AACE/ACE Consensus Statement

Alan J. Garber, MD, PhD, FACE1; Martin J. Abrahamson, MD2;

Joshua I. Barzilay, MD, FACE3; Lawrence Blonde, MD, FACP, FACE4;
Zachary T. Bloomgarden, MD, MACE5; Michael A. Bush, MD6;
Samuel Dagogo-Jack, MD, DM, FRCP, FACE7; Ralph A. DeFronzo, MD, BMS, MS, BS8;
Daniel Einhorn, MD, FACP, FACE9; Vivian A. Fonseca, MD, FACE10;
Jeffrey R. Garber, MD, FACP, FACE11; W. Timothy Garvey, MD, FACE12;
George Grunberger, MD, FACP, FACE13; Yehuda Handelsman, MD, FACP, FNLA, FACE14;
Robert R. Henry, MD, FACE15; Irl B. Hirsch, MD16;
Paul S. Jellinger, MD, MACE17; Janet B. McGill, MD, FACE18;
Jeffrey I. Mechanick, MD, FACN, FACP, FACE, ECNU19;
Paul D. Rosenblit, MD, PhD, FNLA, FACE20; Guillermo E. Umpierrez, MD, FACP, FACE21

From the 1Chair, Professor, Departments of Medicine, Biochemistry
and Molecular Biology, and Molecular and Cellular Biology, Baylor
College of Medicine, Houston, Texas, 2Beth Israel Deaconess Medical
Center, Department of Medicine and Harvard Medical School, Boston,
Massachusetts, 3Division of Endocrinology, Kaiser Permanente of Georgia
and the Division of Endocrinology, Emory University School of Medicine,
Diabetes Research Center, Mountain Brook, Alabama, 13Grunberger Diabetes
Institute, Clinical Professor, Internal Medicine and Molecular Medicine &
Michigan, 14Medical Director & Principal Investigator, Metabolic Institute of
America, President, American College of Endocrinology, Tarzana, California,
15Professor of Medicine, University of California San Diego, Chief, Section of

Atlanta, Georgia, 4Director, Ochsner Diabetes Clinical Research Unit,
Department of Endocrinology, Diabetes and Metabolism, Ochsner Medical
Center, New Orleans, Louisiana, 5Clinical Professor, Mount Sinai School of
Medicine, Editor, Journal of Diabetes, New York, New York, 6Clinical Chief,
Division of Endocrinology, Cedars-Sinai Medical Center, Associate Clinical
Professor of Medicine, Geffen School of Medicine, UCLA, Los Angeles,
California, 7A.C. Mullins Professor & Director, Division of Endocrinology,
Diabetes and Metabolism, University of Tennessee Health Science Center,
Memphis, Tennessee, 8Professor of Medicine, Chief, Diabetes Division,
University of Texas Health Science Center at San Antonio, San Antonio,
Texas, 9Immediate Past President, American College of Endocrinology,
Past-President, American Association of Clinical Endocrinologists,
Medical Director, Scripps Whittier Diabetes Institute, Clinical Professor
of Medicine, UCSD, Associate Editor, Journal of Diabetes, Diabetes and
Endocrine Associates, La Jolla, California, 10Professor of Medicine and
Pharmacology, Tullis Tulane Alumni Chair in Diabetes, Chief, Section of
Endocrinology, Tulane University Health Sciences Center, New Orleans,
Louisiana, 11Endocrine Division, Harvard Vanguard Medical Associates,
Boston, Massachusetts, Division of Endocrinology, Beth Israel Deaconess
Medical Center, Boston, Massachusetts, 12Professor and Chair, Department
of Nutrition Sciences, University of Alabama at Birmingham, Director, UAB
Diabetes, Endocrinology & Metabolism, VA San Diego Healthcare System,
San Diego, California, 16Professor of Medicine, University of Washington
School of Medicine, Seattle, Washington, 17Professor of Clinical Medicine,
University of Miami, Miller School of Medicine, Miami, Florida, The Center
for Diabetes & Endocrine Care, Hollywood, Florida, 18Professor of Medicine,
Division of Endocrinology, Metabolism & Lipid Research, Washington
University, St. Louis, Missouri, 19Clinical Professor of Medicine, Director,
Metabolic Support, Division of Endocrinology, Diabetes, and Bone Disease,
Icahn School of Medicine at Mount Sinai, New York, New York, 20Clinical
Professor, Medicine, Division of Endocrinology, Diabetes, Metabolism,
University California Irvine School of Medicine, Irvine, California,
Co-Director, Diabetes Out-Patient Clinic, UCI Medical Center, Orange,
California, Director & Principal Investigator, Diabetes/Lipid Management
& Research Center, Huntington Beach, California, and 21Professor of
Medicine, Emory University School of Medicine, Director, Endocrinology
Section, Grady Health System, Atlanta, Georgia.
Address correspondence to American Association of Clinical
Endocrinologists, 245 Riverside Avenue, Suite 200, Jacksonville, FL 32202.
E-mail: publications@aace.com. DOI: 10.4158/EP151126.CS
To purchase reprints of this article, please visit: www.aace.com/reprints.
Copyright © 2016 AACE.
Abbreviations:
A1C AACE -
ACCORD

