Philip Levy

STATEMENT BY AN AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/ AMERICAN COLLEGE OF ENDOCRINOLOGY CONSENSUS PANEL ON TYPE 2 DIABETES MELLITUS: AN ALGORITHM FOR GLYCEMIC CONTROL

This report presents an algorithm to assist primary care physicians, endocrinologists, and others in the management of adult, nonpregnant patients with type 2 diabetes mellitus. In order to minimize the risk of diabetes-related complications, the goal of therapy is to achieve a hemoglobin A1c (A1C) of 6.5% or less, with recognition of the need for individualization to minimize the risks of hypoglycemia. We provide therapeutic pathways stratified on the basis of current levels of A1C, whether the patient is receiving treatment or is drug naïve. We consider monotherapy, dual therapy, and triple therapy, including 8 major classes of medications (biguanides, dipeptidyl-peptidase-4 inhibitors, incretin mimetics, thiazolidinediones, alpha-glucosidase inhibitors, sulfonylureas, meglitinides, and bile acid sequestrants) and insulin therapy (basal, premixed, and multiple daily injections), with or without orally administered medications. We prioritize choices of medications according to safety, risk of hypoglycemia, efficacy, simplicity, anticipated degree of patient adherence, and cost of medications. We recommend only combinations of medications approved by the US Food and Drug Administration that provide complementary mechanisms of action. It is essential to monitor therapy with A1C and self-monitoring of blood glucose and to adjust or advance therapy frequently (every 2 to 3 months) if the appropriate goal for each patient has not been achieved. We provide a flow-chart and table summarizing the major considerations. This algorithm represents a consensus of 14 highly experienced clinicians, clinical researchers, practitioners, and academicians and is based on the American Association of Clinical Endocrinologists/American College of Endocrinology Diabetes Guidelines and the recent medical literature.

American Association of Clinical Endocrinologists medical guidelines for clinical practice for the management of diabetes mellitus.

Acknowledgments We would like to recognize Elliot Sternthal, MD, FACE, and Joseph Vassalotti, MD, for their review of these guidelines and thoughtful comments.

AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY - CLINICAL PRACTICE GUIDELINES FOR DEVELOPING A DIABETES MELLITUS COMPREHENSIVE CARE PLAN - 2015

The American Association of Clinical Endocrinologists/American College of Endocrinology Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. Abbreviations: A1C = hemoglobin A1c AACE = American Association of Clinical Endocrinologists ACCORD = Action to Control Cardiovascu...

Diagnosis and management of prediabetes in the continuum of hyperglycemia: when do the risks of diabetes begin? A consensus statement from the American College of Endocrinology and the American Association of Clinical Endocrinologists.

Alan J. Garber, MD, PhD, FACE, Yehuda Handelsman, MD, FACP, FACE, Daniel Einhorn, MD, FACP, FACE, Donald A. Bergman, MD, FACE, Zachary T. Bloomgarden, MD, FACE, Vivian Fonseca, MD, FACE, W. Timothy Garvey, MD, James R. Gavin III, MD, PhD, George Grunberger, MD, FACP, FACE, Edward S. Horton, MD, FACE, Paul S. Jellinger, MD, MACE, Kenneth L. Jones, MD, Harold Lebovitz, MD, FACE, Philip Levy, MD, MACE, Darren K. McGuire, MD, MHSc, FACC, Etie S. Moghissi, MD, FACP, FACE, and Richard W. Nesto, MD, FACC, FAHA

ACE/AACE consensus conference on the implementation of outpatient management of diabetes mellitus: consensus conference recommendations.

Among the more than 20 million Americans who have diabetes, approximately 30% of the cases are undiagnosed (1). An additional 42 million people in the United States have pre-diabetes (impaired glucose tolerance [IGT], impaired fasting glucose, or both), a condition that often leads to diabetes if it is not treated (1). The dramatic 41% increase in prevalence of diabetes during the 1990s was characterized by a shift to a younger age at onset. The prevalence of diabetes increased more than 70% in the age-group 30 to 39 years (1). The longer the duration of poorly controlled diabetes, the greater the risk for development of vascular complications, including retinopathy, end-stage kidney disease, neuropathy, and coronary artery disease. These complications are not only debilitating but also expensive. In 2002, health-care costs for diabetes in the United States surpassed

American association of clinical endocrinologists medical guidelines for the clinical use of dietary supplements and nutraceuticals

132 billion (1). These costs were primarily related to the treatment and consequences of complications of diabetes (2). Several large prospective studies have shown that intensive treatment of diabetes can decrease the chronic complications associated with this disease (3-6). There seems to be no glycemic threshold for reduction of complications; the lower the hemoglobin A1c (A1C) level, the lower the rate of occurrence of diabetes-related complications (7). Advances in pharmacologic therapies and new treatment technologies can facilitate reduction of blood glucose values in patients with diabetes to near-normal and achieve glycemic goal levels recommended in current practice guidelines. Nevertheless, the management of patients with diabetes in the United States has actually worsened during the past decade (8). Data from the National Health and Nutrition Examination Survey III in 1994 showed that only 44% of patients with type 2 diabetes achieved an A1C level of less than 7% (9). By the year 2000, this proportion actually decreased to 37% (10). Recently, at an American Association of Clinical Endocrinologists (AACE) meeting, a report on the state of diabetes health showed that, in a study of 157,000 Americans in 39 states, two-thirds of the subjects with type 2 diabetes had A1C values above the American College of Endocrinology (ACE) goal for glycemic control of 6.5% or less (American College of Endocrinology/ American Association of Clinical Endocrinologists. State of Diabetes in America: Striving for Better Control. Available at: http://www.aace.com/pub/StateofDiabetes/ stateofdiabetes.php). Clearly, more aggressive and comprehensive application of these available treatment options, supported by diabetes education, is needed. On January 31, 2005, ACE and AACE convened a 2day consensus conference to review current research and address questions relevant to the treatment of diabetes. The conference brought together US and international diabetes researchers, clinical and educational experts, and ACE/AACE CONSENSUS CONFERENCE ON THE IMPLEMENTATION OF OUTPATIENT MANAGEMENT OF DIABETES MELLITUS: CONSENSUS CONFERENCE RECOMMENDATIONS

