In addition to BP control, early and intensive management of dyslipidemia is key to preventing macrovascular complications in T2D. The AACE recommends the following lipid targets for patients with T2D, stratified by risk for atherosclerotic cardiovascular disease (ASCVD).

· High risk, defined as T2D with no additional risk factors

o   Low-density lipoprotein cholesterol (LDL-C) <100 mg/dL

o   Non-high-density lipoprotein cholesterol (non-HDL-C) <130 mg/dL

o   Apolipoprotein B <90 mg/dL

· Very high risk, defined as T2D with ≥1 additional risk factor

o   LDL-C <70 mg/dL

o   Non-HDL-C <100 mg/dL

o   Apolipoprotein B <80 mg/dL

· Extreme risk, defined as T2D plus prior ASCVD or chronic kidney disease (stage 3 or 4)

o   LDL-C <55 mg/dL

o   Non-HDL-C <80 mg/dL

o   Apolipoprotein B <70 mg/dL

If patients do not meet these targets, the AACE recommends intensifying lifestyle therapy and glycemic control. Therapeutic success should be measured through focused laboratory evaluations and patient follow-up.

Pharmacology

To reach an HbA1c target ≤6.5% with monotherapy, the hierarchy for medication usage as recommended by the AACE is as follows: metformin, glucagon-like peptide-1 (GLP-1) receptor agonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors, dipeptidyl peptidase 4 (DPP-4) inhibitors, thiazolidinediones, and alpha-glucosidase inhibitors. Monotherapy should be initiated in patients with a baseline HbA1c of <7.5% and increased to dual therapy if targets have not been achieved within 3 months. With more severe cases and comorbidities, intensified therapy is indicated.

As part of the 2019 update, the AACE/ACE algorithm includes a summary of antidiabetic medications to outline risk and benefits for each drug class. Below is an overview of this summary highlighting the benefits and possible contraindications or adverse effects in several diabetes drug classes.

AgentPossible benefitsAdverse effects
MetforminSlight weight loss· Contraindicated in patients with estimated glomerular filtration rates <30 mL/minute/1.73 m2
· Use with caution in patients with gastrointestinal symptoms
GLP-1 receptor agonists· Weight loss
· Liraglutide may have benefits in patients with renal complications
· Liraglutide is approved by the FDA for the prevention of major adverse cardiac events
· Exenatide not indicated in patients with creatinine clearance <30 mL/minute
· Use with caution in patients with gastrointestinal symptoms
SGLT2 inhibitors· Weight loss
· Empagliflozin may have benefits in patients with renal complications
· Empagliflozin is approved by the FDA to reduce cardiovascular mortality
· Canagliflozin has been shown to reduce major adverse cardiac events
· Not indicated for patients with estimated glomerular filtration rates <45 mL/minute/1.73 m2
· May cause genital mycotic infections
· Mild risk for fracture
· Risk for diabetic ketoacidosis in various stress settings
DPP-4 inhibitors Alogliptin and saxagliptin may carry increased risk for hospitalizations for heart failure
Alpha-glucosidase inhibitors Use with caution in patients with gastrointestinal symptoms
ThiazolidinedionesMay reduce risk for stroke· Slight weight gain
· Moderate risk for coronary heart failure
· Moderate risk for fracture
Sulfonylureas · Moderate to severe risk for hypoglycemia
· Weight gain
· Heightened risk for hypoglycemia in patients with renal complications
· May carry risk for ASCVD
Insulin · Moderate to severe risk for hypoglycemia
· Weight gain
· Heightened risk for hypoglycemia in patients with renal complications
· Risk for coronary heart failure

To download the entire visual algorithm, click here.

Some authors declared associations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

Reference

Garber AJ, Abrahamson MJ, Barzilay JI, et al. Consensus statement by the American Association of Clinical Endocrinologists and American College of Endocrinology on the comprehensive type 2 diabetes management algorithm – 2019 Executive Summary. Endocr Pract. 2019;25(1):69-100.

This article originally appeared on Endocrinology Advisor