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  1. 1. TASK FORCEAlan J.Garber,MD,PhD,FACE- Chair Martin J.Abrahamson,MDJoshua I.Barzilay,MD,FACE Lawrence Blonde,MD,FACP,FACE ZacharyT.Bloomgarden,MD,MACE Michael A.Bush,MDSamuel DagogoJack,MD,FACE Michael B.Davidson,DO,FACE Daniel Einhorn,MD,FACP,FACEW.1'Imothy Garvey,MDGeorge Grunberger,MD,FACP,FACEYehuda Handelsman,MD,FACP,FACE,FNLAlrl B.Hirsch,MDPaul S.Jellinger,MD,MACEJanet 8. McGill,MD,FACEJeffrey I.Mechanick,MD,FACE,ECNU,FACN,FACP Paul D.Rosenblit,MD,FACEGuillermo Umpierrez,MD,FACEMichael H.Davidson,MD,AdvisorCopyright D 2013 AACE May not be reproduced in any form without euptru written permission from AACE.
  2. 2. TABLE of CONTENTSCopyrighl G 20!!AACE May not be reproduced In any form wuhour express wlmen pemmnon from AACE. COI~'lIIEIIENSIVE DIABETES ALGORI IIIMCOMPLICATIONS-CENTRIC MODEL FOR CARE OF THE OVERWEIGHT/ OBESE PATIENTIRII)| ABI- ISIS AIGORI I H MGOALS OF GLYCEMIC CONTROL. G LYCEMIC CONTROL ALGORITHMALGORITHM FOR ADDING/ INTFNSIFYING INSULINCVD RISK FACTOR MODIFICATIONS ALGORITHM IIROFII F8 OF ANIiIIi>I, IsI4TIC I= Il4I)| L.. Il IONSPRINCIPLES FOR TREATMENT OF TYPE 2 DIABETES
  3. 3. COMPLICATIONS-CENTRIC MODEL FOR CARE " OF THE OVERWEIGHT/ OBESE PATIENTEVALUATION FOR COMPLICATIONS AND STAGINGCARDIOMETABOLIC DISEASE BIOMECHANICAL COMPLICATIONSNO COMPLICATIONS BMIz 27 WITH COMPLICATIONSStage Severity of ComplicationsLOW MEDIUM HIGH(i) Therapeutic targets for improvement in complications,STEP 2 SELECT:(ii) Treatment modality and (iii) Treatment intensity for weight loss based on stagingMD/ RD counseling;web/ remote program;structured multidisciplinary programIf therapeutic targets for improvements in complications not met,intensify lifestyle and/ or medical and/ or surgical treatment modalities for greater weight lossCopyright 0 2013 AACE May not be reproduced in any form without eupreu written perrnission from AACE.
  4. 4. PREDIABETES ALGORITHMlFG(100125) I IGT(140-199) I METABOLIC SYNDROMEINCEP zoos) LIFESTYLE MODIFICATION (Including Medically Assisted Weight Loss) CVD Risk Factor Modications AlgorithmNORMAL GLYCEMIAj _ Progression Low Risk MedicationsTZDGLP-1 RAProceed to Hyperglycemia Algorithmlfglycemia not normalized,consider with cautionCopyright2013 AACE May not he rrprndurrriiri any form without vxpwsi wrirre-Ii perrmss/ ori from AACE.
