine Therapies ="0

Intensiy 'iestyleModiication

Intensiy or combine R3"includin! incretin mimetic

(ith SB" TD" and?ormetormin

= $ 0

0 $

'i2estyle

Modi2ication

'i2estyle

Modi2ication

I < =.>9 A8C Goal

1ot Achieved

Alternatives

Glinides

SB 6lo( dose7

Prandial insulin>"

Preerred4

MetorminE

TD8/"88

AGIDPP$E Inhibitor

Alternatives Prandial insulin>"

Premi3ed insulinpreparations

)asal insulinanalo!F

MetorminGlinidesAGITDSBDPP$E Inhibitor

2007 AACE. All rights reserved. No portion of the Roadmap may be altered,reprod!ed or distribted in any form "ithot the e#press permission of AACE.

AC#?AAC# Diabetes Road Map Tas& %orce











#ndocr Pract. 2//08;42=/$2=

:

AC# Glycemic Goals

< =.>9 A8CH 88/ m!?d' %PG

H 88/ m!?d' Preprandial

H 8E/ m!?d' 2$hr PPG

Access Roadmap at4

(((.aace.com?pub

Available as e3enatide

8 Indicated or patients not at !oal despite SB and?ormetormin or TD therapy incretin mimetic is not

indicated or insulin$usin! patients

E Preerred irst a!ent in most patients

> Rapid$actin! insulin analo! 6available as lispro" aspart and

!lulisine7" inhaled insulin" or re!ular insulin

= Appropriate or most patients

0 2 or more a!ents may be reuired

Analo! preparations preerred

F Available as !lar!ine and detemir

8/ A recent report (NEJM; 6/14/0! s"##ests a possib$e $ink o%

rosi#$ita&one to cardio'asc"$ar e'ents tat re)"ires %"rter e'a$"ation*

88Cannot be used in 1*+A C+% Class ; or E
http://www.aace.com/pub/http://www.aace.com/pub/http://www.aace.com/pub/http://www.aace.com/pub/http://www.aace.com/pub/


3/8

$ F

Initial

A8C9

Achieve AC#

Glycemic Goals:

6 %PG" PPG" and A8C 7Intervention

Continuous

Titration o R3

6 2 $ ; months 7

I < =.>9 A8C Goal

1ot Achieved

Tar!et4 %PG

and PPG




Goals

Intensiy 'iestyle Modiication

Intensiy or combine R3includin!

prandial insulin>"" incretin

mimetic8" or amylin analo!

6(ith prandial insulin>"7

Tar!et4 %PG

and PPG




Goals

Combine Therapies

to Address %PG and PPG0

Combine Therapies

to Address %PG and PPG0

F $ 8/

Prandial insulin>"


1P+ Jther approved

combinations

MetorminTD8/"88

SBGlinidesDPP$E Inhibitor)asal insulin analo!F

Prandial insulin>"


1P+ Jther approved

combinations

Metormin

TD

SB

Glinides

)asal insulin analo!F

I < =.>9 A8C Goal

1ot Achieved

'i2estyle

Modi2ication

'i2estyle

Modi2ication


Initiate or intensiy insulintherapy or add incretin mimetic8

Road Map to Achieve Glycemic Goals4 1a5ve to Therapy6Type 27












:

AC# Glycemic Goals

< =.>9 A8C

H 88/ m!?d' %PG



#ndocr Pract. 2//08;42=/$2=

Access Roadmap at4

(((.aace.com?pub

Available as pramlintide

8 Indicated or patients not at !oal despite SB and?or

metormin or TD therapy incretin mimetic is not

indicated or insulin$usin! patients

> Rapid$actin! insulin analo! 6available as lispro" aspart and

!lulisine7" inhaled insulin" or re!ular insulin

0 2 or more a!ents may be reuired

Analo! preparations preerred

F Available as !lar!ine and detemir

8/ A recent report (NEJM; 6/14/0! s"##ests a possib$e $ink o%

rosi#$ita&one to cardio'asc"$ar e'ents tat re)"ires %"rter e'a$"ation*

88 Cannot be used in 1*+A C+% Class ; or E 2007 AACE. All rights reserved. No portion of the Roadmap may be altered,reprod!ed or distribted in any form "ithot the e#press permission of AACE.


