Joslin SEEMS a Fan of AACE Algorithm

It seems that we are going to be continually bombarded with the American Association of Clinical Endocrinologists (AACE) Diabetes Algorithms. This time it is the Joslin Diabetes Center trumpeting the algorithms. The author of the Joslin blog tells us what we know and that is that the algorithms are for practitioners, both the endocrinologists and primary care physicians (PCPs). And yes, most people with diabetes are cared for by a primary care physicians, but that means they will have one diabetes medication stacked on another.

If things hold true, many of the diabetes patients will be kept on oral medications for too long a time as A1c's rise. The algorithms recommend moving to insulin, but many PCPs are very hesitant to move diabetes patients to insulin because they are also afraid of hypoglycemia.

I admit that the following statement by the Joslin blog author has me concerned and wondering why they are agreeing that diabetes is progressive. “They also place greater emphasis on the use of medication early in the pre-diabetes stage of the disease. Including medications as a concomitant part of treatment from the beginning, acknowledges both the difficulty of lifestyle therapy and the progressive nature of the disease.” This disagrees with the statement of Dr. Anne Peters from the University of Southern California, “The authors have eliminated hemoglobin A1c as part of the diagnostic criteria for prediabetes and don't describe in much detail how to decide when to treat somebody with prediabetes. There is no current US Food and Drug Administration-approved medication for the treatment of prediabetes.”

This tells me that Joslin is not afraid to use diabetes medications “off label” and with metformin being economical, this may be acceptable, as most insurance companies will not reimburse for pre-diabetes medications. The fact that Joslin considers diabetes progressive should concern every patient at Joslin, and especially if you are working to prevent progression to complications.

Joslin also apparently follows the American Diabetes Association guideline of 7% as the ideal A1c level and this also indicates that they consider diabetes progressive and that there is no means to prevent this – how very depressing. I can agree with the statement that A1c needs to be individualized for the elderly that are having other disease or comorbid problems, but they don't say this. They only say the target A1c needs modification based on individual risk factors and circumstances. Then the blog concludes with the statement, “Prevention of hypoglycemia is paramount when developing a treatment strategy for patients.”

There are so many issues left unsaid and others that are hinted at, that one needs to wonder who sets policies at Joslin and then if anyone follows these policies, if any exist. In the last few months, more conflicting comments have appeared in Joslin's blogs and in other sources. Then they refuse to identify the person writing the blog by saying the blog is by Joslin Communications.

Discussion on the AACE Algorithm Shortcomings

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.

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