How should I treat an elevated Hemoglobin A1c (HbA1c) level of 10.1%?

From the Guidelines

An A1c of 10.1% requires immediate medical attention and treatment with a combination of lifestyle modifications and medication therapy, likely including metformin and insulin, to reduce the risk of diabetes complications and improve quality of life. According to the most recent and highest quality study 1, the American Diabetes Association recommends a comprehensive treatment plan that includes both lifestyle changes and medication therapy. For lifestyle changes, focus on:

• A low-carbohydrate diet
• Regular physical activity (aim for 150 minutes per week)
• Weight management if needed
• Consistent blood glucose monitoring

Medication will almost certainly be necessary; your doctor may prescribe metformin (typically starting at 500mg once or twice daily, gradually increasing to 1000mg twice daily as tolerated) as first-line therapy. Additional medications such as SGLT-2 inhibitors (like empagliozin 10-25mg daily), GLP-1 receptor agonists (like semaglutide weekly injection), or insulin therapy might be needed given your high A1c. Insulin therapy often begins with basal insulin (like glargine 10 units at bedtime, adjusted based on fasting glucose levels) 1.

Key considerations for treatment include:

• The presence of established ASCVD or indicators of high ASCVD risk
• Other comorbidities
• Risk for specific adverse drug effects
• Safety, tolerability, and cost of medications
• Patient preferences and characteristics

The goal of treatment is to achieve an A1c target and reduce the risk of diabetes complications, including heart disease, kidney damage, nerve damage, and vision problems. With appropriate treatment, you can expect to see improvement in your A1c within 3 months 1.

From the FDA Drug Label

The results are displayed in Table 8 Table 8: Mean Change in Fasting Plasma Glucose and HbA1c at Week 29 Comparing Metformin Hydrochloride Tablets /Glyburide (Comb) vs Glyburide (Glyb) vs Metformin Hydrochloride Tablets (MET): in Patients with Type 2 Diabetes Mellitus with Inadequate Glycemic Control on Glyburide

• Not statistically significant MET (n=210) p-Values Comb (n=213) Glyb (n=209) Glyb vs Comb MET vs Comb MET vs Glyb Fasting Plasma Glucose (mg/dL) Baseline 250.5 247.5 253.9 NS * NS * NS * Change at FINAL VISIT –63.5 13.7 –0.9 0.001 0.001 0.025 Hemoglobin A1c (%) Baseline 8.8 8.5 8.9 NS * NS * 0.007 Change at FINAL VISIT –1.7 0.2 –0.4 0.001 0.001 0. 001

The patient's HbA1c of 10.1 is higher than the baseline values in the studies.

• The studies show that metformin can decrease HbA1c by approximately 1.4% to 1.7%.
• However, the studies do not provide a direct answer to how to treat an HbA1c of 10.1.
• A conservative clinical decision would be to consider metformin as a potential treatment option, but the dosage and treatment plan should be determined by a healthcare professional based on the individual patient's needs and medical history 2.

From the Research

Treatment Approach for A1C of 10.1

To address an A1C level of 10.1, it's crucial to consider a personalized therapeutic approach, taking into account factors such as age, body weight, complications, and disease duration, as suggested by the study 3. This approach aims to guide clinicians in using therapeutic agents more effectively, efficiently, and safely.

Therapeutic Strategies

• The study 4 compares the cardiovascular safety and efficacy of metformin-SGLT2i versus metformin-sulfonylureas in type 2 diabetes, indicating that combination therapy with metformin and sodium-glucose cotransporter-2 inhibitors is a safe and efficacious alternative to combination therapy with metformin and sulphonylureas for patients with type 2 diabetes who are at risk of cardiovascular comorbidity.
• Another study 5 highlights the safety concerns of add-on sulfonylurea therapy in patients with type 2 diabetes using metformin, showing an increased risk of all-cause mortality and major hypoglycemic episodes compared to other oral antihyperglycemic agents.

Importance of A1C Measurement

• The study 6 emphasizes the significance of HbA1c as a valid and reliable measure of average glucose exposure, which is widely accepted as a prognostic and diagnostic biomarker for diabetes.
• The study 7 demonstrates that A1C explains virtually all of the difference in risk of complications between intensive and conventional therapy groups, suggesting that A1C is a crucial factor in determining the risk of microvascular complications.

Considerations for Treatment

• When selecting a therapeutic strategy, it's essential to consider the individual patient's characteristics, such as age, body weight, and disease duration, as well as the potential risks and benefits of different treatment options, as discussed in the study 3.
• The choice of treatment should be based on the latest evidence and guidelines, taking into account the patient's specific needs and circumstances.