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Episode 74: 2026 AACE Algorithm for Management of Adults with Type 2 Diabetes: Key Updates and Clinical Insights
00:35:45
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Dr. Susan Sampson
Foreign.
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Dr. Lawrence Blond
Welcome to ACE Podcasts.
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Vin Tangprecha
Thanks for tuning in as we elevate clinical endocrinology by taking deep dives into trends and topics that can help us
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Dr. Earl Hirsch
improve our patient care and global health.
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Vin Tangprecha
Find the latest episodes on aace.com podcasts. And now let's meet the endocrine experts who will be talking with us today. Hello, everyone, and welcome to this ACE Podcast focusing on the new ACE Diabetes algorithm. Its official title is the ACE Endocrinology Consensus Statement Algorithm for Management of adults with type 2 diabetes. This will be published in Endocrine Practice in April 2026. I'm Vin Tangprecha. I'm the editor of Endocrine Practice, the official journal of ace, and I'm joined today with many of the key experts who put this algorithm together as long as. Along with Our ACE Past ACE President and Chair of the algorithm, Dr. Susan Sampson. Sue, do you want to introduce yourself?
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Dr. Susan Sampson
Hi. Yeah. Thank you, Vin. Really excited to be here with my colleagues who were all instrumental in putting together this amazing updated document. I'm Sue Sampson. I was president of ACE in 2024, but I consider it a great honor to chair this algorithm knowing that my mentor, Dr. Alan Garber, was one of the first architects of this algorithm going back to 2014. So it's a real pleasure to be here, Vin, and I look forward to discussing the algorithm with you.
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Vin Tangprecha
Thank you. Thanks for joining the podcast. And we also have vice chair, Dr. Priya Valanki. Can you introduce yourself?
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Dr. Priya Valanki
Yeah. Thank you. I echo. Dr. Sampson. It's been an honor to work with the task force on this algorithm. I was also the vice chair for the previous iteration. I will say I've learned not only have I learned a lot from the experts, it's been a real pleasure to really update the algorithm and see how see it come to fruition, so. And thank you for the invitation.
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Vin Tangprecha
Great. And Also we have Dr. Blond from Ochsner Clinic. Dr.
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Dr. Lawrence Blond
Blond, my name is Lawrence Blond. I am at what we now call Ochsner Health. I'm at the part of it that's called Ochsner Medical center, where I direct a Oxford diabetes clinical research unit. And amazingly, I have been there since 1974 and I'm still employed. They're amazingly patient with me.
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Vin Tangprecha
That's great. That's a long time in New Orleans. And finally, and last but not least, we have Dr. Hirsch.
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Dr. Earl Hirsch
Yeah. Thank you for the invitation to participate. My name is Earl Hirsch. I'm a professor of medicine at the University of Washington in Seattle. I can't compete with Dr. Blond's. Track Record in New Orleans. But I have been here since 1990, involved in quite a few of the clinical trials which were instrumental in this algorithm. And I'm delighted to participate.
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Vin Tangprecha
Great, thank you. We're always excited when a new ACE guideline comes out. I think these are so important and very useful for many of us in the front lines in the clinic. So, Sue, I thought maybe you could start with how the guidelines came to be and what kind of effort it took to put these guidelines together.
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Dr. Susan Sampson
Yeah. Thank you, Ben. So the last version was in 2020, prior to the pandemic, and then we did update it in 2023, really aligning it with the ACE Diabetes guideline. So this is a consensus statement and algorithm, but it does follow the evidence and is meant to be a more concise instruction manual, so to speak, or pathway for clinicians to know how to approach treatment of diabetes in their patients. The process is long but fun. So we meet over the span over about a year and a half. Yes. Happy to talk to you about this. So there was a 2020 version of the algorithm that we waited until 2023 to update that in order for there to be a diabetes new diabetes guideline, evidence based guideline from ACE. And that 2023 algorithm was really intended to align with that guideline, but for 2026, it was really important that we update the algorithm again. And the reason is that so many clinical trials have come to fruition in the last three years. We have more data and we have more regulatory approvals and expanded use of many of the medications we use to treat diabetes that we really needed to provide guidance to clinicians. You know, ACE wants to be the voice of the accurate evidence based clinical guidance in a timely fashion. And so that's why we updated it. We met over a year and a half, and each meeting we would work together on what the algorithm pathways should look like, and we would work through several iterations. And what you may be surprised at is the algorithms come first, the narrative comes after, in order to support why those particular pathways were chosen. So we hope that we have come up with a great guidance package for people who look after patients with diabetes.
