The American Association of Clinical Endocrinologists (AACE) and the College of Endocrinology (ACE) released online a one-page resource for physicians and healthcare providers for the management of glycemic control in type 2 diabetes.

"Depending on a patient's current A1C level, a physician will use the algorithm to determine whether a mono-, dual-, or triple combination therapy should be considered," Dr. Helena Rodbard, former AACE president and Co-Chair of the Algorithm Task Force said in a press release. "To minimize the risk of diabetic complications, the algorithm will help achieve a hemoglobin A1C value of 6.5 or less when appropriate."

The algorithm (a simple flowchart) starts with lifestyle modification, such as exercise and diet, as the primary impacting factor on a patient's health. Then depending on hemoglobin A1c levels, physicians can use the flow chart to determine if a single medication, dual medications, or a triple-combination therapy should be prescribed.

The algorithm, which was developed by a group of leading endocrinologists, prioritizes medications according to a number of factors. These factors include risk of hypoglycemia, efficacy, simplicity, and anticipated degree of patient adherence. It is based on the AACE/ACE Diabetes Guidelines and recent medical literature.  

The algorithm goes something like this:

If A1c levels were between 6.5 - 7.5% at diagnosis, you would probably be started on a monotherapy (single medicine): either metformin, a thiazolinedione, a DPP-4 inhibitor, or an alpha-glucosidase inhibitor. If that didn't do the trick in maintaining glycemic control after two or three months, you might be moved on to dual therapy. Dual therapy means metformin would be prescribed in addition to a thiazolinedione, a DPP-4 inhibitor, or an alpha-glucosidase inhibitor.

If A1c levels were between 7.6 - 9.0% at diagnosis, you would be started on dual therapy of metformin plus one of the above monotherapies. If blood glucose control were not achieved in two or three months, triple combination therapy would be next. An example of a triple combination therapy would be metformin plus a DPP-4 inhibitor plus a thiazolidinedione.

If A1c levels were above 9.0% at diagnosis and you had symptoms, you would be started on insulin. If you had no symptoms, you would be prescribed a triple combination therapy as described above.

You can view the AACE Glycemic Control Algorithm here.

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Sources:

http://media.aace.com/article_display.cfm?article_id=4935

Consensus statement

http://www.aace.com/pub/pdf/GlycemicControlAlgorithm.pdf

Algorithm

http://www.aace.com/pub/pdf/GlycemicControlAlgorithmPPT.pdf