The American Association of Clinical
Endocrinologists (AACE) diabetes algorithm has been out about two
months and in my meetings with different doctors that have diabetes
patients, acceptance is less than favorable. One doctor even said he
would not be using the Garber algorithms – calling them too
restrictive. Two other doctors just stated they preferred the
American Diabetes Association guidelines. Some doctors (four) have
refused talking to me and several (six) would only make comments
through their staff. All six were very negative about the
algorithms. Even my own diabetes clinic will be using parts of it
and using the ADA guidelines in most cases.
After our group meeting on the
algorithm, we have tried to expand on the items not covered by the
AACE algorithm. We may be mistaken or reached a little, but the
following is the list we have come up with. The first items are
definitely missing and what we see as patients.
#1. We agree with Wil Dubois that
depression or a person's psychological state was totally ignored and
we have to wonder if they were truly thinking about the patient.
#2. When Tom Ross listed exercise in
his blog, we could not help but agree with him. Apparently, they
don't consider exercise as a lifestyle change deserving attention.
#3. Apparently not starting on
medications is not an option for these “experts” as this was not
even mentioned.
#4. To go along with number 3 above,
there is no provisions made for starting on medications and when
lifestyle changes show excellent management, allowing the patient to
stop taking medications.
#5. We all agreed that the “experts”
had passed on prevention during prediabetes or even during early
onset of type 2.
#6. We also were in agreement that
they felt from prediabetes through diabetes that the “experts”
were declaring diabetes as progressive and even the complications
could not be prevented. This no hope attitude is depressing by
itself.
#7. On the cardiovascular algorithm
page, no alternatives for changes to prevent taking statins and blood
pressure medications or circumstances of stopping them.
#8. There is very little clinical
research available to support proper treatment of the elderly and the
young. Therefore, for the majority of people with type 2 diabetes,
it is still guesswork with no clinical evidence to support clear
treatment paths for the elderly. This is ignored by the algorithms..
#9. The final point that was evident
to us was no route to stop oral drugs and go directly to full insulin
therapy. There could be a lot of medical reasons for this to happen,
but the “experts” chose to ignore this
The next points are by Anne L. Peters,
MD, CDE, Professor of Clinical Medicine; Director, Clinical Diabetes
Programs, Keck School of Medicine, University of Southern California,
Los Angeles, California. Dr. Peters is well qualified to make the
statements she makes. She does carefully word one point, but implies
that the algorithm is not as peer-reviewed or vetted as other
guidelines. She was involved in the ADA/EASD (European Association
for the Study of Diabetes) guidelines published in April 2012 and
knows the process they went through for approval.
Her list of shortcomings includes the
following:
#1. This algorithm is somewhat
confusing without text.
#2. The authors have eliminated
hemoglobin A1c as part of the diagnostic criteria for prediabetes.
#3. The authors don't describe in much
detail how to decide when to treat somebody with prediabetes.
#4. The algorithms go through profiles
of the different anti-diabetic agents, but they don't include costs.
In many practice situations, cost becomes important and is something
we need to consider, particularly as we look at the burden that we
are giving our patients with these different medications, some of
which cost a lot.
#5. Then they suggest adding prandial
insulin, but it is added in 3 split doses before breakfast, lunch,
and dinner in a 50/50 ratio between basal and bolus insulin. (My
note:) This means generally that the same number of carbs are
consumed at each meal.
#6. They didn't list the practice
settings of the authors or disclose any of the potential conflicts of
interest. That is important to know as we try to make sense of where
these algorithms came from and how they were developed.
#7. Individualizing targets is
important, particularly in patients with longer-duration disease,
more comorbid conditions, and increased risk for serious sequelae of
severe hypoglycemia.
When Dr. Alan J. Garber, AACE task
force chair, states, "The word that describes it is truly
comprehensive," I would be in disagreement with him and say it
is far from comprehensive for the medical community and the patient
community. The algorithms are aimed at the patient, set targets for
the patient, and put the patient in the algorithms with no hope of
escape. Individual management of diabetes is prohibited and the
patients are supposed to be compliant according to Dr. Garber. How can we follow doctors orders precisely when the doctor
has almost no supporting clinical evidence, especially for the young and the elderly.
To this, I say BS and let him keep his
algorithms. I want a doctor that will work with me, individualize
my progress, and assist me when I hit an area that is causing me
problems. I wish to choose my management priorities with guidance
from my doctor and not some restrictive algorithms.
If you have not read them and wish to
read them, you may download the PDF file by clicking on this link.
This will allow you to download the PDF file or the Power Point Presentation format.
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