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Creating a comprehensive care plan for diabetes that focuses on more than just glycemic control is at the heart of the new clinical practice guidelines for diabetes from the American Association of Clinical Endocrinologists (AACE) and the American College of Endocrinology (ACE).
On April 9, 2015, AACE/ACE announced the publication of the guidelines as well as an updated diabetes algorithm to assist clinicians with the medical management of patients with diabetes mellitus (DM).
The 2015 guidelines advocates for comprehensive control of diabetes by addressing multiple DM risk factors.1
“The major principles of the 2011 DM guidelines, namely a comprehensive approach to the managing of DM, are continued in the 2015,” said chair of the guidelines task force Yehuda Handelsman, MD, who is the medical director and principal investigator of the Metabolic Institute of America in Tarzana, California.
“In 2015, the guidelines have expanded greatly. We are now posting 24 questions and a total of 67 (answers) recommendations. We have also added several new chapters on vaccinations, relationship to cancer and special populations, among others. Many sections were expanded, including screening, sleep apnea, depression and medical management.”
Addressing All Aspects of Diabetes
Handelsman, who is also president of ACE, said comprehensive clinical recommendations are offered for assessing and managing obesity, lipid disorders, hypertension, kidney disease, cardiovascular disease (CVD), hypoglycemia and antihyperglycemic therapy to prevent complications. Many of the new recommendations involve substantial modifications over previous guidelines due to so many newly approved agents, he noted.
“The guidelines are evidence-based and cover all parts of DM from classification through diagnosis, screening management, assessing complications, defining goals and preventing complications. Though written very comprehensively, it is in a manner which is easy to navigate,” Handelsman said.
“The algorithm, though also evidence-based, primarily represents a consensus of experts and focuses just on the management aspect. It is kind of a cookbook to managing diabetes.”
Both the guidelines and algorithm have been constructed to address specific problems in diabetes care in a concise, practical and actionable manner, according to Handelsman.
For instance, the guidelines state that patients with DM should engage in at least 150 minutes per week of moderate-intensity exercise, such as brisk walking (a 15- to 20-minute mile) or its equivalent. They also suggest that individuals with DM incorporate flexibility and strength training exercises.
“The guidelines and the algorithm provided recommendations for managing DM comprehensively addressing all CV risk factors beyond hyperglycemia. The previous guidelines were published in 2011 and the added information to the guidelines represents advances in the past 4 to 5 years,” Dr. Handelsman told Endocrinology Advisor.
“During this time, it became apparent that people who have diabetes will benefit from vaccinations due to impairment in the immune system. We focused on hepatitis vaccines, pneumonia and others.”
The guidelines recommend hepatitis B vaccinations for adults aged 20 to 59 years as soon after as possible after receiving a DM diagnosis and to consider vaccination of adults aged 60 years and older based on assessment of risk and likelihood of an adequate immune response.
“Additionally, diabetes and obesity have been associated with cancer and, in the past 5 years, many medications for diabetes were also implicated. The guidelines make sense of the whole issue and provide relevant practice recommendations,” Handelsman said.
Updated Algorithm
The diabetes management algorithm, first published in 2013, is presented as an illustrated treatment pathway companion to the guidelines.2 It emphasizes the importance of medical and surgical interventions as primary therapeutic approaches in overweight and obese patients with DM.
The algorithm also addresses prevention of diabetes in high-risk patients with prediabetes using AACE’s obesity treatment algorithm. The algorithm includes every FDA-approved class of medications for diabetes and stratifies therapy options based on initial HbA1c levels.
Alan Garber, MD, PhD, who is chair of the algorithm task force, said the updated version provides clinicians with a definitive, point-of-care tool to assess critical factors that accompany diabetes and its treatment.
In Clinical Practice
These guidelines are helpful to endocrinologists and may help improve overall DM care, according to Andrew Ahmann, MD, who is director of the Schnitzer Diabetes Center at the Oregon Health & Science University in Portland.
Ahmann noted that the guidelines were started in the 1990s, and they have influenced care and helped establish important standards and goals over the past 2 decades.
“They have been adopted by many organizations and endorsed by them. The guidelines get promoted and get republished and that has made a difference in our overall care,” Dr. Ahmann said in an interview with Endocrinology Advisor.
“The issue has become more and more complex over the years when it comes to the guidelines. There are ADA (American Diabetes Association) guidelines and some from the Endocrine Society, and primary care physicians have their own. So, it can get confusing as to how to interpret these and how to analyze the differences between different organizations.”
The newest guidelines and algorithm put a lot of pieces of small information together to help build a more complete and cohesive picture, Ahmann explained. He said there is a significant lack of controlled, prospective studies with several agents used to manage DM.
However, Ahmann said the gaps in scientific evidence are addressed in a transparent and easy to understand analysis.
“They are not perfect,” said Dr. Ahmann “We don’t have enough data. We don’t have the perfect studies so they help in that area and they excel.”
