Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2018 Executive Summary

doi:10.4158/CS-2017-0153

Endocrine Practice

Volume 24, Issue 1, January 2018, Pages 91-121

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ABSTRACT

Abbreviations: A1C = hemoglobin A1C; AACE = American Association of Clinical Endocrinologists; ACCORD = Action to Control Cardiovascular Risk in Diabetes; ACCORD BP = Action to Control Cardiovascular Risk in Diabetes Blood Pressure; ACEI = angiotensin-converting enzyme inhibitor; ADVANCE = Action in Diabetes and Vascular Disease: Preterax and Diamicron MR Controlled Evaluation; AGI = alpha-glucosidase inhibitor; apo B = apolipoprotein B; ASCVD = atherosclerotic cardiovascular disease; BAS = bile acid sequestrant; BCR-QR = bromocriptine quick release; BMI = body mass index; BP = blood pressure; CCB = calcium channel blocker; CHD = coronary heart disease; CKD = chronic kidney disease; CVD = cardiovascular disease; DASH = Dietary Approaches to Stop Hypertension; DPP4 = dipeptidyl peptidase 4; eGFR = estimated glomerular filtration rate; ER = extended release; FDA = Food and Drug Administration; GLP1 = glucagon-like peptide 1; HDL-C = high-density lipoprotein cholesterol; IMPROVE-IT = Improved Reduction of Outcomes: Vytorin Efficacy International Trial; LDL-C = low-density lipoprotein cholesterol; LDL-P = low-density lipoprotein particle; Look AHEAD = Look Action for Health in Diabetes; NPH = neutral protamine Hagedorn; OSA = obstructive sleep apnea; RCT = randomized controlled trial; SU = sulfonylurea; SGLT2 = sodium glucose cotransporter-2; SMBG = self-monitoring of blood glucose; T2D = type 2 diabetes; TZD = thiazolidinedione; VADT = Veterans Affairs Diabetes Trial

Section snippets

EXECUTIVE SUMMARY

This algorithm for the comprehensive management of persons with type 2 diabetes (T2D) was developed to provide clinicians with a practical guide that considers the whole patient, his or her spectrum of risks and complications, and evidence-based approaches to treatment. It is now clear that the progressive pancreatic beta-cell defect that drives the deterioration of metabolic control over time begins early and may be present before the diagnosis of diabetes (1). In addition to advocating