4/8


5/8

Road Map to Achieve Glycemic Goals4 Treated Patients6Type 27

H=.>9

Current

A8C9 Current Therapy Intervention

Continue current therapy i all

AC# !lycemic !oals are met

Ad@ust therapy as needed to meet

AC# %PG and PPG !oals

Contine$

ifestyle

%odifi!ation

Monotherapy

or

Combination Therapy


maintain AC#

Glycemic Goals:

Continuous Titration o

R3 62$; months7












:AC# Glycemic Goals< =.>9 A8C

H 88/ m!?d' %PG



#ndocr Pract. 2//08;42=/$2=

Access Roadmap at4

(((.aace.com?pub

Available as e3enatide Available as pramlintide8 Analo! preparations preerred

2 Prandial insulin 6rapid$actin! insulin analo!s available as lispro"aspart" !lulisine" inhaled insulin" or re!ular insulin7 can be added

to any therapeutic intervention at any time to address persistent

postprandial hyper!lycemia

; Available as !lar!ine and detemir

E A recent report (NEJM; 6/14/0! s"##ests a possib$e $inko% rosi#$ita&one to cardio'asc"$ar e'ents tat re)"ires %"rter e'a$"ation*

> Cannot be used in 1*+A C+% Class ; or E



6/8

Current


=.>

to

.>

Contine

$ifestyle

%odifi!at io

n

Monitor ? ad@ust R3

to maintain AC#

Glycemic Goals:

Monotherapy&

'linides, (), A'*, metformin,

+-, -/, premi#ed inslin

preparations, prandial2or

basal inslin1


Initiate Combination Therapy


R3 62$; months7

Combination Therapy4

'linides, (), -/, A'*,

metformin, +-, in!retin

mimeti!, premi#ed inslin

preparations, prandial2or

basal inslin1


Ma3imi,e Combination TherapyMa3imi,e Insulin Therapy

Monitor ? ad@ust R3

to maintain AC#

Glycemic Goals:

Incretin mimetic Lmetormin and?or TD

)asal;or premi3edinsulin preparations8

Amylin analo! (ithprandial insulin2

Metormin L SB or GlinideMetormin L TDE">or AGITD L SBDPP$E L MetorminDPP$E L TD

Incretin mimetic Lmetormin and?or SB

Jther approved combinations includin!approved oral a!ents (ith insulin

I elevated %PG" add or increase basal insulin ;

I elevated PPG" add or increase prandial insulin2

I elevated %PG and PPG" add or intensiy basal;Lprandial2or premi3ed insulin therapy8

Combine (ith approved oral a!ents Amylin analo! (ith prandial insulin2

Add incretin mimetic to patients on SB" TD"and?or metormin


R3 62$; months7













:

AC# Glycemic Goals

< =.>9 A8C

H 88/ m!?d' %PG



Available as e3enatide

Available as pramlintide

8 Analo! preparations preerred

2 Prandial insulin 6rapid$actin! insulin analo!s available as lispro"

aspart" !lulisine" inhaled insulin" or re!ular insulin7 can be added




E A recent report (NEJM; 6/14/0! s"##ests a possib$e $ink

o% rosi#$ita&one to cardio'asc"$ar e'ents tat re)"ires %"rter e'a$"ation*

> Cannot be used in 1*+A C+% Class ; or E

#ndocr Pract. 2//08;42=/$2=

Access Roadmap at4

(((.aace.com?pub



7/8

Current



Initiate Insulin Therapy 6)asal$)olus7

)asal;L prandial insulin2

Premi3ed insulin preparations8

Combine (ith approved oral a!ents

K.>

Contine$

ifestyle

%odifi!ation


maintain AC#

Glycemic Goals:

Monotherapy

or

Combination Therapy


R3 62$; months7













:AC# Glycemic Goals< =.>9 A8C

H 88/ m!?d' %PG



#ndocr Pract. 2//08;42=/$2=

Access Roadmap at4(((.aace.com?pub

8 Analo! preparations preerred

2 Prandial insulin 6rapid$actin! insulin analo!s available as lispro"

aspart" !lulisine" inhaled insulin" or re!ular insulin7 can be added






8/8

Road Map to PR#-#1TType 2 Diabetes

#arlyIdentiication 'iestyleModiication Pharmacolo!ic

Persistent

Monitorin! o

Glucose and

Ris& Reduction

Measures

Intervention

A!e ;/ or above or

Populations at +i!h Ris&4

%PG or 2$h JGTT is the

recommended screenin! procedure

%edi!al Ntrition

+herapy 3%N+4 hysi!al 5itness

rogram

6eight $oss

>$09 reduction in body

(ei!ht 6i over(ei!ht7

;/ minutes e3ercise" >times per (ee& at the

euivalence o bris&

(al&in!

Non/5-A Approved

+-

%etformin

rlistat A'*

Sho(n to be eective in delayin! theonset o type 2 diabetes in clinical studies

A recent report 61#M =?8E?/07 su!!ests

a possible lin& o rosi!lita,one to

cardiovascular events that reuires urther

evaluation

+ypertension

Dyslipidemia Physical %itness ei!ht Control

5amily history of diabetes

Cardiovas!lar disease ver"eight (edentary lifestyle $atino89ispani!, Afri!an

Ameri!an, Asian Ameri!an,

Native Ameri!an, or

a!ifi! *slander reviosly identified *'+

or *5' 9ypertension Elevated trigly!erides,

lo" 9-$, or both 9istory of gestational

diabetes -elivery of a baby "eighing

more than : lbs (evere psy!hiatri! illness












#ndocr Pract. 2//08;42=/$2=

Access Roadmap at4(((.aace.com?pub


Diabetes Roadmap

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