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Vin Tangprecha
Thanks for that. How does this. Well, we'll hear a little bit more, but I'm sure it's. It's very different from the last reiteration of the ACE guideline. Do you want to hit on some of the high points or give us sneak preview?
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Dr. Susan Sampson
Well, I might actually pass it on to Dr. Hirsch, who can talk about one of the major new Additions to this algorithm compared to last time.
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Dr. Earl Hirsch
Yeah. Thanks, Sue. You know, if you're going to have an algorithm on the treatment of type 2 diabetes, we need to make sure that we can diagnose it accurately and that we understand the entire classification, because that has actually changed over time, especially as we are learning about new variants. And so we have a brand new figure which starts with something that shouldn't be controversial, but it actually turns out to be a bit controversial, and that is how one diagnoses diabetes. We use the ADA World Health Organization diagnostic criteria. And that actually can be a bit controversial if you have discordance. And that's. That. That's actually a pretty big topic in of itself. Most people with type 2 diabetes, and this part of the figure, we want individual physicians to look at the phenotype and make sure they generally have most of the phenotypes which we see with metabolic syndrome, including the dyslipidemia. But as it turns out, not everybody who looks like they have type 2 diabetes does. We are seeing more and more people with lean type 2 diabetes, but the most common mistake we see are features suggesting type 1 diabetes. And both in the algorithm and in the text, we get in into all of the issues which should make clinicians think about type 1 diabetes. And I just want to mention something that happened in early March, and that's the fact that at the ATTD meeting in Barcelona, Spain, there was data which really supports the fact that we frequently misclassify people with type 1 diabetes, but they're first diagnosed with type 2 diabetes. There were over six and a half million people that were reviewed. And the bottom line is that 4% of the people initially diagnosed from type 2 actually had type 1. That doesn't seem like a big deal, but it was almost 150,000Americans. Not surprisingly, over half of the Americans were over 50 years of age. The point is, misclassification occurs frequently. But the majority of this new figure we have in the algorithm is not about differentiating type one from type two, but to make sure that the clinicians consider all of the other forms of diabetes that we are now aware of, that includes all the different endocrinopathies. There's a lot of excitement right now. What we are seeing with hypercortisolism and type 2 diabetes, which actually is a part of type 2 diabetes, the anatomic pancreatic disease. Many of us see a lot of people with cystic fibrosis. The big issue, which I think we need a lot of work on, is diagnosing Monogenic diabetes. It's becoming easier to get the diagnose the gene mutations causing one of the different modis or another type of monogenic diabetes medication uses. And there are a vast number of other forms of diabetes that we are learning about. And I think the bottom line is that clinicians want to make sure that before they treat somebody for classic type 2 diabetes, they keep in mind that there may be a host of other disease processes these individuals can have. And my final comment is if somebody has diabetes, that's not to say they may not have two or even more etiologies of their diabetes. The most common is somebody with a family history of type 2 diabetes who also has an autoimmune attack on their islets. It's not part of the algorithm. I like to teach the fellows we call these people with double diabetes. The point is, is that it's getting more complicated as we are learning quite a bit more about this.
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Vin Tangprecha
I see. I think the figure is so helpful that providers who are not endocrinologists should refer to endocrinology if they have these other flavors of diabetes. Is that correct?
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Dr. Earl Hirsch
I think that is so important because this is coming at us so quickly. Many of these more esoteric forms of diabetes and I do believe they do require the assistance of an endocrinologist.
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Vin Tangprecha
The other point I wanted to ask about, earl, is the A1C of 6.5. Now I know that when ACE first came out, that was really forward thinking many years ago and people asked about that number. Do we have anything new about that 6.5 number for that A1C?
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Dr. Earl Hirsch
Boy, this is a whole can of worms.
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Vin Tangprecha
We don't have an hour to talk about it.
