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What Updates Are in the 2023 American Association of Clinical Endocrinology Type 2 Diabetes Algorithm?

  • Authors: News Author: Miriam E. Tucker; CME Author: Laurie Barclay, MD
  • CME / ABIM MOC / CE Released: 6/9/2023
  • Valid for credit through: 6/9/2024, 11:59 PM EST
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Target Audience and Goal Statement

This activity is intended for diabetologists/endocrinologists/metabolism clinicians, family medicine/primary care clinicians, internists, nurses, pharmacists, physician assistants, and other members of the healthcare team for patients with type 2 diabetes mellitus.

The goal of this activity is for members of the healthcare team to be better able to describe recommendations for comprehensive type 2 diabetes mellitus management, based on the updated 2023 American Association of Clinical Endocrinology consensus statement.

Upon completion of this activity, participants will:

  • Assess the overall principles for type 2 diabetes mellitus management, based on the updated 2023 American Association of Clinical Endocrinology consensus statement
  • Evaluate recommendations for management of adiposity-based chronic disease, based on the updated 2023 American Association of Clinical Endocrinology consensus statement
  • Outline implications for the healthcare team


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News Author

  • Miriam E. Tucker

    Freelance writer, Medscape


    Miriam E. Tucker has no relevant financial relationships.

CME Author

  • Laurie Barclay, MD

    Freelance writer and reviewer
    Medscape, LLC


    Laurie Barclay, MD, has no relevant financial relationships.

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  • Leigh Schmidt, MSN, RN, CNE, CHCP

    Associate Director, Accreditation and Compliance, Medscape, LLC


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  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance, Medscape, LLC


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What Updates Are in the 2023 American Association of Clinical Endocrinology Type 2 Diabetes Algorithm?

Authors: News Author: Miriam E. Tucker; CME Author: Laurie Barclay, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 6/9/2023

Valid for credit through: 6/9/2024, 11:59 PM EST


Clinical Context

The first American Association of Clinical Endocrinology (AACE) algorithm for glycemic control was published in 2009, when thiazolidinediones, alpha-glucosidase inhibitors, metformin, and sulfonylureas/glinides were in use, with the addition of exenatide and dipeptidyl peptidase-4 inhibitors. The 2013 update included new sections on management of overweight/obesity, dyslipidemia, and hypertension, with yearly revisions through 2020.

The 2023 algorithm update includes new management approaches aligning with the 2022 AACE type 2 diabetes mellitus clinical practice guideline. It still emphasizes lifestyle modification and overweight/obesity treatment as key pillars in prediabetes/type 2 diabetes mellitus management and now includes a complication-centric approach.

Study Synopsis and Perspective

The latest AACE type 2 diabetes management algorithm uses graphics to focus on individualized care while adding newly compiled information about medication access and affordability, vaccinations, and weight loss drugs.

The clinical guidance document was presented May 5 at the AACE Annual Meeting 2023 in Seattle, Washington, and simultaneously published in Endocrine Practice.[1]

Using text and colorful graphics, the document summarizes information from last year’s update and other recent AACE documents, including those addressing dyslipidemia and use of diabetes technology.[2-4]

“The algorithm takes from the larger clinical practice guideline and distills down those management principles in a much more digestible way, and a way that can be used every day in the clinic,” lead author Susan L. Samson, MD, PhD, chair of endocrinology, diabetes, and metabolism at the Mayo Clinic Florida, Jacksonville, told Medscape Medical News.

Asked to comment, Anne L. Peters, MD, professor of clinical medicine at Keck School of Medicine of the University of Southern California, Los Angeles, told Medscape Medical News, “I like their simple graphics. For the Department of Health Services in Los Angeles County, we have been painstakingly trying to create our own flow diagrams. . .These will help.”

Eleven Separate Algorithms With Text and Graphics

Included are 11 visual management algorithms, with accompanying text for each one. The first lists 10 overall management principles, including “Lifestyle modification underlies all therapy,” “Maintain or achieve optimal weight,” “Choice of therapy includes ease of use and access,” “Individualize all glycemic targets,” “Avoid hypoglycemia,” and “Comorbidities must be managed for comprehensive care.”

