Alan J. Garber
The American Association of Clinical Endocrinologists and the American College of Endocrinology announced the publication of the 2018 AACE/ACE Comprehensive Type 2 Diabetes Management Algorithm, including updates on lipid-lowering and antihypertensive medications for the prevention of cardiovascular disease.
The 2018 algorithm and accompanying consensus statement also include a revised assessment of glucose-lowering medications for type 2 diabetes, particularly those with proven benefits in mitigating atherosclerotic CVD, as well as recommendations for obesity management and lifestyle therapy. The algorithm, originally drafted in 2013, serves as a supplement to the AACE/ACE Clinical Practice Guidelines for Developing a Diabetes Mellitus Comprehensive Care Plan, first released in 2015.
“With cardiovascular disease of particular concern with type 2 diabetes patients, this algorithm provides important updates regarding glucose-lowering therapies and their impact on cardiovascular outcomes,” Endocrine Today Chief Medical Editor Alan J. Garber, MD, PhD, FACE, chair of the AACE/ACE Comprehensive Diabetes Management Algorithm Task Force, said in a statement. “This comprehensive tool also provides updates on other areas of therapy to ensure optimal patient care is achieved.”
The algorithm also features a suggested hierarchy of use for glycemic-control medications in type 2 diabetes based on the patient’s initial HbA1c as well as the strength of the recommendations supported by expert analysis. Combination therapy is usually required, the researchers wrote, and should involve agents with complementary mechanisms of action.
Additionally, although some patients with type 2 diabetes can achieve lipid profile improvements through lifestyle therapies, the algorithm recommends more intensive pharmacotherapy to reduce CVD risk for those in low- and moderate-risk categories. Updated treatment goals include LDL cholesterol level of 130 mg/dL or lower and non-HDL cholesterol level of 160 mg/dL or lower for moderate-risk patients, and LDL cholesterol level of 160 mg/dL or lower and non-HDL cholesterol level of 190 mg/dL or lower for low-risk patients.
In the consensus statement, the researchers noted that considerable residual risk persists, even after aggressive statin monotherapy, for primary prevention in patients with type 2 diabetes and multiple CV risk factors, and for secondary prevention in patients with stable clinical atherosclerotic CVD. In these patients, other lipid-modifying agents, such as PCSK9 inhibitors, should be employed in combination with maximally tolerated statin therapy when therapeutic levels of LDL cholesterol or non-HDL cholesterol have not been reached, they wrote.
“The atherogenic cholesterol goals appear identical for very high-risk primary prevention and for very high-risk secondary (or recurrent events) prevention,” the researchers wrote. “However, the AACE does not define how low the goal should be and now recognizes that even more-intensive therapy, aimed at lipid levels far lower than an LDL cholesterol of < 70 mg/dL or non-HDL cholesterol of < 100 mg/dL, might be warranted for the secondary prevention group.”
The algorithm and consensus statement are available at www.aace.com/publications/algorithm.
Disclosures: Garber reports he is a consultant for Novo Nordisk and Intarcia. Please see the consensus statement for all other authors’ relevant financial disclosures.