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A prospective, multicentre, randomized, open-label comparison of a long-acting basal insulin analog glargine plus glulisine with premixed insulin in insulin naïve patients with Type 2 diabetes – A study from India
2024, Primary Care Diabetes
We aimed to compare the effectiveness of Glargine plus Glulisine to premixed insulin analogue, as measured by HbA1c ≤ 7.0% in insulin naive Type 2 Diabetes (T2D) patients with elevated fasting and/or postprandial plasma glucose.
Insulin-naive T2D patients (116 men, 84 women) on ≥ 2 oral hypoglycemic agents with inadequate glycemic control were randomized either to group 1 (insulin Glargine plus Glulisine, n = 101) or group 2 (Premixed Insulin analogue, n = 99).
In the intention to treat analysis, at week 24, percentage of patients with good glycaemic control (HbA1c ≤ 7.0%) was similar between the two groups (16.8% in Group 1 vs. 13.1% in Group 2, χ2 – 0.535, p = 0.47). Significant reductions in fasting and postprandial levels were observed in groups 1 and 2 at both post-baseline time points (Week 12 and 24). In group 1, reduction in HbA1c from baseline to week 12 was 0.6 ± 0.1 and 0.7 ± 0.2 at week 24, p < 0.0001 for all. In group 2, no significant change in HbA1c was observed. In group 1, 83.2% required an additional dose of glulisine and in group 2, 88.9% required an additional dose of premixed insulin. Hypoglycemic events were similar in both groups (0.12 events per person-year in group 1 and 0.13 events per person-year in group 2). Weight gain was non-significant in both groups.
Glargine plus Glulisine, though in higher dose was effective as premixed insulin in lowering HbA1c. Hypoglycemic events per person-year were similar in both groups.
Novel gene-based therapeutic approaches for the management of hepatic complications in diabetes: Reviewing recent advances
2024, Journal of Diabetes and its Complications
Diabetes mellitus is a chronic metabolic disorder marked by hyperglycemia and systemic complications, including hepatic dysfunction, significantly contributing to disease progression and morbidity. This article reviews recent advances in gene-based therapeutic strategies targeting hepatic complications in diabetes, offering a promising approach for precision medicine by addressing underlying molecular mechanisms. Traditional treatments for hepatic complications in diabetes often manage symptoms rather than molecular causes, showing limited efficacy. Gene-based therapies are poised to correct dysfunctional pathways and restore hepatic function. Fundamental gene therapy approaches include gene silencing via small interfering RNAs (siRNAs) to target hepatic glucose production, lipid metabolism, and inflammation. Viral vectors can restore insulin sensitivity and reduce oxidative stress in diabetic livers. Genome editing, especially CRISPR-Cas9, allows the precise modification of disease-associated genes, offering immense potential for hepatic complication treatment. Strategies using CRISPR-Cas9 to enhance insulin receptor expression and modulate aberrant lipid regulatory genes are explored. Safety challenges in gene-based therapies, such as off-target effects and immune responses, are discussed. Advances in nanoparticle-based delivery systems and targeted gene editing techniques offer solutions to enhance specificity and minimize adverse effects. In conclusion, gene-based therapeutic approaches are a transformative direction in managing hepatic complications in diabetes. Further research is needed to optimize efficacy, safety, and long-term outcomes. Nevertheless, these innovative strategies promise to improve the lives of individuals with diabetes by addressing hepatic dysfunction's genetic root causes.
Plant-based and Early Time-restricted Eating for Prevention and Treatment of Type 2 Diabetes in Adults: A Narrative Review
2024, Canadian Journal of Diabetes
Type 2 diabetes (T2D) is a significant public health challenge for which effective lifestyle interventions are needed. A growing body of evidence supports the use of both plant-based eating patterns and early time-restricted eating (eTRE) for the prevention and treatment of T2D, but research has not yet explored the potential of these dietary strategies in combination. In this narrative review we assessed the evidence by which plant-based diets, in conjunction with eTRE, could support T2D care. The electronic databases MEDLINE and the Web of Science were searched for relevant articles published throughout the last decade. Observational research has shown that healthy plant-based eating patterns and eTRE are associated with reductions in T2D risk. Interventional trials demonstrated that plant-based diets promote improvements in glycated hemoglobin, insulin resistance, glycemic control, and cardiometabolic risk factors. These changes may be mediated, in part, by reductions in oxidative stress, dietary acid load, and hepatocellular and intramyocellular lipids. The eTRE strategies were also shown to improve insulin resistance and glycemic control, and mechanisms of action included enhanced regulation of circadian rhythm and increased metabolic flexibility. Integrating these dietary strategies may produce additive benefits, mediated by reduced visceral adiposity and beneficial shifts in gut microbiota composition. However, potential barriers to concurrent implementation of these interventions may exist, including social challenges, scheduling constraints, and tolerance. Prospective trials are needed to examine their acceptability and clinical effects.
Le diabète de type 2 (T2D) représente un défi significatif pour la santé publique nécessitant des interventions efficaces sur le mode de vie. Un corpus croissant de preuves soutient l'utilisation de régimes alimentaires à base de plantes et d'une alimentation précoce restreinte dans le temps (ARTp) pour la prévention et le traitement du DT2, mais la recherche n'a pas encore exploré le potentiel de ces stratégies diététiques en combinaison. Cet examen narratif a évalué les preuves que les régimes à base de plantes, en conjonction avec l'ARTp, pourraient soutenir le traitement du DT2. Les bases de données électroniques Medline et Web of Science ont été consultées à la recherche d'articles pertinents publiés au cours de la dernière décennie. La recherche observationnelle a montré que les habitudes alimentaires saines à base de plantes et l'ARTp sont associées à une réduction du risque de DT2. Des essais interventionnels ont démontré que les régimes à base de plantes favorisent l'amélioration de l'hémoglobine glyquée