Three more algorithms cover the diabetes-adjacent topics of adiposity-based chronic disease, prediabetes, dyslipidemia, and hypertension.[5]

Four separate graphics address glucose lowering. Two are “complications-centric” and “glucose-centric” algorithms, another covers insulin initiation and titration, and a table summarizes the benefits and risks of currently available glucose-lowering medications, as well as cost.

Splitting the glucose-lowering algorithms into separate “complications-centric” and “glucose-centric” graphics is new, Dr Samson said. “The complications one comes first, deliberately. You need to think about: Does my patient have a history of or high risk for cardiovascular disease, heart failure, stroke, or diabetic kidney disease? And you want to prioritize those medications that have evidence to improve outcomes with those different diabetes complications versus a one-size-fits-all approach.”

And for patients without those complications, the glucose-centric algorithm considers obesity, hypoglycemia risk, and access/cost issues. “So, overall the diabetes medication algorithm has been split in order to emphasize that personalized approach to decision-making,” Dr Samson explained.

Also new is a table listing the benefits and risks of weight-loss medications, and another covering immunization guidance for people with diabetes based on recommendations from the Centers for Disease Control and Prevention. “Coming out of the pandemic, we’re thinking about how can we protect our patients from infectious disease and all the comorbidities. In some cases, people with diabetes can have a much higher risk for adverse events,” Dr Samson noted. 

“We want this to be a living document that should be updated in a timely fashion, and so, as these new indications are approved and we see more evidence supporting their different uses, this should be updated in a really timely fashion to reflect that,” Dr Samson said.

The end of the document includes a full page of each graphic, meant for wall posting.

Dr Peters noted that for the most part, the AACE guidelines and algorithm align with joint guidance by the American Diabetes Association (ADA) and European Association for the Study of Diabetes (EASD).[7]

“For many years there seemed to be big differences between the AACE and ADA guidelines for the management of type 2 diabetes. Although small differences still exist. . .the ADA and AACE guidelines have become quite similar,” she said.

Dr Peters also praised the AACE algorithm for providing “a pathway for people who have issues with access and cost.”

Dr Samson has reported receiving research support to the Mayo Clinic from Corcept, serving on a steering committee and being a national or overall principal investigator for Chiasma and Novartis, as well as being a committee chair for the American Board of Internal Medicine. Dr Peters has reported relationships with Blue Circle Health, Vertex, and Abbott Diabetes Care; receiving research grants from Abbott Diabetes Care and Insulet; and holding stock options in Teladoc and Omada Health.

Endo Pract. 2023;29:P305-340.

AACE Annual Meeting 2023. Presented May 6, 2023.

