What is the target Hemoglobin A1C (HbA1C) level for patients with Type 2 Diabetes Mellitus?

From the Guidelines

The A1C target for most adults with type 2 diabetes should be between 7% and 8%. This target should be individualized based on several factors, including patient preferences, general health, life expectancy, treatment burden, and costs of care 1. For patients with a life expectancy less than 10 years due to advanced age, residence in a nursing home, or chronic conditions, the goal should be to minimize symptoms related to hyperglycemia rather than targeting a specific HbA1c level, as the harms of intensive glycemic control may outweigh the benefits in this population 1.

Key Considerations

• The American College of Physicians recommends personalizing goals for glycemic control in patients with type 2 diabetes, taking into account the benefits and harms of pharmacotherapy, patient preferences, and individual characteristics 1.
• The evidence from clinical trials suggests that intensive glycemic control to achieve HbA1c levels below 7% does not consistently reduce clinical microvascular events or macrovascular events, but may increase the risk of hypoglycemia and other adverse effects 1.
• The choice of glycemic target should depend on consideration of other variables, such as risk for hypoglycemia, weight gain, and other drug-related adverse effects, as well as the patient's age, life expectancy, other chronic conditions, functional and cognitive impairments, fall risk, ability to adhere to treatment, and medication burden and cost 1.

Treatment Approach

• Treatment to achieve the target HbA1c level typically begins with lifestyle modifications, such as diet, exercise, and weight management, and metformin, which is generally well-tolerated and low-cost 1.
• If the HbA1c level remains above target after 3 months, additional medications may be added, such as SGLT-2 inhibitors, GLP-1 receptor agonists, DPP-4 inhibitors, sulfonylureas, or insulin 1.
• Regular monitoring of HbA1c every 3-6 months is recommended to assess treatment effectiveness and adjust the treatment plan as needed 1.

Individualized Care

• Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%, as the benefits of more intensive glycemic control may not outweigh the risks of hypoglycemia and other adverse effects 1.
• For patients with multiple comorbid conditions, limited life expectancy, or increased risk for hypoglycemia, the goal should be to minimize symptoms rather than achieve a specific HbA1c target, and the treatment plan should be individualized to balance the benefits and harms of glycemic control 1.

From the Research

A1C Target for Diabetes Type 2

• The American College of Physicians (ACP) recommends an HbA1c target level between 7% and 8% for most patients with type 2 diabetes 2.
• The American Diabetes Association recommends aiming for HbA1c levels less than 7% for many nonpregnant adults and considering a target of 6.5% if it can be achieved safely 2.
• Current guidelines specify HbA1c targets around or less than 7.0%, with more or less stringent goals being appropriate for selected patients 3.
• A study found that 13.4% of patients achieved an HbA1c of <7% without hypoglycemic events when taking glipizide with metformin, compared to 22.2% of patients who achieved an HbA1c of <7% without hypoglycemic events when taking saxagliptin with metformin 4.
• Metformin is recommended as first-line therapy for type 2 diabetes, given its relative safety and beneficial effects on hemoglobin A1c, weight, and cardiovascular mortality (compared with sulfonylureas) 5.

Factors Influencing A1C Targets

• Patient-specific factors, including cardiovascular risks, risk of hypoglycemia, metabolic changes, and cost, influence the choice of additional therapy after metformin 4.
• The ACP advises deintensification of therapy for patients who have an HbA1c level lower than 6.5% and avoidance of HbA1c-targeted treatment for patients with a life expectancy of less than 10 years 2.
• The physician's perception of the relative importance of parameters, such as the risk of hypoglycemia and cardiovascular disease, influences the setting of HbA1c targets 3.

Comparison of Therapies

• Sulfonylureas are potent glucose-lowering drugs, but their use is associated with a higher risk of hypoglycemia compared to DPP-4 inhibitors 6, 4.
• DPP-4 inhibitors may be considered a clinically stable choice for second-line therapy after completing maximally tolerated doses of metformin, despite their lower efficacy in lowering HbA1c compared to sulfonylureas 4.
• Metformin-based combinations have similar reductions in hemoglobin A1c values, except for DPP-4 inhibitors, which have smaller effects 5.