A1C, de la résistance à l'insuline, du contrôle de la glycémie et des facteurs de risque cardiométaboliques. Ces changements peuvent être médiés, en partie, par des réductions du stress oxydatif, de la charge acide alimentaire et des lipides hépatocellulaires et intramyocellulaires. Les stratégies d'ARTp ont également permis d'améliorer la résistance à l'insuline et le contrôle de la glycémie, avec des mécanismes d'action incluant une meilleure régulation du rythme circadien et une plus grande flexibilité métabolique. L'intégration de ces stratégies alimentaires pourrait produire des bénéfices additionnels, médiés par une réduction de l'adiposité viscérale et des changements bénéfiques dans la composition du microbiote intestinal. Cependant, il peut exister des obstacles potentiels à la mise en œuvre simultanée de ces interventions, notamment des défis sociaux, des contraintes de calendrier et la tolérance. Des essais prospectifs sont nécessaires pour examiner leur acceptabilité et leurs effets cliniques.
The prevalence of glycemic control in patients with type 2 diabetes treated with insulin: a systematic review and meta-analysis
2023, Public Health
To estimate the overall prevalence of glycemic control among patients with type 2 diabetes (T2D) treated with insulin.
Systematic review and meta-analysis.
A systematic search was performed in PubMed, EMBASE, Cochrane CENTRAL, and ProQuest Dissertation and Theses from 2000 to January 2022. Cross-sectional studies were included if they were conducted on more than 292 patients with T2D and reported the number of insulin-treated patients who were justified as achieving glycemic control. The Joanna Briggs Institute critical appraisal checklist was used to assess the quality of the included studies. Pooled estimates of the prevalence of glycemic control were calculated and reported with a 95% confidence interval (95% CI) using a random-effects model. All analyses were conducted using RStudio Version 2022.02.0, Build 443 (meta package).
A total of 42 studies (234,345 patients) met the inclusion criteria and were classified as having a low risk of bias. The overall estimated prevalence of glycemic control to insulin therapy among patients with T2D was 26.02% (95% CI: 23.17, 29.08). A subgroup of 34 studies that set the target HbA1c <7% showed that 23.75% (95% CI: 21.47, 26.18) of patients with T2D treated with insulin were justified as achieving good glycemic control.
This study provided summative evidence that glycemic control among patients with T2D treated with insulin was suboptimal and should be appropriately addressed.
American Association of Clinical Endocrinology Consensus Statement: Comprehensive Type 2 Diabetes Management Algorithm – 2023 Update
2023, Endocrine Practice
This consensus statement provides (1) visual guidance in concise graphic algorithms to assist with clinical decision-making of health care professionals in the management of persons with type 2 diabetes mellitus to improve patient care and (2) a summary of details to support the visual guidance found in each algorithm.
The American Association of Clinical Endocrinology (AACE) selected a task force of medical experts who updated the 2020 AACE Comprehensive Type 2 Diabetes Management Algorithm based on the 2022 AACE Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan and consensus of task force authors.
This algorithm for management of persons with type 2 diabetes includes 11 distinct sections: (1) Principles for the Management of Type 2 Diabetes; (2) Complications-Centric Model for the Care of Persons with Overweight/Obesity; (3) Prediabetes Algorithm; (4) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Dyslipidemia; (5) Atherosclerotic Cardiovascular Disease Risk Reduction Algorithm: Hypertension; (6) Complications-Centric Algorithm for Glycemic Control; (7) Glucose-Centric Algorithm for Glycemic Control; (8) Algorithm for Adding/Intensifying Insulin; (9) Profiles of Antihyperglycemic Medications; (10) Profiles of Weight-Loss Medications (new); and (11) Vaccine Recommendations for Persons with Diabetes Mellitus (new), which summarizes recommendations from the Advisory Committee on Immunization Practices of the U.S. Centers for Disease Control and Prevention.
Aligning with the 2022 AACE diabetes guideline update, this 2023 diabetes algorithm update emphasizes lifestyle modification and treatment of overweight/obesity as key pillars in the management of prediabetes and diabetes mellitus and highlights the importance of appropriate management of atherosclerotic risk factors of dyslipidemia and hypertension. One notable new theme is an emphasis on a complication-centric approach, beyond glucose levels, to frame decisions regarding first-line pharmacologic choices for the treatment of persons with diabetes. The algorithm also includes access/cost of medications as factors related to health equity to consider in clinical decision-making.
In Vivo Evaluation of Nanoemulsion Formulations for Metformin and Repaglinide Alone and Combination
2023, Journal of Pharmaceutical Sciences
Repaglinide and Metformin are used to treat Type 2 diabetes. Repaglinide with poor water solubility has relatively low oral bioavailability (56%) and undergoes hepatic first-pass metabolism. The oral bioavailability of metformin HCl is also low (about 50-60%). The purpose of this study was to prepare nanoemulsion formulations containing metformin HCl or repaglinide alone or in combination and characterize them in vitro and in vivo. Nanoemulsion formulations containing metformin HCl and/or repaglinide were successfully prepared and in vitro characterized. In addition, in vivo efficacy of nanoemulsion formulations was evaluated in a streptozotocin-nicotinamide-induced diabetic rat model. Biochemical, histopathological, and immunohistochemical evaluations were also performed. The mean droplet size and zeta potential values of nanoemulsion formulations were in the range of 110.15±2.64-120.23±2.16 nm and -21.95 – -24.33 mV, respectively. The percent entrapment efficiency values of nanoemulsion formulations were in the range of 93.600%-96.152%. All nanoemulsion formulations had a PDI of ≤0.223. A statistically significant decrease was observed in the blood glucose values of the diabetic rats treated with nanoemulsion formulations containing active substance/substances, compared to diabetic rats (control) (p<0.05). Nanoemulsion formulations (especially nanoemulsion containing metformin HCl and repaglinide combination) have a better antidiabetic activity and are more effective in reducing oxidative stress caused by diabetes.