Study Highlights

  • The algorithm includes 10 overall principles for type 2 diabetes mellitus management.
  • Lifestyle modification, which underlies all therapy, includes exercise, healthy dietary changes, smoking cessation, reduced alcohol intake, and assessment/management of sleep disorders and depression.
  • Patients should maintain/achieve optimal weight, as excess weight causes insulin resistance, increases prediabetes/diabetes risk, and leads to multiple complications beyond dysglycemia, increasing morbidity/mortality.
  • Choice of antihyperglycemic therapy should reflect glycemic targets, atherosclerotic cardiovascular disease, congestive heart failure, chronic kidney disease, overweight/obesity, and nonalcoholic fatty liver disease.
  • Clinicians should use select antihyperglycemic therapy/therapies most likely to improve overall outcomes (eg, glucagon-like peptide-1 receptor agonists (such as liraglutide, semaglutide, or dulaglutide) or sodium glucose cotransporter 2 inhibitors (such as empagliflozin or canaglifozin) for patients with established or high risk for atherosclerotic cardiovascular disease, heart failure, and/or chronic kidney disease; or pioglitazone, a thiazolidinedione, for those with stroke or nonalcoholic fatty liver disease).
  • Choice of therapy should consider ease of use and access, with barriers including availability, cost, insurance coverage, and formularies.
  • Optimal hemoglobin A1c (A1C) is 6.5% or less, or as close to normal as is safe and achievable for most patients, as tight glycemic control has well-established impact in preventing/stabilizing microvascular and microangiopathic complications of type 2 diabetes mellitus.
  • This may require targeting fasting plasma glucose to less than 110 mg/dL and 2-hour postprandial glucose to less than 140 mg/dL.
  • Patient-specific characteristics warranting a less stringent A1C target (7%-8%) include limited life expectancy, history or unawareness of severe hypoglycemia, advanced chronic kidney disease, severe comorbidities with high cardiovascular disease risk, long diabetes mellitus duration with difficulty attaining an A1C goal, and/or prohibitive cognitive and/or psychological status.
  • Clinicians should individualize all glycemic targets (A1C, glucose management indicator, time in range, fasting blood glucose, and postprandial glucose), and adjust every 3 months or sooner, as failure to escalate therapy or initiate new therapies is a major threat to achieving health outcomes in persons with overweight/obesity, prediabetes, and type 2 diabetes mellitus.
  • Clinicians should choose antihyperglycemic agents and A1C goals to avoid hypoglycemia (blood glucose <70 mg/dL), which increases risk for adverse outcomes including mortality.
  • Dipeptidyl peptidase-4 inhibitor, glucagon-like peptide-1 receptor agonist, and sodium glucose cotransporter 2 inhibitor have lower hypoglycemic risk than insulin and sulfonylureas.
  • Continuous glucose monitoring is highly recommended to facilitate safely reaching goals.
  • Clinicians must manage hypertension, dyslipidemia, and other comorbidities for comprehensive care, as these further increase risk for cardiovascular disease, chronic kidney failure, and retinopathy.
  • The Complications-Centric Model for the Care of Persons with Overweight/Obesity describes components underlying comprehensive assessment for staging overweight/obesity in the context of adiposity-based chronic disease and guides proposed interventions to improve overall health and guide adiposity-based chronic disease management.
  • Lifestyle intervention (nutrition, weight loss, and exercise) to lose weight is a key pillar of comprehensive prediabetes treatment to reduce progression to type 2 diabetes mellitus.
  • Weight loss (>5% to >15% body weight) improves many cardiometabolic/biomechanical components of adiposity-based chronic disease, including increased glycemia, dyslipidemia, elevated blood glucose, cardiovascular disease, nonalcoholic fatty liver disease, sleep apnea, and osteoarthritis.
  • Comprehensive lifestyle intervention should also target sleep hygiene, alcohol moderation, smoking cessation, and monitoring for mood disturbances that can affect compliance.
  • Clinicians must consider pharmacologic and surgical interventions, including bariatric procedures, as indicated by patient-centered assessment.
  • Persons with overweight/obesity should be evaluated for associated complications beyond body mass index, including prediabetes, dyslipidemia, hypertension, nonalcoholic fatty liver disease, atherosclerotic cardiovascular disease, congestive heart failure with reduced or preserved ejection fraction, chronic kidney disease, obstructive sleep apnea, osteoarthritis, gastroesophageal reflux disease, urinary incontinence, hypogonadism, polycystic ovary syndrome, and reduced fertility.
  • Staging persons with overweight/obesity can affect the approach to interventions.
  • Step 1 is to calculate body mass index to identify overweight (≥25 kg/m2) or obesity (≥30 kg/m2), with lower thresholds for some Asians (≥23.5 and ≥25 kg/m2, respectively).
  • Step 2 assesses for adiposity-based chronic disease complications and incorporates weight bias/stigma and mental health.
  • Patients may have elevated body mass index without physical complications (stage 1),or lack substantially elevated body mass index but have adiposity-based chronic disease, mandating action.
  • Stage 2 obesity includes patients with at least 1 mild to moderate obesity complication.
  • Stage 3 includes patients with multiple and/or more severe complications and those already diagnosed with type 2 diabetes mellitus as a severe adiposity-based chronic disease complication.
  • Combining body mass index with stage can inform clinicians of needed interventions.
  • Step 3 requires a comprehensive lifestyle modification plan including nutrition, physical activity, sleep, counseling, medications, and interventions.

Clinical Implications

  • This 2023 diabetes algorithm update emphasizes lifestyle modification and treatment of overweight/obesity as key pillars in prediabetes/diabetes management, along with appropriate management of atherosclerotic risk factors of dyslipidemia and hypertension.
  • A complication-centric approach, beyond glucose levels, should frame decisions regarding first-line pharmacotherapy.
  • Implications for the Health Care Team: Access/cost of medications as factors related to health equity should be considered in clinical decision-making.


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