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Dr. Earl Hirsch
No. Well, as it turns out, I think everybody would agree and this is not controversial. The lower the better, as long as you can minimize hypoglycemia. I don't think anybody would disagree with that statement. The problem is, and this has been a big deal focus of my research the last five to 10 years, is that an A1C in one person is not necessarily the A1C in somebody else. Red blood cell survivals are different. Glycation appears to be different reasons that aren't really well understood. At least I don't understand. African Americans on average tend to have a higher A1C for the same mean glucose compared to Caucasians. There are other populations we don't even know. And so there is often going to be discordance when looks at CGM and whether they're looking at the GMI or they're looking at the mean glucose and looking, comparing that to the A1C. And so while I do believe that 6.5 for diagnosis, I don't think that's going away. I don't think that having as low of an A1C is possible. If you can get to 6.5 without a lot of hypoglycemia, that's great. I do think, and this is not related to the guidelines as much, but I do think that as time goes on we are going to be more looking at CGM metrics for those who have access to it. Not everybody has access to this, especially when you go outside of the United States. And my final comment is we now have an updated GMI which was just presented last week and is about to be published, if it hasn't been published already, which will more accurately reflect the mean glucose we see on the cgms.
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Vin Tangprecha
Thanks for that very concise answer. I think you're right. I think we're moving towards glucose, not a 1C so much. We really care about the glucose. Right.
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Dr. Susan Sampson
And to and to that point, Ben, under the, the management principles that we really talked extensively about, it doesn't just say individualize A1C anymore. It says individualized glycemic targets. And that includes A1C of course, course. But also as Earl mentioned, GMI time and range, fasting glucose plus prandial glucose. So you really have to find the right measures for your patient based on what data they are able to show you in the clinic. And if they have cgm, even better.
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Vin Tangprecha
That's a great segue. To my next question about the complications. I wanted Dr. Blond to talk about the key complications that we're trying to prevent and what's new in terms of studies that have driven this evidence.
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Dr. Lawrence Blond
So beginning with the last version of the algorithm, there was the development of one of the algorithms which Here is Figure 6 was a algorithm that was called Comorbidities and complications centric glycemic control algorithm where one starts with this really first. So on this algorithm it proposes that clinicians first consider the risks and pre existing conditions for each person with type 2 diabetes and use that as a basis to choose their initial pharmacotherapy sort of independent on glucose levels to improve the individual's outcomes. And if one looks at this and it's now been updated and so one is going to select therapy based on complications and comorbidities independent of glycemic targets and other type 2 diabetes therapies. In looking at this, the order of the complications and comorbidities. Going from left to right is purposeful. Starting at heart failure, chronic kidney disease, ASCVD or high risk for ascvd, stroke or tia. One uses that to make the decisions. If an individual had none of these conditions, then the table tells us to go to algorithm 7, the glucocentric glycemic control algorithm. But if they have one of these that that's what's dealt with first. And if for newly diagnosed patients, if they have very high A1Cs above glycemic target, then it's recommended to consider starting with two or more therapies to get to goal faster. And if the A1C is high enough to have one of those being started with insulin and to in those individuals to not use a GLP1 receptor agonist alone without something else because it would take a long time to get to control. And then for each of the so after that one is taking care of the urgency for very high glucose levels. And then look to see does someone have heart failure and which are the agents SGLT2 inhibitor or GLP1 receptor agonist or GIP GLP1 receptor agonist to start with, with the one that's at the top is of this list. The higher levels are the are the first recommended areas. And then looking at chronic kidney disease, one can use SGLT2 inhibitors or GLP1 receptor agonists. Again SGLT inhibitors for most people would be first and then ASCVD or high risk for ASCVD being treated with GLP1 receptor agonists first or SGLT2 inhibitors for people with stroke or TIA HLP1 receptor agonist or for some individuals possibly pioglitazone. And then finally look at mast cell or metabolic dysfunction associated steatotic liver disease which would be addressed with GLP1 receptor agonists or GIP GLP1 receptor agonists for some people, possibly pioglitazone and then one individualized glycemic targets. Avoid therapeutic inertia, titrate to goal dose for risk reduction, add beneficial agents not in use to address multiple comorbidities and complications. And then if there's need for additional glucose lowering, then one would go from this algorithm Figure 6 to Algorithm 7, glucocentric glycemic control algorithm.
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Vin Tangprecha
Thanks for walking us through this. Now I remember past ACE guidelines. It was everyone got metformin no matter what. Now are you saying if you have heart failure CKD skip that, go right to SGLT2.