ACCORD BP
ACEI
AGI
apo B ARB
ASCVD - (Endocr Pract. 2016;22:84-113)
BAS BMI =
BP CHD = coro- Principles
CKD
CVD DKA -
DPP-4 EPA -
FDA
GLP-1 HDL-C
LDL-C -
LDL-P - -
Look AHEAD
NPH OSA
SFU SGLT-2
SMBG -
T2D TZD =

EXECUTIVE SUMMARY -

-
-
-
-

- -
-

-
 -
-

- -

- -

-
Clinical
- Practice Guidelines for Healthy Eating for the Prevention
- and Treatment of Metabolic and Endocrine Diseases in
Adults
-
-
-

Lifestyle Therapy -

-
-

of trans

- -

Drowsiness:
somnolencia
 -
-
-

m
- -

Obesity
Prediabetes

- -
-
- -

Solely: solamente
 -
-
P

- -

T2D Pharmacotherapy

- -

-
-

-
-

thereby
enhancing:
mejorando
- de este modo
-

- -

- -

- -

- -

-
-
 -
-
-

- -
-
-
-
-

- -

-
Insulin

***** -
- -
-

-
-
-

- -

-
-

-
-

-
-
 -

-
- -

-
-

- -
onset: inicio
offset: compensar

-
-

-
BP
 non-HDL-C:
CT - LDL - TGC/5
CT= total colesterol
TGC/5= VLDL-C

-
-

Lipids

- -
- -

ESTATINAS:
INH de HMG-Co
- reductasa

- -

- Inhibe la absorción de colesterol a nivel intestinal

milieu: medio / ambiente
- Potencia efecto de estatinas
 Table 1
AACE Lipid Targets for Patients With Type 2 Diabetes
High-risk patients Very-high-risk patients
(T2D but no other major risk and/or (T2D plus 1 major ASCVD riska or
age <40 years) established ASCVD)

BAS: BILE ACID SEQUESTRANT

Resinas secuestradoras de ácidos biliares

P -

-
P -
-
-

-
-

- -
 -

ACKNOWLEDGMENT

DISCLOSURE

Dr. Alan J. Garber

Dr. Martin J. Abrahamson

Dr. Joshua I. Barzilay

Dr. Lawrence Blonde -

Dr. Zachary Bloomgarden -

Dr. Michael A. Bush

Dr. Samuel Dagogo-Jack -

Dr. Ralph A. DeFronzo

Dr. Daniel Einhorn

Dr. Vivian A. Fonseca -

 Dr. Guillermo E. Umpierrez

Dr. Jeffrey R. Garber

Dr. W. Timothy Garvey - Amanda M. Justice

REFERENCES

Butler AE, Janson J, Bonner-Weir S, Ritzel R, Rizza

RA, Butler PC.
Diabetes.

Dr. George Grunberger Handelsman Y, Bloomgarden ZT, Grunberger G, et

al.

-
Endocr Pract.

Dr. Yehuda Handelsman Wadden TA, West DS, Neiberg RH, et al.

Obesity (Silver Spring).

Look AHEAD Research Group, Pi-Sunyer X,
Blackburn G, et al. -

Diabetes Care.

Ratner R, Goldberg R, Haffner S, et al. -

Dr. Robert R. Henry
Diabetes Care.
Hoskin MA, Bray GA, Hattaway K, et al.

Curr Nutr
Rep.
Evert AB, Boucher JL, Cypress M, et al. Nutrition ther-
Dr. Irl B. Hirsch
Diabetes Care.
Keogh JB, Clifton PM.
Dr. Paul S. Jellinger J Nutr Metab.

Ditschuneit HH, Flechtner-Mors M, Johnson TD, Adler

G.
Am J Clin Nutr.
Dr. Janet B. McGill
Flechtner-Mors M, Ditschuneit HH, Johnson TD,
Suchard MA, Adler G.

Obes Res.
Sbrocco T, Nedegaard RC, Stone JM, Lewis EL.
Dr. Jeffrey I. Mechanick -
-
J Consult Clin Psychol.
Dr. Paul D. Rosenblit
Fuller PR, Perri MG, Leermakers EA, Guyer LK.

Addict
Behav.
Meyers AW, Graves TJ, Whelan JP, Barclay DR.
 J Consult Clin Gottlieb DJ, Redline S, Nieto FJ, et al.
Psychol.
Perri MG, McAllister DA, Gange JJ, Jordan RC, Sleep.
McAdoo G, Nezu AM. Chaput JP, Després JP, Bouchard C, Tremblay A.
J
Consult Clin Psychol.
Metz JA, Stern JS, Kris-Etherton P, et al. Obesity (Silver Spring).
Ayas NT, White DP, Manson JE, et al.

Arch Intern Med. Arch Intern Med.

Gonzalez-Campoy JM, St Jeor ST, Castorino K, et Lindberg E, Carter N, Gislason T, Janson C.
al.
- Am J Respir Crit Care Med.
Winkelman JW, Redline S, Baldwin CM, Resnick HE,
Newman AB, Gottlieb DJ.
Endocr
Pract. Sleep.
Balducci S, Alessi E, Cardelli P, Cavallo S, Fallucca F, Valencia-Flores M, Orea A, Castaño VA, et al.
Pugliese G.
Obes Res.
Anderson RJ, Freedland KE, Clouse RE, Lustman
Diabetes Care. PJ.
Manders RJ, Van Dijk JW, van Loon LJ. Diabetes Care.