A Work in Progress, but a Useful Construct

Reviewers Donald A. Bergman, MD, FACP, FACE Jeffrey R. Garber, MD, FACE Carlos R. Hamilton, Jr., MD, FACE Yehuda Handelsman, MD, FACP, FACE Kalman E. Holdy, MD John S. Kukora, MD, FACS, FACE Philip Levy, MD, FACE Pasquale J. Palumbo, MD, MACE Steven M. Petak, MD, JD, FACE Leonid Poretsky, MD Philip Rabito, MD, FACE Herbert I. Rettinger, MD, FACE, MBA Helena W. Rodbard, MD, FACE F. John Service, MD, PhD, FACE, FACP, FRCPC Talla P. Shankar, MD, FACE

The potential role of colesevelam in the management of prediabetes and type 2 diabetes mellitus.

The metabolic syndrome is a construct that has come into common usage over the last few decades. In 1956, Jean Vague1 first demonstrated that upper-body obesity determined predisposition to diabetes mellitus, atherosclerosis, gout, and renal calculi; however, it was the presentation of this concept by Gerald Reaven in his Banting Lecture in 19882 that initiated the current focus on this entity as a clinical and pathological construct. Dr Reaven suggested that 3 major conditions—non–insulin-dependent diabetes mellitus (type 2 diabetes mellitus), hypertension, and coronary artery disease—had an causal commonality (resistance to insulin-stimulated glucose uptake and hyperinsulinemia) and referred to this constellation of abnormalities as “syndrome X.” He did not include abdominal obesity in the original description, nor did he comment significantly on a potential clinical role for his observations. In fact, his concluding sentences stated, “What remains to be seen is the magnitude of the role that resistance to insulin-stimulated glucose uptake plays in the etiology of human disease. I can only hope that this presentation has outlined the possibilities for future efforts to answer this question.” Response by Kahn p 1818 Since that time, this construct has evolved conceptually and functionally into an entity that many refer to as a “syndrome.” More recently, there have been many questions about the legitimacy of this designation, summarized by Kahn et al3 in a September 2005 position statement for the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Their comments called into question many of the assumptions that underlay the designation of “syndrome,” and they posed the following key questions: How clear is the existing definition of the metabolic syndrome for diagnostic purposes? How useful is the syndrome definition in predicting cardiovascular disease (CVD) risk? Do the individual components of the syndrome convey “risk” …

The early use of insulin in type 2 diabetes

Abstract Successful management of prediabetes and type 2 diabetes mellitus (T2DM) requires a multifaceted, multidisciplinary approach that involves patient education and support, lifestyle modifi cation, and appropriate use of pharmacologic interventions with frequent monitoring and adjustment to ensure that target goals for hyperglycemia, dyslipidemia, and hypertension are achieved and maintained. Studies have shown that the bile acid sequestrant colesevelam HCl reduces hemoglobin A1cand low-density lipoprotein-cholesterol levels in patients with prediabetes and T2DM. This article briefl y reviews current treatment guidelines for patients with prediabetes and T2DM and the potential role of colesevelam in the management of prediabetes and T2DM with oral antidiabetes agents.

American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan.

60?70% of all patients with Type 2 Diabetes Mellitus will ultimately require insulin therapy for the management of their diabetes. Irisulin may be used alone, or in combination with oral agents. The early use of insulin can be very important in decreasing the incidence of micro-vascular complications and in helping to delay the onset of macro-vascular complications. The United Kingdom Prospective Diabetes Study and the Kumamoto Study have shown the beneficial effects of good glucose control in type 2 diabetes mellitus. The DECODE study has related overall mortality to the level of glucose control and specifically to the postprandial glucose. The American Association of Clinical Endocrinologists has established a goal of 6.5% or less for HgbAlc. The appropriate use of insulin will allow us to achieve this goal without causing the patient any undue harm. There are many barriers to insulin therapy including psychological barriers of both the patient and the doctor, and unrealistic fears of both insulin therapy and therapy with self-administered injections. These barriers will be discussed as well as methods to overcome them. Insulin therapy is beneficial and has no long term adverse effects. The incidence of severe hypoglycemia is extremely low in type 2 diabetes. Weight gain is minimal. Insulin therapy by reducing glucose toxicity may also increase the effectiveness of oral anti-hyperglycemic agents. The physician taking care of patients with diabetes should be aggressive and should have no fears of initiating insulin therapy. Insulin dosage is flexible and good control is possible in most patients. The most common use of insulin in type 2 diabetes is as an add-on to oral agents if control with oral agents alone is unsatisfactory. Frequently this involves the use of a single dose of intermediate or long acting insulin or an insulin mixture in the evening. If control is not attained with a single dose, then the patient can be placed on an insulin mixture 2 or 3 times a day. An alternative would be a short acting insulin analogue prior to each meal with a longer acting insulin given 1 or 2 times a day. Titration schedules for insulin dosing will be presented. Insulin available in Russia will be listed along with some guidelines on using these insulins. Increasing the use of insulin and starting insulin earlier in type 2 diabetes will lead to better control of diabetes, increased patient compliance, and decreased long-term complications of diabetes mellitus.