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Dr. Lawrence Blond
Well, so it depends on a lot of factors. What other things that they have, as you say, but that, you know, that would be correct. And similarly, one might go directly to insulin plus other treatments if one had very high A1C levels to begin with.
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Vin Tangprecha
I think that's a huge change. Is that because there's just more data supporting these drugs and these complications?
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Dr. Lawrence Blond
Well, first of all. So one can certainly, in people who get treated with one of these other things and need additional control, one can certainly add metformin as an option. It still has a, it still has a role, but we know a lot more, and as I indicated in the beginning, we know that besides control of glucose, that some of our newer agents also have an ability to have beneficial effects on some of the complications, like heart failure, chronic kidney disease and ascvd. These were things that we didn't, we didn't have therapies that we knew of that could address these. So these are treatments that in addition to having an effect at improving glycemia, also can affect some of the complications of diabetes directly.
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Vin Tangprecha
Okay, thank you. Maybe I'm going to ask Dr. Valenke. Dr. Blond mentioned there's this other algorithm, the glucocentric glycemic control algorithm. Maybe you can walk us through. How do you decide which algorithm to start with and what is the difference between the two algorithms?
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Dr. Priya Valanki
Yeah, thanks, Lynn. So one of the things we wanted to highlight is, as Dr. Bland said, look for severe hyperglycemia. We want it to be somewhat prescriptive in this algorithm and avoid inertia, which is one of principles of this algorithm. And really, if there's severe hyperglycemia, insulin first. However, if there's complications, think of the complications and reducing the complications. Because even though all these drugs are diabetes medications, they have shown, all these new studies have shown that these reduction of complications are independent of glycemic control. So, and that's why the comorbidities, we always say look at the comorbidities first and then if you don't get glycemic control, add on these other agents. Based on what we laid out, and I think the main thing that we, outside of the severe hyperglycemia, the other, the main change I would say we made is that we said preferred and less preferred. So really what we want this algorithm is to be, you know, for a primary care doctor, for an endocrinologist in a busy clinic, this is a slide they can put up on a wall. And something that's easy, it's evidence based, it's something that they, they can look at. And of course, you know, we all want patient centered selection. But and some of the things we wanted to highlight was that, you know, hypoglycemia risk, avoid hypoglycemia. So we put the medications down there, certain medications, and then most, a lot of people with type 2 diabetes are overweight or obese. And of course with the new GLP1s, GIP, all the studies coming out, we have that in there. But one thing I did notice with our 2023 guideline, a lot of the downloads were outside of the United States, all over the world. So we really wanted to emphasize access and cost. What medications can you use if you can't afford these newer medications? You know, we still want glycemic control. So that is something else we emphasized in this algorithm. So those are the main highlights. And of course you still don't get glycemic control. Then you go to the insulin algorithm and that too we, I think a lot of people are afraid of starting insulin. There's a lot of inertia around that. So with that we really tried to be prescriptive about it, to really guide people through titration. So we hope that this will be helpful for primary care docs, endocrinologists, for everybody.
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Vin Tangprecha
I think it's so helpful to have this hanging in your clinic. I think one of the biggest questions and you touched on is when do we start insulin or when does the primary care start insulin? Is that something they need to refer to endocrinologists or is there something more specific you can guide someone in the clinic? In the primary care clinic?
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Dr. Susan Sampson
Yeah.
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Dr. Priya Valanki
I mean, I think if you can have more endocrinologists, sure, they can refer to us, but we all know there's a shortage. So you know somebody who has hyperglycemia, so if they have polyuria, polydipsia, a 1C greater than, I would even say 10. But Ada says 11, we'd say greater than 10. And if they're, especially if they have catabolic symptoms, start insulin. I think that's the key. Of course, you know, if somebody said long standing diabetes and you can't achieve control with two or three oral agents plus GLP1, GIP, GLP1, then we move on to insulin. So that's my short answer.
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Vin Tangprecha
Earl. When do you start insulin?