Med Sci Sports Exerc. Anderson RJ, Grigsby AB, Freedland KE, et al.
Hansen D, Dendale P, Jonkers RA, et al.
- Int J Psychiatry Med.
Harkness E, Macdonald W, Valderas J, Coventry P,
Gask L, Bower P.
Diabetologia.
Praet SF, Manders RJ, Lieverse AG, et al.
Diabetes Care.
Med Sci Sports Exerc. Garvey WT, Garber AJ, Mechanick JI, et al.
De Feyter HM, Praet SF, van den Broek NM, et al.
-
Diabetes Care.
Endocr Pract.
Church TS, Blair SN, Cocreham S, et al. - Mechanick JI, Garber AJ, Handelsman Y, Garvey WT.
-
Endocr
JAMA. Pract.
Bray GA, Ryan DH.
Balducci S, Zanuso S, Nicolucci A, et al. Circulation.
Kip KE, Marroquin OC, Kelley DE, et al.
-

Arch Intern Med. Circulation.

Vinik AI, Vinik EJ, Colberg SR, Morrison S. Yusuf S, Hawken S, Ounpuu S, et al.
Clin Geriatr Med.
Lancet.
Colberg SR, Sigal RJ, Fernhall B, et al.
Hutton B, Fergusson D.
-
Diabetes Care.
Am J Clin Nutr.
McNeil J, Doucet É, Chaput JP.
Can J Diabetes. Torgerson JS, Hauptman J, Boldrin MN, Sjöström L.

Cappuccio FP, Cooper D, D’Elia L, Strazzullo P, Miller

MA.
-
Eur Heart J. Diabetes Care.
Patel SR, Malhotra A, White DP, Gottlieb DJ, Hu FB. Smith SR, Weissman NJ, Anderson CM, et al.

Am J Epidemiol. N Engl J Med.

O’Neil PM, Smith SR, Weissman NJ, et al.

Endocr Pract.
Obesity (Silver Spring).
Fidler MC, Sanchez M, Raether B, et al. Garber AJ, Handelsman Y, Einhorn D, et al.
-
J Clin Endocrinol -
Metab.
Garvey WT, Ryan DH, Look M, et al.
Endocr Pract.
Knowler WC, Barrett-Connor E, Fowler SE, et al.

Am J Clin Nutr. N Engl J Med.

Garvey WT, Ryan DH, Henry R, et al.
Chiasson JL, Josse RG, Gornis R, et al. -
- -
Diabetes Care.
Allison DB, Gadde KM, Garvey WT, et al. JAMA.
Chiasson JL, Josse RG, Gornis R, et al.
Obesity (Silver
Spring). Lancet.
Gadde KM, Allison DB, Ryan DH, et al. Knowler WC, Fowler SE, et al.

Lancet.
Lancet. DREAM (Diabetes REduction Assessment with
rampipril and rosiglitazone Medication) Trial
Garvey WT, Ryan DH, Bohannon NJ, et al. Investigators, Gerstein HC, Yusuf S, et al.
-
Diabetes Care.

Apovian CM, Aronne L, Rubino D, et al. Lancet.

Knowler WC, Hamman RF, Edelstein SL, et al.
Obesity (Silver
Spring). Diabetes.
Hollander P, Gupta AK, Plodkowski R, et al.
DeFronzo RA, Tripathy D, Schwenke DC, et al.
-
N Engl J Med.
Diabetes Care. Kim SH, Abbasi F, Lamendola C, et al. -
Wadden TA, Foreyt JP, Foster GD, et al.
Diabetes Care.
Rosenstock J, Klaff LJ, Schwartz S, et al.
Obesity (Silver Spring).
Greenway FL, Fujioka K, Plodkowski RA, et al.
Diabetes Care.
ADVANCE Collaborative Group, Patel A, MacMahon
Lancet. S, et al.
N Engl J Med.
Wadden TA, Hollander P, Klein S, et al. -
Ismail-Beigi F, Craven T, Banerji MA, et al.

Int J Obes (Lond).

Astrup A, Carraro R, Finer N, et al. Lancet.
ACCORD Study Group, Chew EY, Ambrosius WT, et
Int J Obes (Lond). al.
N Engl J Med.
Astrup A, Rössner S, Van Gaal L, et al. - Action to Control Cardiovascular Risk in Diabetes
Study Group, Gerstein HC, Miller ME, et al.
Lancet. N Engl J
Pi-Sunyer X, Astrup A, Fujioka K, et al. Med.
- Riddle MC, Ambrosius WT, Brillon DJ, et al.
N Engl J Med.
Mechanick JI, Youdim A, Jones DB, et al.
Diabetes Care.
Duckworth W, Abraira C, Moritz T, et al. Parks M, Rosebraugh C.

N Engl J Med. N Engl J Med.

Hayward RA, Reaven PD, Wiitala WL, et al. Zinman B, Wanner C, Lachin JM, et al.

N Engl J Med. N Engl J Med.

