Magazine article Drug Topics

Two Organizations Offer Key Strategies for T2DM Management

Magazine article Drug Topics

Two Organizations Offer Key Strategies for T2DM Management

Article excerpt

Late last year, the American Diabetes Association (ADA) released "2012 ADA/EASD Management of Hyperglycemia in Type 2 Diabetes: A Patient-Centered Approach," its updated position statement for the treatment of type 2 diabetes melJitus (T2DM), while the American Association of Clinical Endocrinologists (AACE) released its algorithm, "Comprehensive Diabetes Management Algorithm 2013: Consensus Statement," earlier this year. Even though these two key sets of guidelines differ from each other, pharmacists can benefit from the recommendations presented in both publications.

The AACE algorithm

The algorithm developed by AACE (,http://bit.ty/AACEalgorithm) is considered to be somewhat more prescriptive than ADA's position statement, providing guidance, based on HbAlc levels and symptoms, on when practitioners should consider monotherapy, dual therapy, and triple therapy for diabetes.

"AACE intends the algorithm to be as user-friendly as possible, since diabetes management is so complex and is a source of confusion for many," said Devra Dang, PharmD, associate clinical professor, University of Connecticut School of Pharmacy.

In addition, for the first time, AACE looks beyond glycémie control to address diabetes prevention and management of dyslipidemia; it also compares the benefits and risks of all FDAapproved medications for T2DM, said George Grunberger, MD, FACP, owner of the Grunberger Diabetes Institute in Bloomfield Hills, Mich. Grunberger was a member of the AACE committee that developed the 2013 Consensus Statement.

"We realize that type 2 diabetes care is so complex, and pharmacists and physicians need some help. We tried to be more prescriptive," said Grunberger.

In AACE's algorithm, drug therapy selection is stratified according to a patient's baseline Ale. For patients with a baseline Ale between 6.5% and 7.5%, monotherapy (preferably with metformin) is recommended. After that, AACE recommends, dual therapy should be initiated when the baseline Alcis between 7.6% and 9%. Triple therapy or transition to insulin therapy is usually reserved for patients with a baseline Ale >9%.

"With the AACE algorithm, we acknowledge that you are who you are as you show up in the doctor's office, and the management needs to be individualized accordingly. We look at the Ale you bring into the office as a principal guide to the initial choice of drug therapy," Grunberger said.

Visual aid

AACE's algorithm includes an easyto-understand bar chart for glycémie control. In its "Glycémie Control Algorithm" chart, the importance of various therapies is represented by the length of the bars, and color codes also allow pharmacists and physicians to evaluate the safety and effectiveness of different treatments and therapies.

"We created a decision tree that emphasizes safety and understanding of the risks vs. the benefits of the various drug classes. Hopefully, people can follow it and go from one area to the other to meet the individual's glycémie targets," Grunberger said.

The Glycémie Control Algorithm chart stresses the importance of lifestyle modifications (including medically assisted weight loss), represented by the most prominent bar in the chart, which tops any of the bars depicting the drug therapies. The color-coded bars let pharmacists and physicians know the relative safety of the numerous drugs approved by FDA to treat T2DM. Green bars represent medications and treatments that are relatively safe, while yellow bars indicate therapies about which "there is some caution, and physicians should carefully consider the balance of risk vs. benefit before recommending them," Grunberger said.

For patients with an Ale of 7.5% or less, metformin is the top drug of choice, represented by the longest bar and the bar's green coloring.

"However, quite a few patients cannot tolerate metformin or it is contraindicated for them, so we list other drugs logically suited for the individual patient. …

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