Our Meeting about the AACE Algorithm

The PDF is currently available here.

Note:  If you have not downloaded the algorithm from the AACE site, you may not be able to now.  In trying to establish links for this blog, I was receiving the following message - "AACE Members can view the NEW COMPREHENSIVE DIABETES MANAGEMENT ALGORITHM FOR TREATMENT OF DIABETES AND PREDIABETES PATIENTS."  along with site address for members.  This tells me that they have been taken to task and many people are unhappy with their algorithm.

Our group had many emails about the algorithm when it appeared and several wanted to have a meeting about it, as they were not following it. Brenda asked how many would be able to attend and then said we should have it at her place. Ten of us attended and with Tim's digital projector, we all had good seats. Max and Rob had the main questions, as they were not following the progress of the algorithm.

Because Tim had requested them to bring a pad of paper and complete beforehand their body mass index (BMI), their ideal weight, and list their other medical problems we were ready to go. Other medical problems include, blood pressure, cholesterol, any of the complications, and comorbid conditions they know they have. I knew that this part could get personal, therefore I opened by saying that I was asking everyone to be honest with themselves, but if they felt it necessary to keep information from the rest of us, that was their business.

I had expected to have someone qualify under the BMI of 25 to 26.9, but no one did without having one qualifier to drive them into the complications side. On that side, only two of us had BMIs greater than 27. Now we needed to look to the last page. I knew then that we had a problem. Except for Max and I, none of the rest qualified for the algorithm. Everyone else had BMIs under 25. Looking at the algorithm, they did not fit the examples or the usage. In addition, all of us were on insulin and that did not compute for the flow of the algorithm. Even Max and I have A1c's below the target of the algorithm. Max's latest is 6.1% and my latest is 6.3%. Everyone else is below 6.0% with Sue having the current lowest at 5.2%.

Okay, I know. The algorithm is for newly diagnosed patients and creates an entry point. Still, this could drive doctors crazy. Even at that, I knew I would have to use hypothetical examples. I selected a man with blood pressure and cholesterol problems with a BMI of 33. I added that his A1c was 9.8% at diagnosis. Moving forward we determined that he probably would fit the “medium” or “high” stage severity of complications. We chose “medium” for the example. This would mean that this person would follow the arrow down and have the MD/RD counseling, and next have the medication therapy.

Since this person had diabetes, the Prediabetes Algorithm is bypassed. At the Goals for Glycemic Control we would need to follow the A1c greater than 6.5% box and this person's goals would be individualized. This is where people were having problems so we continued to the Glycemic Control Algorithm. With the diagnosis A1c of 9.8% and two complications, this person would continue at the far right side. This would mean a weight loss pill, basal insulin (long acting), and two or three oral medications.

Although not stated on this page, point 9 on the last page does verify that this person has three months to improve or go to “add or intensify insulin. What is not said is if this person is able to bring the A1c down below 6.5%, it does not say which direction the person would go. The other factor is the BMI which does not give a clue about what medication factor the person would b e taking.

Point 9 on page 10 of the algorithm is a long point, but basically says everything affecting diabetes is in play. Effectiveness of therapy must be evaluated frequently (every three months) until stable using multiple criteria. This includes A1c, SMBG records including fasting and post-prandial data, documented and suspected hypoglycemia, and monitoring for other potential adverse events (weight gain, fluid retention, hepatic, renal, or cardiac disease). The following is to be monitored, co-morbidities, relevant laboratory data, concomitant drug administration, diabetic complications, and psycho-social factors affecting patient care.

The group discussed this and felt that the person would start on the left side of the algorithm and proceed down that side. And then to the next page for the CVD (cardiovascular disease) Risk Factor Modifications Algorithm. Going through this example cleared many of the questions. The group felt that somehow we were the lucky ones and had been allowed to set our own goals and work toward them with help from the rest of the group.

Allen said that he now understood why I was so negative about the algorithm in my first blog here. Brenda chimed in that she agreed with my first blog and wondered why the authors were so shortsighted in so many areas. John said now he understood why I commented on so many points missing and why the authors are so sure that prediabetes and even diabetes can't be stopped in its tracks and not become progressive. He continued that this is probably the most depressing set of guides he has seen. It is as if they want people to go from prediabetes to diabetes and stuff them full of medications when people are able to manage prediabetes and diabetes and stop taking medications. The authors do not even make allowances for this and left this out of the notes.

Max said they don't even allow for people to switch to a full regimen of insulin like we were able to do. He added it will be interesting talking to our endocrinologists at our next appointment. 

Tim said he would send out notes and thanked me for working with him to get the information captured and into a Powerpoint presentation. Brenda thanked both of us and the presentation really brought home the good points and the not so great items.

Everyone wanted to hear about the projector Tim had used, so the meeting was adjourned. Tim said he had it on loan and that he was thinking about investing in one for himself and using it for our meetings. Brenda asked why the other four were missing and Allen said they had other commitments, but they were going to be sorry after what Tim had used. Tim said he is short on the amount necessary to purchase one for himself, but in another few months it may be possible. He then said that the one he had on loan would be available several more months.

Rob asked how difficult it was to capture the images we had used. I said I have a program that is a few versions older than the latest, but that it works for our needs. I said if someone has something for a program that can be made into images, that I would do it beforehand like I did for this and have them saved to a Powerpoint presentation and sent as an attachment to the person and to Tim. Tim said it does take some time because of all the capture and proofing, so don't wait until the night before the meeting. I told Tim thank you and said that operator inefficiencies are to blame. I used to be able to do this easily, but since that was on a version older than I have now, I am still learning the update. Max asked who had it and I said I would email the information to those that wanted it.