ACCORD Study Group, Gerstein HC, Miller ME, et Bloomgarden Z.
al. J Diabetes.
N Engl J Med.
Peters AL, Buschur EO, Buse JB, Cohan P, Diner JC,
Bonds DE, Miller ME, Bergenstal RM, et al. - Hirsch IB.
-
Diabetes Care.
BMJ. Nauck MA. -
Pop-Busui R, Evans GW, Gerstein HC, et al. Drug Des Devel
Ther.
Handelsman Y, Henry RR, Bloomgarden ZT, et al.
Diabetes Care.
Vinik A.
J Clin Endocrinol Metab. -
Endocr Pract.
Bailey CJ, Turner RC. N Engl J Med. Deacon CF. -
Diabetes
Kahn SE, Haffner SM, Heise MA, et al. - Obes Metab.
- Ahrén B.
N Engl J Med. -
Roumie CL, Hung AM, Greevy RA, et al. Best Pract Res
Clin Endocrinol Metab.
Dormandy JA, Charbonnel B, Eckland DJA, et al.
Ann Intern Med.

Salpeter SR, Greyber E, Pasternak GA, Salpeter EE. Lancet.

Cochrane Database Syst DeFronzo RA.

Rev. -
Kidney Disease: Improving Global Outcomes CKD Diabetes.
Work Group. Lincoff AM, Wolski K, Nicholls SJ, Nissen SE.

Kidney Int Suppl. -

Lipska KJ, Bailey CJ, Inzucchi SE. JAMA.
Home PD, Pocock SJ, Beck-Nielsen H, et al.
Diabetes Care. -
Reinstatler L, Qi YP, Williamson RS, Garn JV, Oakley -
GP Jr. Lancet.

Hiatt WR, Kaul S, Smith RJ.

Diabetes Care.
Leishear K, Boudreau RM, Studenski SA, et al. N Engl J Med.
Bolen S, Feldman L, Vassy J, et al.
J Am Geriatr Soc.

Wile DJ, Toth C. Ann Intern Med.

- Kahn SE, Zinman B, Lachin JM, et al.
Diabetes Care.
Diabetes
Deacon CF, Mannucci E, Ahrén B. Care.
Schwartz AV, Sellmeyer DE, Vittinghoff E, et al.

J Clin Endocrinol Metab.

Diabetes Obes Metab. Ferwana M, Firwana B, Hasan R, et al.
Leech CA, Dzhura I, Chepurny OG, Schwede F, -
Genieser HG, Holz GG. Diabet Med.
- Lewis JD, Habel LA, Quesenberry CP, et al.

Islets. JAMA.
Rosak C, Mertes G. - Diabetes Obes Metab.

Diabetes Metab Syndr Obes. anka HU, Plewe G, Riddle MC, Kliebe-Frisch C,
Hanefeld M, Cagatay M, Petrowitsch T, Neuser D, Schweitzer MA, Yki-Järvinen H.
Petzinna D, Rupp M.
-
Eur Heart J. Diabetes Care.
Tunis SL, Sauriol L, Minshall ME.
Phung OJ, Scholle JM, Talwar M, Coleman CI.
-
Appl Health Econ Health Policy.
JAMA.
Forst T, Hanefeld M, Jacob S, et al. Yki-Järvinen H, Kauppila M, Kujansuu E, et al.
- -
N Engl J Med.
Diab Vasc Dis Res.
Wilding JP, Woo V, Soler NG, et al.
Fonseca VA, Handelsman Y, Staels B.
- Ann
Diabetes Obes Metab. Intern Med.
Defronzo RA. Rosenstock J, Jelaska A, Frappin G, et al.

Diabetes Care.
Gaziano JM, Cincotta AH, O’Connor CM, et al. -
Diabetes Care.

Diabetes Care. Barnett AH, Charbonnel B, Donovan M, Fleming D,

Chen R.
Gaziano JM, Cincotta AH, Vinik A, Blonde L, Bohannon
N, Scranton R. Curr Med Res Opin.

J Buse JB, Bergenstal RM, Glass LC, et al.

Am Heart Assoc.
DeVries JH, Bain SC, Rodbard HW, et al. Ann Intern Med.
-
Russell-Jones D, Vaag A, Schmitz O, et al.
Diabetes Care. -
-
Rosenstock J, Rodbard HW, Bain SC, et al.
Diabetologia.
Vilsbøll T, Rosenstock J, Yki-Järvinen H, et al.
J Diabetes
Complications. Diabetes Obes Metab.
Riddle MC, Rosenstock J, Gerich J, Insulin Glargine
Study Investigators. Hirsch IB. N Engl J Med.

Diabetes Care. Owens DR, Luzio SD, Sert-Langeron C, Riddle MC.

Hermansen K, Davies M, Derezinski T, Martinez Ravn

G, Clauson P, Home P.
Diabetes Obes Metab.
Lankisch MR, Ferlinz KC, Leahy JL, Scherbaum WA,
Diabetes Care. Orals Plus A, group Ls.

Rosenstock J, Dailey G, Massi-Benedetti M, Fritsche A,

Lin Z, Salzman A. - Diabetes Obes Metab.

Diabetes Care. Leahy JL.

Endocrinol Metab Clin North Am.
Monami M, Marchionni N, Mannucci E. Peyrot M, Rubin RR, Polonsky WH, Best JH.