  5. 5. A1 c . 6.5%Individualize goals for patients with concurrent illness and at risk for hypoglycemia Copyright - 1013 AACE M(IVI7f)Iltl'If[lfC| (llI(Pt. lII| IIIIVFUIVIIWllIl)I1Ifl[)Ifil| VNHfII; |flH? lS/ DllIIUlYlAI([
  6. 6. GLYCEMIC CONTROL ALGORITHM LIFESTYLE MODIFICATION I (Including Medically Assisted Weight Loss) I'j. . =IIiI-oi:~. Iuc- 2 '/ ..-2.I aww ms :l. :}d. '-:alum:at:. aura. l_. ..__. .. _.? .l i MONOTHERAPY DUAL THERAPYDUAL THERAPY Metforminour-1 RA GLP-I RA @DPP4-I TZD IINSULIN 2 OTHERTRIPLE THERAPY ,WPLE AGENTS THERAPYDPP4 - i AG~i5GLT2 SGLT-2 ITZOTZD SU/ GLN Basal insulin 56. ) Colosevelam 6 II Alc : - 6.S'5'u in 3 months add second drug| Dua|Therapy. Basal Insulin DPP4-i G Colesevelam GBrornocripline OR @AG-I S Bromocriptine0R 6AG-I ADD OR INTENSIFY INSULINIt not at goal in 3 months proceed to triple therapy If not at goal in 3months proceed LEGEND Order ol medications listed area suggested luerarcliy of usage to orintenstfy W mve" Wen A :U" Wm ( man Based upon phase 3 clinical trials data In5UI'" WQWFY D,p, ,IbI. , hemp. ROGRESS| ON OF DlSEAS Copy right20 I 3 AAC E May not be rI-produced In any form wirlmut express written pe rmisslon from AACE
  7. 7. - 5 3 3 E"::/:., : i.tgi. igv-. I,-iii-uzirmiiini.t, E . . | ~' v' ' Cgilnlglhli vieiufu. -i_l~ *i 1 " T V AdgI_GD'; ';1_| RA Add Prandiailnsulin// IIDII In: I.> -i. .:- Iri: c-I i us:". :< min I m "J4".ml Iv>1i. . zur-It-Lg r~IIilt-I-: iiv-ii-u Insulin titration every 2-3 days to reach glycemlc goal:- Fixed regimen:Increase TDD by 2 U - Adjustable regimen: - F86 > 180 mg/ dL:add 4 U- FBG I40-180 mg/ dL:add 2 U- FBG 110-139 mg/ dL:add I U - Ii hypoglycemia.reduce TDD by: - 86 < 70 mg/ dL:10% 20%- [36 < 40 mg/ dL:20% 40%-. :w -Iaxiini-ii Ii":-lll'i u: .i, giIIi-I lIL1liIaiI):pillllllltuol llnllllli/ IA '- Glycemlc Control 2/ Not at Goal" Insulin titration every 2-3 days to reach glycoinlc goal:- Increase basal TDD as follows:- Fixed regimen:increase TDD by 2 U - Adjustable regimen: ' - FBG > 180 mg/ dL: add4U Consider discontinuing or reducing sulfonylurea after .F35 140-130 mg/ di_;add 2 ubasal insulin started (basal analogs preferred to NPH) .F35 100.139 mg/ di;add 1 u- Increase prandial dose by 10% for any meal ifthe 2-hr postprandial or next premeal glucose is > 180 mg/ dL" 5'V"" 503':- Premixed:Increase TDD by 10% if fasting/ premeal- For most patients with T2D.an Aic < 7%,fasting and 35 > 130 mg/ dL premeal BG < li0 mg/ dL in the absence of hypoglycemia.. if 135", -jg AM hypoglycemia reduce ba5,3| insulin- Aic and FBG targets may be adjusted based on patients .|f nag)-mime hypoglycemia,reduce basal and/ or presupper age,duration of diabetes,presence of comorblditles.or pre. ven(ng snack shortjrapid-acfing insulin dlabellt CmP3"5u 3'15 hYP9'Ye"l3 "SK - If between meal daytime hypoglycemia.reduce previouspremeal short/ rapid-acting insulin Copyright D 2013 AACE May not ill replodurrd In any form without express written palmixsiori from AACE
  8. 8. or add nonstatln LDl. -C- / lowering therapies irzgltIiId5 J)*- -35 All THERAPEUTIC LIFESTYLE CHANGES (SeeObesity/ llgorlthm stall! ) 0:lull}m: l$_1-+1-7"3l| !': lH('- l.ire -1II| rnLoyll nil! -ll-J: Pf -Inn-ur-~~~. Ilm-asuaw.Ir-His: ,' .I L ivlsgllar-In-I / Try alternate statin.lower statln dose or lrequency,-Wt-Iih liwr ex: I lntenslfy therapies to attain goals accordingto risk levelsRepeat lipid panel;7 assess adequacy./_/ tolerance of therapyRISK LEVELS 3") iii): -"IO:HIn" x I 1: 1.3:: LDL-C lmgldl. ) (ion