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This document represents the official position of the American Association of Clinical Endocrinologists and American College of Endocrinology. Where there were no randomized controlled trials or specific U.S. FDA labeling for issuesin clinical practice, the participating clinical experts utilized their judgment and experience. Every effort was made to achieve consensus among the committee members. Position statements are meant to provide guidance, but they are not to be considered prescriptive for any individual patient and cannot replace the judgment of a clinician.

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AACE/ACE Consensus StatementConsensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2018 Executive Summary

ABSTRACT

Section snippets

EXECUTIVE SUMMARY

Endocr Pract

Am J Clin Nutr

Addict Behav

Clin Geriatr Med

Can J Diabetes

Endocr Pract

Endocrine Pract

Endocr Pract

Endocr Pract

Lancet

Am J Clin Nutr

Am J Clin Nutr

Lancet

Lancet

Lancet

Endocr Pract

Endocr Pract

Lancet

Lancet

Lancet

Lancet

Beta-cell deficit and increased beta-cell apoptosis in humans with type 2 diabetes

Diabetes

One-year weight losses in the look ahead study: Factors associated with success

Obesity (Silver Spring)

Reduction in weight and cardiovascular disease risk factors in individuals with type 2 diabetes: One-year results of the look ahead trial

Diabetes Care

Impact of intensive lifestyle and metformin therapy on cardiovascular disease risk factors in the diabetes prevention program

Diabetes Care

Prevention of diabetes through the lifestyle intervention: Lessons learned from the diabetes prevention program and outcomes study and its translation to practice

Curr Nutr Rep

Nutrition therapy recommendations for the management of adults with diabetes

Diabetes Care

Adjust to target in type 2 diabetes: Comparison of a simple algorithm with carbohydrate counting for adjustment of mealtime insulin glulisine

Diabetes Care

Meal replacements for weight loss in type 2 diabetes in a community setting

J Nutr Metab

Metabolic and weight loss effects of long-term dietary intervention in obese patients: Four-year results

Obes Res

Behavioral choice treatment promotes continuing weight loss: Preliminary results of a cognitive-behavioral decision-based treatment for obesity

J Consult Clin Psychol

An evaluation of a television-delivered behavioral weight loss program: Are the ratings acceptable?

J Consult Clin Psychol

Effects of four maintenance programs on the long-term management of obesity

J Consult Clin Psychol

A randomized trial of improved weight loss with a prepared meal plan in overweight and obese patients: Impact on cardiovascular risk reduction

Arch Intern Med

Clinical practice guidelines for healthy eating for the prevention and treatment of metabolic and endocrine diseases in adults: Cosponsored by the American Association of Clinical Endocrinologists/the American College of Endocrinology and the Obesity Society

Endocr Pract

Effects of different modes of exercise training on glucose control and risk factors for complications in type 2 diabetic patients: A meta-analysis: Response to snowling and hopkins

Diabetes Care

Low-intensity exercise reduces the prevalence of hyperglycemia in type 2 diabetes

Med Sci Sports Exerc

Continuous low- to moderate-intensity exercise training is as effective as moderate- to high-intensity exercise training at lowering blood hba(1c) in obese type 2 diabetes patients

Diabetologia

Influence of acute exercise on hyperglycemia in insulin-treated type 2 diabetes

Med Sci Sports Exerc

Exercise training improves glycemic control in long-standing insulin-treated type 2 diabetic patients

Diabetes Care

Effects of aerobic and resistance training on hemoglobin a1c levels in patients with type 2 diabetes: A randomized controlled trial &lsqb;erratum in JAMA. 2011;305:892]

JAMA

Effect of an intensive exercise intervention strategy on modifiable cardiovascular risk factors in subjects with type 2 diabetes mellitus: A randomized controlled trial: The italian diabetes and exercise study (IDES)

Arch Intern Med

Exercise and type 2 diabetes: The American College of Sports Medicine and the American Diabetes Association: Joint position statement executive summary

Diabetes Care

Sleep duration predicts cardiovascular outcomes: A systematic review and meta-analysis of prospective studies

Eur Heart J

Association between reduced sleep and weight gain in women

Am J Epidemiol

Association of usual sleep duration with hypertension: The Sleep Heart Health Study

Sleep

Short sleep duration is associated with reduced leptin levels and increased adiposity: Results from the Quebec family study

Obesity (Silver Spring)

A prospective study of sleep duration and coronary heart disease in women

Arch Intern Med

Role of snoring and daytime sleepiness in occupational accidents

AACE/ACE Consensus Statement
Consensus Statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the Comprehensive Type 2 Diabetes Management Algorithm – 2018 Executive Summary

Effects of aerobic and resistance training on hemoglobin a1c levels in patients with type 2 diabetes: A randomized controlled trial [erratum in JAMA. 2011;305:892]