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Dr. Earl Hirsch
When it's needed is the answer. I do too, but it's actually more complicated. My colleague here in Seattle, Steven Kahn, published the Rice study showing that the beta cell lesion in adolescents and young adults with type 2 diabetes is more aggressive and more toxic than their Parents and their grandparents. So for all of these adolescents and young adults we're seeing with type 2 diabetes today, they're going to need insulin much sooner. And I think for those of us who see these younger type 2 patients, we need to keep that in mind that we likely are going to have to move to insulin sooner than before. And the other point I want to make, we now have three, and we are later this year probably going to have four automated insulin delivery devices approved here in the U.S. now, this may not be accessible to everybody in other countries. Some people yet, yes. But using aid and the data that has been published and the data that will be published on this is something else that we have traditionally not thought of for people with type 2 diabetes. But it's a population that is just exploding. And clinical endocrinologists are, in my view, the best to really push this forward. For these individuals who need both basal and prandial insulin, do you think that's
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Vin Tangprecha
gonna replace the need for some of the newer drugs? Just replace them with insulin right away, early on, or.
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Dr. Earl Hirsch
No, I don't. I mean, with insulin, we are still gonna get weight gain. There's always gonna be a risk of hypoglycemia. And I think what we've learned in the last few years, independent of all the benefits from CKD and heart failure and ascvd, is that if we can use insulin sparing agents, so much the better. But with all that being said, insulin is still our most dependable tool. It almost always works. There are very few people where you can say insulin doesn't work. And I don't think we should be afraid of insulin. And as a rule of thumb, I don't think I've ever met an endocrinologist who has been.
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Vin Tangprecha
Me neither. I was gonna ask Dr. Blunt. As a budding endocrinologist, we always learned that diabetes was bad, it was bad for nephropathy, cardiovascular disease. I don't see anything retinopathy on this algorithm. Why is that?
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Dr. Lawrence Blond
I don't know the answer to that. So, yeah, may need to look at the. Whether or not in the writing this says anything about the ophthalmologic issues of diabetes.
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Vin Tangprecha
I just thought it was interesting with the. Like the dcct. Any of those focus on retinopathy?
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Dr. Earl Hirsch
Yeah, I'd like to comment on that. Obviously, in type 1 diabetes and young people with type 1 diabetes, it's the first complication one sees. It's the easiest one to look at. It's more common than albuminuria in type 1 diabetes but I actually agree with you, Vin, that it is a prominent microvascular complication. But where retinopathy is getting all of its attention today, and I believe rightly so, is when the glucose levels come down quickly, whether it's with an aid system or a GLP one. And actually it's. It's faster because you can get a time and range going from 30 to 70 in one day with an aid system, whereas with the GLP1, it's going to take longer. And this is a topic we've learned a lot about in the last few years. I think, sue, maybe this would be worthy of actually a separate discussion in another article, given what we've learned about this topic.
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Dr. Susan Sampson
Yeah, absolutely, Vin. I think the way this algorithm was really designed and what we were looking for is what are the pathways to diagnosis and then medical management of hyperglycemia. And so when we chose to do the algorithms, for example, the complication centric that Larry was talking about, we did have reviewers say to us, hey, where's phenerinone? Where's other drugs that we know improve, for example, diabetic kidney disease? And the answer back to the reviewers was happy to add in a sentence or two, but this is really about choosing glycemic therapy that has a benefit to cardiovascular or kidney or stroke or Mastle D. So the, you know, the reader is really directed Back to the ACE 2022 guidelines, which have a pretty extensive section on neuropathy, retinopathy, nephropathy in terms of looking at those. And also the focus of the algorithm in the past, all the way back to 2014 through to 2020. And then when we, as our group did the 2023 version is, you know, cardiovascular disease. Right. So we now have a new ACE dyslipidemia guideline and that was used to align the algorithm that talks about how do you manage lipids in diabetes and prediabetes. There's an algorithm on hypertension and those that's really intended to reduce cardiovascular risk. So you're correct, we don't have sections on managing those microvascular complications. But the reason is that this was really about choosing glycemic therapy but choosing. Right, right.
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Dr. Lawrence Blond
Although actually in the part of this algorithm which has a discussion, there is in fact a mention that phenerinone is recommended for individuals with CKD associated with type 2 diabetes. And they gave specific recommendations based on improved kidney and cardiovascular composite outcomes from the Figaro DKD and Fidelio DKD trials.
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Vin Tangprecha
Well, this has been a great conversation before we end today's podcast, I would like to hear from each person what their favorite part of the algorithm is or what is the key takeaway that the audience should take. I'll start with Dr. Blond first, and I'll then end with Dr. Sampson. So we'll do Dr. Blond and Hurst and B'. Lanki.
