New AACE Diabetes Guidelines Released

AACE/ACE Release New, Comprehensive Clinical Practice Guidelines and Updated Algorithm for Developing a Comprehensive Diabetes Mellitus Care Plan

Thursday, April 9, 2015 4:33 pm EDT
Dateline:
JACKSONVILLE, Fla

JACKSONVILLE, Fla.–(BUSINESS WIRE)–The American Association of Clinical Endocrinologists (AACE) today announced the publication of new, expansive diabetes clinical practice guidelines and an updated diabetes algorithm to assist clinical caregivers with the medical management of patients with diabetes mellitus (DM).
The 2015 guidelines advocate for comprehensive control of diabetes beyond a simple focus on glycemic control to address multiple DM risk factors. The guidelines promote individual patient goals and the development of a personalized management plan. To that end, comprehensive clinical recommendations are offered for assessing and managing obesity, lipid disorders, hypertension, kidney disease, cardiovascular disease, hypoglycemia and anti-hyperglycemic therapy to prevent complications; most have been modified substantially over previous guidelines.

The two documents are published online at https://www.aace.com/files/dm-guidelines-ccp.pdf and https://www.aace.com/publications/algorithm and in the April 2015 issue (Volume 21, Issue 4) of the association’s peer-reviewed scientific journal Endocrine Practice.

For more information see the press release.

After I quick read through there appear to be few changes in this new guidelines. The committee is still made of “thought leaders” heavily supported by industry. I’m pleased that the AACE still recommends normalizing blood sugars and getting A1c < 6.5%, FPG < 110 mg/dl and PPG < 140 mg/dl. They still fell short of nutrition recommendations; they actually seem to imply that a vegan/vegetarian diet is good. Their primary evidence base for nutrition recommendations is apparently a bunch of dieticians rather than actual science. They did extend monogenic diabetes to consider not only children but young adults, but they still miss the idea that monogenic diabetes can be present at any age. I’m sure there are other changes. I didn’t look at changes in pumping or CGM use.

What do you think? Can we trust these guidelines? Are they helpful to use? Are there good things in them?

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Personally, I think the PPG should be more like <120. I have no problem with the A1c or Fasting goals.
I do think one should set their own personal goals. based on their situation and what risks they are willing to take.

I downloaded the PowerPoint regarding the algorithm, and also did some scanning of the 24 questions the AACE has posed. The pdf containing the overview, questions, etc, was pretty deep for me and the EL-1s, Grade B, BEL3 notations were way more than my after work brain was ready for.

Overall, it looks as though they have done a reasonable job of giving endos a path to follow with questions to work on individualizing treatment protocols. I also think the goal of individualizing treatment protocols is tremendously important - I am perhaps a bit worried that they aren’t going far enough.

I also liked that they were emphasizing looking beyond glycemic control to help patients with all aspects of what diabetic life means, including the mental state (aka depression).

I was surprised that one of the questions wasn’t when to use a CGM.

@Lloyd Well, they have PPC at 1 hour of <=140, while at 2 hours at <=120 – so you may be “saying” the same thing. Regardless, these goals should be individualized.

@YogaO One of the questions wasnt about CGM use, but one of the answers (to 3.Q18) was - “R53. Continuous glucose monitoring (CGM) should be considered for patients with T1D and T2D on basal-bolus therapy to improve A1C levels
and reduce hypoglycemia (Grade B; BEL 2). Early reports suggest that even patients not taking insulin may benefit from CGM (Grade D; BEL 4).” (on page 20).

Thanks. By the time I got to about section 3.Q5, my mind was swimming, so I had to take a break.

Now that I have looked at 3.Q18 and the responses, I like the first response to A1C measurement - “twice yearly for all patients with DM and at least 4 times yearly in patients not at target.”

I’m am impressed with your reading abilities. You seem to be able to get deeper into this than I could on a first pass. Just to make things even less clear, ADA has revised their Standards of Medical Care in Diabetes for Primary Care Providers. An abridged version is here.

http://clinical.diabetesjournals.org/content/33/2/97.full.pdf

I suspect that most folks encounter diabetes, and start treatments, with a Primary Care Physician. So possible these have a larger impact as the gateway to self management.

To the original post, One thing I feel is important as an advocacy end is constantly calling for patient to be part of the team of “thought leaders.” A patient at every table.

That is driving by this from Back to Baics (p16)

But where the backsliding has occurredis having the actual patient seated at the table with scientists, policy makers, private industry, and regulators pushing for specific changes and demanding accountability. We have reverted back to the old paradigm, but instead of patients deferring to doctors and scientists, they now defer to the organizations and scientists representing their interests.

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I’m not all that impressed with guidelines like that and think they contribute to the challenges many people have with diabetes.

I am a very small sample size but a few folks (Clare [or maybe she’s Clare3 I saw in the chatroom now?], Sportster, Terry and others have reported that lowering targets and using smaller ranges seemed to both lower their A1Cs, well below the guidelines in either the ADA or the AACE recommendations, and make it…easier, which has been my experience. I wish I had screenshotted the thread in old Tu but well, you know.

To me, 140 as a post-meal target seems to correlate very closely with a n A1C near the Organizational Goal Range [OGR, I think I will use this acronym because it is so cumbersome to say ADA and AADE and JDRF anytime I want to talk about this interesting topic…] as an average rather than a 3x/ day postprandial BG. It’s nice that they propose allowing “selected individual patients” (this the ADA…) a shot (ha) at <6.5%.

I don’t like that. I would prefer a more open paradigm in which everybody could be allowed, encouraged and supported to achieve their best. I also don’t like that the guidelines are pretty much devoid of tactical suggestions. This would perhaps help foster dialogues that would remove the notions of “good and evil” that many members have reported feeling from their doctors. Goals would be completely individual. A person with elevated A1C would have the opportunity to consider their approach more flexibly, look at what they are doing and try small, incremental steps to improve, using tried and true tactics like “one meal at a time” or “nudge bolusing” or “basal testing” or whatever to improve. The dialogue created by fixation on “the goal” seems less likely than a more flexible approach to be helpful to those with the greatest need for assistance and support.

Of course, I’m not a doctor…

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By “Thought Leader” I was referring to the practice of having corruption in the development of guidelines. Sometimes these people are called “Key Opinion Leaders.” This occurs when the members of the panel developing the guideline are essentially employees of industry and do not represent the interests of patients. This practice is abhorrent and deceitful.

The full ADA Standards Medical Care in Diabetes can be found on-line as well. The ADA continues to be rather useless. For example their position on carbs remains almost unchanged. They now admit that low carb diets are ok for weight loss and have now even begrudgingly accepted that low carb works for diabetes management. But they basically admit, they can’t figure out whether carb restriction is helpful for glycemic control (Duh). The ADA has basically delegated nutrition recommendations to a bunch of dieticians and the entire system, USDA recommendations and AND recommendations is in my opinion not to be trusted. I won’t follow a guideline developed by Pepsico.

As patients we deserve to have guidelines developed by people who are not corrupted by industry ties and use real evidence based approaches. And a panel that can’t understand the evidence (as the ADA claims) is not competent to develop guidelines.

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