The latest type 2 diabetes (T2D) management guidance from the American Association of Clinical Endocrinology (AACE) covers newer diabetes medications, comorbidities, and — for the first time — diabetes classification.

“The task force members felt that it’s a type 2 algorithm, so we need to really make sure it’s type 2 diabetes. There are lots of data showing that people are missed,” writing panel vice-chair Priyathama Vellanki, MD, told Medscape Medical News.

In addition, the new consensus statement algorithm has “an emphasis on a complications- and comorbidities-centric approach, beyond glucose levels,” she said.

Published in Endocrine Practice, the document updates AACE’s 2023 T2D treatment algorithm with evidence from multiple recent randomized clinical trials that have supported new indications for glucose-lowering medications.

“Since the publication of the last algorithm, there have been new studies on diabetes drugs that affect comorbidities, such as heart failure and cardiovascular disease, as well as metabolic dysfunction-associated steatotic liver disease and obstructive sleep apnea,” said Vellanki, associate professor of endocrinology at Emory University School of Medicine and section chief of endocrinology at Grady Health System, Atlanta.

“There have also been new approvals from the FDA as well for these newer diabetes medications for other comorbidities. So that’s why we had to update,” she added.

Overall Principles

The document provides 11 colorful graphic algorithms, with the first one listing these overall principles:

• Lifestyle modification is the foundation for all therapy.
• Use a comprehensive approach for weight loss to achieve clinical goals.
• Choice of pharmacologic therapy is guided by glycemic targets and comorbidities.
• Choice of therapy considers ease of use and access.
• Individualize glycemic targets.
• Optimal A1c is ≤ 6.5% (48 mmol/mol) or as close to normal as is safe and achievable.
• Avoid therapeutic inertia and get to the goal as soon as possible.
• Avoid hypoglycemia.
• Continuous glucose monitoring is highly recommended to reach glycemic goals in adults with diabetes.
• Comorbidities and complications must be managed for comprehensive care.

Subsequent algorithms cover prediabetes and diabetes classification and provide steps for risk reduction for dyslipidemia, hypertension, “comorbidities- and complications-centric glycemic control,” and “glucose-centric glycemic control.” Each begins with lifestyle interventions before outlining factors to consider with pharmacologic intervention. 

“We really wanted to emphasize looking for the complications. Take an agent that works on that first, then you still need glycemic control,” Vellanki explained. 

Another graphic guides insulin initiation and titration, followed by two profile charts of pharmacotherapy, one for T2D and the other for obesity. Access/cost for each of the drugs is included in both, represented graphically with $, $$, and $$$ designations. 

“We were very cognizant of the fact that our 2023 guideline was downloaded all over the world. We wanted to make the algorithm applicable in several settings, so we put in cost as a consideration,” said Vellanki.

A final graphic covers vaccination recommendations for adults with diabetes, and two additional tables list atherosclerotic cardiovascular risk calculators and statin therapies, respectively.

A Quick Visual Guide

Asked to comment on the publication, Tracey McLaughlin, MD, endocrinologist and professor of medicine at Stanford University School of Medicine, Palo Alto, California, told Medscape Medical News, “I think it is terrific,” noting that in addition to including the new clinical trial information and consideration of comorbidities, “the algorithms also specify, within the new class of incretin therapies, which one has the strongest evidence for each [comorbidity].” 

And, McLaughlin noted, “The figures are very easy to follow. Overall, I think these will be widely adopted by clinicians and will have a positive impact in helping clinicians choose the treatment algorithms in a more personalized approach based on solid evidence for health benefits.”

Vellanki advised that clinicians keep the graphics visible, particularly the medication lists. “It’s always helpful to have those pinned up in your clinic. It was meant to be a quick guide.”

Vellanki reported consulting for Eli Lilly and holding stock in Astellas Pharmaceuticals. McLaughlin reported consulting for Dexcom, Regeneron, Amylyx, and Novo Nordisk; has received research grants from Lilly, Vogenyx, Weight Watchers, Recordati, and Merck; and is a stockholder and scientific advisory board member at January AI.

Miriam E. Tucker is a freelance journalist based in the Washington, DC area. She is a regular contributor to Medscape, with other work appearing in the Washington Post, NPR’s Shots blog, and Diatribe. She is on X @MiriamETucker and BlueSky @miriametucker.bsky.social.