Diabetes Res Clin Pract. -

Curr Med Res Opin.
Home PD, Fritsche A, Schinzel S, Massi-Benedetti M.
Wright A, Burden AC, Paisey RB, Cull CA, Holman
RR. -
 -
Diabetes Care. Circulation.
Stewart K. ACSM’s
United Kingdom Hypoglycaemia Study Group. Resource Manual for Guidelines for Exercise Testing and
- Prescription.
Diabetologia.
James PA, Oparil S, Carter BL, et al.
DeWitt DE, Hirsch IB.
JAMA.
JAMA.
Moghissi E, Ismail-Beigi F, Devine RC.
Endocr Pract. Heart Outcomes Prevention Evaluation Study
Investigators.
Zoungas S, Patel A, Chalmers J, et al. -
N Engl J Med.
Lancet.
Bangalore S, Kumar S, Lobach I, Messerli FH.
Hansson L, Zanchetti A, Carruthers SG, et al.
-

Circulation.
Lancet.
McBrien K, Rabi DM, Campbell N, et al. Dahlof B, Devereux RB, Kjeldsen SE, et al.

Arch Intern Med. Lancet.

Sleight P, Redon J, Verdecchia P, et al.
Rahman M, Pressel S, Davis BR, et al.

J Hypertens. -

ACCORD Study Group, Cushman WC, Evans GW,

et al. Arch Intern Med.
N Engl J Med. Telmisartan Randomised AssessmeNt Study in
Whelton PK, He J, Cutler JA, et al. - ACEiswcDI, Yusuf S, Teo K, et al. -

JAMA.
Azadbakht L, Mirmiran P, Esmaillzadeh A, Azizi T, Lancet.
Azizi F.
Pahor M, Psaty BM, Alderman MH, Applegate WB,
Diabetes Care. Williamson JD, Furberg CD.
Buse JB, Ginsberg HN, Bakris GL, et al.
- Diabetes Care.
Jamerson K, Weber MA, Bakris GL, et al.

Diabetes Care. N Engl J Med.

Levitan EB, Wolk A, Mittleman MA. Parving HH, Brenner BM, McMurray JJ, et al.
Arch Intern
Med. N Engl J Med.
Liese AD, Nichols M, Sun X, D’Agostino RB Jr, Haffner Fried LF, Emanuele N, Zhang JH, et al. -
SM.
N Engl J Med.
Diabetes Care. Go AS, Mozaffarian D, Roger VL, et al.
Sacks FM, Svetkey LP, Vollmer WM, et al.
Circulation.
National Cholesterol Education Program Expert Panel
N Engl J Med. on Detection Evaluation, and Treatment of High Blood
Cholesterol in Adults.
Vollmer WM, Sacks FM, Ard J, et al.

Ann Intern Med.

Corrao G, Bagnardi V, Zambon A, La Vecchia C. Circulation.
Austin MA, Breslow JL, Hennekens CH, Buring
Prev Med. JE, Willett WC, Krauss RM.
Costanzo S, Di Castelnuovo A, Donati MB, Iacoviello L, JAMA.
de Gaetano G.
Reaven GM. - Bruckert E, Hayem G, Dejager S, Yau C, Bégaud B.
Diabetes.
Boekholdt SM, Hovingh GK, Mora S, et al.
- Cardiovasc Drugs Ther.
J Am Coll Masuda D, Nakagawa-Toyama Y, Nakatani K, et al.
Cardiol.
Cannon CP, Blazing MA, Giugliano RP, et al. Eur J Clin Invest.
N
Engl J Med. Blom DJ, Hala T, Bolognese M, et al.
Colhoun HM, Betteridge DJ, Durrington PN, et al. N Engl J
- Med.
Robinson JG, Farnier M, Krempf M, et al.
-
Lancet. N Engl J Med.
Knopp RH, d’Emden M, Smilde JG, Pocock SJ. Sabatine MS, Giugliano RP, Wiviott SD, et al.
-
- N Engl J Med.
Ramasamy I. -
Clin Chem Lab Med.
Diabetes Care. Zhang XL, Zhu QQ, Zhu L, et al.

Cholesterol Treatment Trialists’ (CTT) Collaboration, BMC Med.

Baigent C, Blackwell L, et al. Verbeek R, Stoekenbroek RM, Hovingh GK.

Eur J Pharmacol.
Lancet.
Cholesterol Treatment Trialists’ (CTT) Collaborators, Bays H, Gaudet D, Weiss R, et al.
Kearney PM, Blackwell L, et al. - -
J Clin
Lancet. Endocrinol Metab.
Colhoun HM, Ginsberg HN, Leiter LA, et al.
Athyros VG, Papageorgiou AA, Symeonidis AN, et
al.

Angiology.
Heart Protection Study Collaborative G. Davidson MH, Dillon MA, Gordon B, et al.
- -
-
Lancet. Arch Intern Med.
Ahmed S, Cannon CP, Murphy SA, Braunwald E. Handelsman Y. -
- Diabetes Care.
Eur
Heart J. Rosenson RS, Abby SL, Jones MR.
de Lemos JA, Blazing MA, Wiviott SD, et al.
Atherosclerosis.
Frick MH, Elo O, Haapa K, et al.
JAMA.
Ridker PM, Morrow DA, Rose LM, Rifai N, Cannon
CP, Braunwald E. N Engl J
Med.
Rubins HB, Robins SJ, Collins D, et al.