Diabetes Guidelines You Can't Avoid

In diabetes it is not what the patient wants, but what the doctor can command and bully his way into making the patient do. Now the American Association of Clinical Endocrinologists (AACE) has developed another way, an algorithm this time, to force, where possible, patients into submission. Much of what is shown in the layout of the algorithm is aimed at convincing the patient to follow their doctor's wishes and desires. How else will they, the doctors, meet their goals? I wonder how soon this will be put into effect. The algorithm is available herehttps://www.aace.com/publications/algorithm in PDF format.

Following the Table of Contents, the first page is – Complications-Centric Model for Care of the Overweight/Obese Patient. They start the information off with Step 1 - evaluation for complications and staging. This is not a nice way of saying how we are to be treated. Step 2 is treatment options where only three options are allowed – lifestyle modification, medical therapy, and surgical therapy (a must if body mass index is equal to or greater than 35) They will push medication on top of medication in the medical therapy and insulin is one of those mentioned when we exhausted our options with the oral medications. They leave no doubt that surgical procedures will be sought for BMI's over the limit.

Step 3 is where they may actually dismiss us as patients as they state, “If therapeutic targets for improvements in complications not met, intensify lifestyle and/or medical and/or surgical treatment modalities for greater weight loss.” Apparently, diabetes patients will no longer have a choice and must be made compliant.

The next page is the Prediabetes Algorithm. In searching the page, they do not allow patients to stay off of medications or start and then wean themselves off medications. The assumption is that prediabetes will progress to diabetes. There is one improvement and that is the use of metformin for those at low risk. Maybe now we will see some action by Medicare and insurance. The counter to this is multiple medications when fasting plasma glucose is greater than 100 mg/dl with two-hour plasma glucose greater than 140 mg/dl.

The next page covers - Goals for Glycemic Control. They leave no doubt about where they are coming from and what they will be setting for their patients. If you are a compliant healthy patient without concurrent illness and at low hypoglycemic risk, you will be allowed to have an A1c of 6.5% or lower. If on the other side (greater than 6.5%), they will individualize goals for patients with concurrent illness and at risk for hypoglycemia.

On the next page, we come to what should make anyone with diabetes nervous. The page is titled Glycemic Control Algorithm. It is further subtitled Lifestyle Modification (Including Medically Assisted Weight Loss). So not to forget, they are supposedly talking about a couple of the weight loss medications approved by the FDA. Still in my mind, this should be classified as medication weight loss therapy and not medically assisted weight loss. This sounds more like surgery than medication therapy.

There are three entry A1c listings - 1) A1c that is less than 7.5%, 2) A1c that is equal to or greater than 7.5%, and 3) A1c greater than 9.0%. 1) above starts out as Monotherapy. Metformin is listed first, but they also list several others and even some that should be used with caution because of studies lately that show problems affecting the heart and other side effects. The bottom should raise alarm bells as you are only given three (only three) months to show improvement, or you will be moved to Dual therapy. Here basal (long acting insulin) may be part of the therapy, but this is supposed to be done with caution.

If you don't show improvement in dual therapy by the end of three months, you are to be moved to Triple therapy. This means three oral medications and with the order of suggested usage, they are going with oral medications that should be used with caution or basal insulin. If you don't succeed in three months here, you are to be moved to insulin therapy and oral medications.

Now look at 2) above. Here you will start on Dual therapy and if no improvement in three months, you move to Triple therapy. If you don't succeed on triple therapy in three months, insulin therapy is up next. If you started at 3) above, then if you have no symptoms (probably meaning no complications or concurrent illness) you may start at Dual therapy if your A1c is under 8.0%, otherwise you may start at Triple therapy and this is when basal insulin is recommended in Dual or Triple therapy. Now if you have symptoms, then you are to start on basal insulin and other oral medications as necessary.

The page following this is – Algorithm for Adding/Intensifying Insulin. The left side of the page is for basal (long-acting insulin) and not using sulfonylureas but other oral medications. I will not get into the titration part. That is between you and your doctor. On the right side is more intensifying of oral medications and adding prandial (mealtime) insulin (or short- or rapid- acting insulin).

The last three pages discuss cardiovascular disease (CVD) risk factor modifications algorithm, profiles of antidiabetes medications. I was surprised that for the most part, the page is right on. For comparison on most, use the different inserts here for each medication. The cardiovascular page discusses statins and blood pressure lowing medications.

The last page summarizes the guiding principles for the algorithms. I some ways this is difficult to swallow as it explains the importance of a lifestyle modification, the individualization of treatments, and their targets. The minimization of weight gain and hypoglycemia are worthy discussions.

I summary, I am surprised at what is not included. This would be exercise (covered in a blog by Tom Ross) and allowing patients to start without medications or using medications for bringing prediabetes and diabetes under excellent management and then weaning off medications as lifestyle goals are met. No mention is made of working at the prediabetes level of lifestyle changes to prevent the onset of type 2 diabetes.  Also missing is the option for those patients wanting off oral medications and onto the full insulin therapy.  Apparently this is not allowed under the algorithm.   For these reasons, I feel strongly that the algorithm is shortsighted and presents a defeatist attitude.

As a patient, I am very concerned about how they feel that diabetes is progressive and they offer no hope of people preventing this. One article about the algorithm may be read here and another here.