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Dr. Lawrence Blond
So I think that both the area that Dr. Hirsch discussed with the new algorithm about diabetes really added a lot, and the changes that have been made based on the science that has progressed since 2023, the algorithm that I showed also are, I think, potentially very helpful to clinicians to deal with patients in terms of what do you do? Someone comes in, they have several things. What do you do first? And the idea that the first thing to do is to address some of the complications, if they're significant, which will also lower glucose. But to address that first, based on the ability to use some of the new medications that will improve care for people with heart failure, for chronic kidney disease, for ascvd, for stroke, and. And mast. That's really a lot that has changed and improved.
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Dr. Earl Hirsch
Well, from my point of view, I have enough gray hair on my head to really think about this going back over the last 40 years, 45 years when I was a medical student, and thinking about how simplistic this was before we had Metformin. And now when I look at the therapies and the fact that we can individualize the therapies based on all these other attributes of the patients with their liver, with their kidneys, with their heart, and we have drugs specific for that. Not to mention the really important thing. Let's make sure we're talking about the right patient, that we're talking about somebody with type 2 diabetes and somebody that's not misdiagnosed. But if I was going to take the one thing about this algorithm most proud of is that it's digestible, and it's digestible the way we have everything split out with the algorithms, with the text. You don't have to read the whole thing. You can go to the part that you need at that moment with that patient, exactly at that time. And I think this is something that fellows, residents, and students will also find very helpful.
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Vin Tangprecha
Thanks, Dr. Blanke.
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Dr. Priya Valanki
Yeah, I echo what Dr. Blonde and Dr. Hirsch said. But I think what's really exciting for me, you know, I've been in medical school. I was in medical school long ago, but not as long as Dr. Hirsch. But, you know, what we've been taught is that A1C, A1C is the goal. And we didn't mention this in here, but I really like the idea that we emphasize cgm, using CGM to really look at GMI postprandial glucose. So I think we're really getting to individualized therapy with all of this. And I think that's where the field is. I mean, that is where the field is going. So it's really exciting to see that emphasized in this for me as an endocrinologist in this algorithm.
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Vin Tangprecha
Thanks. We'll end with our chair, Dr. Sampson.
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Dr. Susan Sampson
I love the whole thing, Vin. That's like asking, who is your favorite child? But I love all of the algorithms. But I will say the one thing over the years that I have seen really visible in clinics, hanging up on the cupboard doors above the desk where the computer sit are the tables at the end that really summarize what are all of the benefits as well as the adverse effects you need to watch out for for each of the glycemic medications. It's called the profiles of pharmacotherapy for type 2 diabetes. It's been present in the algorithm since the first iteration in 2014, and it is continually updated. And I think it's incredibly helpful right at eye level to know what you're looking for. Also, we had a lot of discussion at the group as to whether we needed the table of pharmacotherapy for obesity because ACE has a new obesity algorithm. And the gist of that discussion was, yes, we still need it there because this algorithm still emphasizes that lifestyle and weight management and all of the positive benefits that come with weight reduction are a cornerstone of treatment for type 2 diabetes. And so having these profiles of pharmacotherapy for weight management is also essential. And we kept it in the algorithm for the convenience of the clinician so they don't have to go look for yet another algorithm. It's right in front of them. Those are my favorite parts. And just if I can add one more thought, we are very proud of that last slide, which talks about vaccines in patients with diabetes and the need to protect our diabetes patients from preventable vaccine, preventable diseases. And that has been updated. And it's also something that often we're not. It's not top of mind in our busy clinics when we look after these patients. So also really love that very last. That last slide, which talks about that and talks about the schedule. So lots of good stuff in here.
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Vin Tangprecha
Yeah, you stole my answer, Sue. I love all the figures. You print them out, you post them in clinic. Very user friendly. But this has been a great conversation. I'm glad you all were here to discuss this. We're really lucky because this hasn't come out yet. This will be launched in April and there'll be a lot of buzz about this at the annual meeting. So I hope to see you all there and really excited to be talking about this all in 2026 and beyond. So thank you all.
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Dr. Susan Sampson
Awesome. Thanks Finn. Thank you.
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Vin Tangprecha
Thanks for listening to another great ACE podcast. Join us for another episode@aace.com podcasts and help us in our mission to elevate clinical endocrinology. Together we are ace.