J Am Coll Cardiol.
Shepherd J, Barter P, Carmena R, et al. -
- N Engl J Med.
ACCORD Study Group, Ginsberg HN, Elam MB, et
al.
Diabetes Care. N Engl J Med.
Cannon CP, Steinberg BA, Murphy SA, Mega JL, Manninen V, Tenkanen L, Koskinen P, et al. Joint
Braunwald E.
J
Am Coll Cardiol.
Sniderman AD. Circulation.
Bruckert E, Labreuche J, Deplanque D, Touboul PJ,
J Amarenco P.
Clin Lipidol. -
 Yokoyama M, Origasa H, Matsuzaki M, et al.
J Cardiovasc Pharmacol. -
Scott R, O’Brien R, Fulcher G, et al. -
Lancet.

Oikawa S, Yokoyama M, Origasa H, et al.

Diabetes Care.

Sacks FM, Carey VJ, Fruchart JC.

N Engl J Med. Atherosclerosis.
Saito Y, Yokoyama M, Origasa H, et al.

Atherosclerosis. Atherosclerosis.
Carlson LA. Roncaglioni MC, Tombesi M, Avanzini F, et al.
J Intern Med.
Pan J, Lin M, Kesala RL, Van J, Charles MA. N Engl J Med.
Bosch J, Gerstein HC, Dagenais GR, et al.
Diabetes Obes Metab.
N Engl J Med.
- Jellinger PS, Smith DA, Mehta AE, et al.
N Engl J Med.
HPS2-THRIVE Collaborative Group, Landray MJ, -
Haynes R, et al. Endocr Pract.
N Engl J Med. Hegele RA, Ginsberg HN, Chapman MJ, et al. The

Lavigne PM, Karas RH. Lancet Diabetes

Endocrinol.
J Am Coll Cardiol. Christian JB, Arondekar B, Buysman EK, Jacobson
Canner PL, Furberg CD, Terrin ML, McGovern ME. TA, Snipes RG, Horwitz RI.
-
Am J Med.
Am J Cardiol.
 AACE/ACE COMPREHENSIVE TYPE 2
DIABETES MANAGEMENT ALGORITHM
Martin J. Abrahamson, MD
Joshua I. Barzilay, MD, FACE
Lawrence Blonde, MD, FACP, FACE
Zachary T. Bloomgarden, MD, MACE
Michael A. Bush, MD
Samuel Dagogo-Jack, MD, DM, FRCP, FACE
Ralph A. DeFronzo, MD
COPYRIGHT © 2016 AACE MAY NOT BE REPRODUCED IN ANY FORM WITHOUT EXPRESS WRITTEN PERMISSION FROM AACE.
2016
TA SK FOR CE
Alan J. Garber, MD, PhD, FACE, Chair
Daniel Einhorn, MD, FACP, FACE
Vivian A. Fonseca, MD, FACE
Jeffrey R. Garber, MD, FACP, FACE
W. Timothy Garvey, MD, FACE
George Grunberger, MD, FACP, FACE
Yehuda Handelsman, MD, FACP, FNLA, FACE
Robert R. Henry, MD, FACE
Irl B. Hirsch, MD
Paul S. Jellinger, MD, MACE
Janet B. McGill, MD, FACE
Jeffrey I. Mechanick, MD, FACP, FACE, FACN, ECNU
Paul D. Rosenblit, MD, PhD, FNLA, FACE
Guillermo Umpierrez, MD, FACP, FACE
 TABL E OF CONTENTS
Comprehensive Type 2 Diabetes Algorithm
I. Lifestyle Therapy

II. Complications-Centric Model for Care

of the Overweight/Obese Patient

III. Prediabetes Algorithm

IV. Goals for Glycemic Control

V. Glycemic Control Algorithm

VI. Algorithm for Adding/Intensifying Insulin

VII. ASCVD Risk Factor Modifications Algorithm

VIII. Profiles of Antidiabetic Medications

IX. Principles for Treatment of Type 2 Diabetes

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 LIFE S T YLE THE R A P Y
R I S K S T R ATIFICATION FOR DIA BE TE S COMPLIC AT ION S

INTENSITY STRATIFIED BY BURDEN OF OBESITY AND RELATED COMPLICATIONS

P Maintain optimal weight

+
P Calorie restriction
P Plant-based diet; high polyunsaturated P Structured counseling
Nutrition P Meal replacement
and monounsaturated fatty acids
P Avoid trans fatty acids;
limit saturated fatty acids

+ +
P 150 min/week moderate exertion
P Medical evaluation/
Physical (eg. walking, stair climbing) P Structured
clearance
Activity P Strength training program
P Medical supervision
P Increase as tolerated

Sleep P About 7 hours per night

+ P Screen for obstructive sleep apnea

Behavioral
Support
P Community engagement
P Screen for mood disorders + P Refer to mental healthcare professional
P Behavioral therapy

Smoking
Cessation
P No tobacco products
+ P Structured programs

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 COMPLICATIONSCENTR IC M ODEL FOR CARE
OF THE OV ERWEIG HT/ OBESE PATIENT

S TEP 1 E VA L U AT I O N F O R C O M P L I C AT I O N S A N D S TA G I N G

C AR D IOME TABOLIC D ISEASE | BIOMECHA NIC A L COM P L IC AT IONS

N O COM PLIC AT IONS COM P LI C ATI ONS

BMI ≥25 BMI 25–26.9 BMI ≥ 27: Stage Severity of Complications

MILD TO MODERATE SEVERE

S TEP 2 SELEC T:
Therapeutic targets for
improvement in complications + Treatment
modality + Treatment intensity based
on staging

Lifestyle Therapy: Physician/RD counseling, web/remote program, structured multidisciplinary program

Medical Therapy Phentermine, orlistat, lorcaserin, phentermine/topiramate ER,

(BMI ≥ 27): naltrexone/bupropion, liraglutide 3 mg

Surgical Therapy (BMI ≥ 35): Gastric banding, sleeve, or bypass

If therapeutic targets for complications not met, intensify lifestyle, medical, and/or surgical treatment
S TEP 3 modalities for greater weight loss.

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 PREDIABETES ALGORITH M
I FG ( 10 0– 1 2 5 ) | IGT ( 1 4 0– 1 9 9 ) | M E TA B O L IC SYN D RO M E ( N C E P 2 0 0 1 )

LIFESTYLE THERAPY
(Including Medically Assisted Weight Loss)

T REAT A S C V D WE IG HT LOSS TR EAT HYP E R GLYCE M IA

RIS K FAC TO RS T H ER APIES FPG > 100 | 2-hour PG > 140

ASC VD RISK FAC TOR N ORMA L 1 P R E -D M MU LTIPL E PR E- DM

MO DIFIC AT IONS ALGORIT HM G LYC E M I A C RI TE RI ON CR ITER IA

DYSLIPIDEMIA HYPE R T E NSION

Low-risk Consider with
ROUTE ROUTE
Progression Intensify Medications Caution
Weight
Loss Metformin TZD
Therapies
OV E R T Acarbose GLP-1 RA
D I A B E TE S
LEGEND

Orlistat, lorcaserin,
phentermine/topiramate ER, PR OCE E D TO
naltrexone/bupropion, liraglutide 3 mg, HYP E R G LYC E M I A If glycemia
or bariatric surgery as indicated for
ALG OR I T HM not normalized
obesity treatment

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 G OA LS FOR G LYCE MIC CON T R OL

INDIV ID UALIZ E GOALS

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

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 G LYC EMIC CONTR OL A LGORI T HM

LIFESTYLE THERAPY
(Including Medically Assisted Weight Loss)

Entry A1C < 7.5% Entry A1C ≥ 7.5% Entry A1C > 9.0%

MON OT H E R A PY * S YM PTO M S
D UAL T HE R APY*
Metformin NO YE S
GLP-1 RA T R I PL E T HE R APY*
GLP-1 RA
SGLT-2i DUAL INSULIN
SGLT-2i GLP-1 RA
Therapy ±
DPP-4i SGLT-2i Other
DPP-4i

TZD
MET TZD MET TZD
OR Agents
or other or other
TRIPLE
1st-line Basal Insulin 1st-line Basal insulin
AGi Therapy

+
agent agent +
Colesevelam DPP-4i
SU/GLN 2nd-line

+
agent
Bromocriptine QR Colesevelam
AGi Bromocriptine QR
A DD O R I NTENS I FY
SU/GLN AGi I NS UL I N
If not at goal in 3 months
Refer to Insulin Algorithm
SU/GLN
proceed to Dual Therapy If not at goal
in 3 months
proceed to LEGEND
Triple Therapy If not at goal in
3 months proceed Few adverse events and/or
to or intensify possible benefits
insulin therapy
* Order of medications represents a suggested hierarchy of usage; Use with caution
length of line reflects strength of recommendation

P R O G R E S S I O N O F D I S E A S E
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 ALG ORITH M FOR ADDING/INTENSIF YING INS ULIN

S T A R T B A S A L (Long-Acting Insulin) I N T E N S I F Y (Prandial Control)

A1C < 8% A1C > 8% Add Add Prandial Insulin

GLP-1 RA

TDD 0.1–0.2 U/kg TDD 0.2–0.3 U/kg Or SGLT-2i

Or DPP-4i

Basal Plus 1, Plus 2, Basal Bolus

Insulin titration every 2–3 days Plus 3
to reach glycemic goal:
r Begin prandial r Begin prandial
r Fixed regimen: Increase TDD by 2 U insulin before insulin before
r Adjustable regimen: largest meal each meal
Glycemic
r FBG > 180 mg/dL: add 20% of TDD r If not at goal, r 50% Basal /
Control Not
r FBG 140–180 mg/dL: add 10% of TDD progress to 50% Prandial
r FBG 110–139 mg/dL: add 1 unit
at Goal*
injections before TDD 0.3–0.5 U/kg
r If hypoglycemia, reduce TDD by: 2 or 3 meals
r BG < 70 mg/dL: 10% – 20%
r Start: 10% of basal r Start: 50% of TDD
r BG < 40 mg/dL: 20% – 40%
dose or 5 units in three doses
before meals
Consider discontinuing or reducing sulfonylurea after
starting basal insulin (basal analogs preferred to NPH)
Insulin titration every 2–3 days to reach glycemic goal:
*Glycemic Goal:
r Increase prandial dose by 10% or 1-2 units if 2-h postprandial
r <7% for most patients with T2D; fasting and premeal or next premeal glucose consistently > 140 mg/dL
BG < 110 mg/dL; absence of hypoglycemia r If hypoglycemia, reduce TDD basal and/or prandial insulin by:
r A1C and FBG targets may be adjusted based on patient’s r BG consistently < 70 mg/dL: 10% - 20%
age, duration of diabetes, presence of comorbidities, r Severe hypoglycemia (requiring assistance from another
diabetic complications, and hypoglycemia risk person) or BG < 40 mg/dL: 20% - 40%

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 A S C V D R I S K FACTOR MODIF ICATIONS ALGORITHM

DYSLIPIDEMIA HYPERTENSION

L I F E S T Y L E T H E R A P Y (Including Medically Assisted Weight Loss)

LIPID PA N EL: Assess ASCVD Risk G OAL : SYSTOL IC <130,

DIASTOL IC <80 mm Hg

STATI N THE R A PY ACEi For initial blood pressure

If TG > 500 mg/dL, fibrates, Rx-grade omega-3 fatty acids, niacin or >150/100 mm Hg:

If statin-intolerant ARB D UAL THER APY

Calcium
Try alternate statin, lower statin Repeat lipid panel; Intensify therapies to
Channel
dose or frequency, or add nonstatin assess adequacy, attain goals according ACEi Blocker
LDL-C- lowering therapies tolerance of therapy to risk levels
or
ß-blocker
ARB
DM but no other major risk DM + major ASCVD risk(s) (HTN, Fam Hx,
RISK LE VELS HIGH and/or age <40 VERY HIGH low HDL-C, smoking) or ASCVD* Thiazide
DESIRABLE LEVELS DESIRABLE LEVELS
LDL-C (mg/dL) <100 <70
If not at goal (2–3 months)
Non-HDL-C (mg/dL) <130 <100
TG (mg/dL) <150 <150 Add calcium channel blocker,
TC/HDL-C <3.5 <3.0 ß-blocker or thiazide diuretic
Apo B (mg/dL) <90 <80
LDL-P (nmol/L) <1200 <1000 If not at goal (2–3 months)

Add next agent from the above

Intensify lifestyle therapy (weight loss, physical activity, dietary changes)
IF NOT AT DESIRABLE LEVELS: group, repeat
and glycemic control; consider additional therapy
If not at goal (2–3 months)
TO LOWER LDL-C: Intensify statin, add ezetimibe, PCSK9i, colesevelam, or niacin
Additional choices (α-blockers,
TO LOWER Non-HDL-C, TG: Intensify statin and/or add Rx-grade OM3 fatty acid, fibrate, and/or niacin central agents, vasodilators,
TO LOWER Apo B, LDL-P: Intensify statin and/or add ezetimibe, PCSK9i, colesevelam, and/or niacin aldosterone antagonist)
TO LOWER LDL-C in FH:** Statin + PCSK9i

Achievement of target blood

Assess adequacy & tolerance of therapy with focused laboratory evaluations and patient follow-up pressure is critical

* E V E N M O RE IN T E N S IV E T HE R A PY MI GHT BE WAR R ANT ED ** FAMI LI AL HYPER C HOLEST ER OLEMIA

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 PR OF I L E S OF ANTIDIABETIC MEDICATIONS

TZD SU
MET GLP-1 RA SGLT-2i DPP-4i AGi (moderate COLSVL BCR-QR INSULIN PRAML
dose) GLN
Moderate/
Severe Moderate
HYPO Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral Neutral
Mild to Severe

Slight
WEIGHT Loss Loss Neutral Neutral Gain Gain Neutral Neutral Gain Loss
Loss

Not
Effective
Contra- Dose
Exenatide with
indicated Adjustment More
RENAL/ Not eGFR < 45 More
CKD Necessary Neutral Neutral Hypo Neutral Neutral Neutral
GU Stage
Indicated
(Except Risk
Hypo Risk
CrCl < 30 Genital
3B,4,5 Linagliptin)
Mycotic
Infections

GI Sx Moderate Moderate Neutral Neutral Moderate Neutral Neutral Mild Moderate Neutral Moderate

CHF Neutral Moderate Neutral Neutral

Possible
CARDIAC Neutral Neutral Neutral Neutral Neutral Neutral
Benefit
ASCVD Benefit Neutral ? Safe

Moderate
BONE Neutral Neutral Neutral Neutral Neutral Fracture Neutral Neutral Neutral Neutral Neutral
Risk

Few adverse events or possible benefits Use with caution Likelihood of adverse effects ? Uncertain effect

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PR INC I PL E S OF THE AACE/ACE COMPREHENSIVE
T Y PE 2 DI ABETES M AN AG EM EN T ALGORITHM

1. Lifestyle therapy, including medically supervised weight loss, is key to managing type 2 diabetes.

2. The A1C target must be individualized.

3. Glycemic control targets include fasting and postprandial glucoses.

The choice of therapies must be individualized on basis of patient characteristics, impact of net cost
4. to patient, formulary restrictions, personal preferences, etc.

5. Minimizing risk of hypoglycemia is a priority.

6. Minimizing risk of weight gain is a priority.

Initial acquisition cost of medications is only a part of the total cost of care which includes
7. monitoring requirements, risk of hypoglycemia, weight gain, safety, etc.

8. This algorithm stratifies choice of therapies based on initial A1C.

9. Combination therapy is usually required and should involve agents with complementary actions.

10. Comprehensive management includes lipid and blood pressure therapies and related comorbidities.

11. Therapy must be evaluated frequently until stable (e.g., every 3 months) and then less often.

12. The therapeutic regimen should be as simple as possible to optimize adherence.

13. This algorithm includes every FDA-approved class of medications for diabetes.

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