How to communicate the severity and risk of diabetes to a patient with severe hyperglycemia (Hemoglobin A1c (HbA1c) elevation)?

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Last updated: May 16, 2025 • View editorial policy

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From the Guidelines

I would explain to the patient that an A1C of 10.6% indicates severe uncontrolled diabetes that requires immediate attention, as it puts them at significant risk for serious complications including heart attack, stroke, kidney failure, blindness, nerve damage, and foot ulcers that could lead to amputation, as stated in the 2016 American Diabetes Association standards of medical care in diabetes 1. This level means their average blood sugar has been around 260 mg/dL for the past three months, which is dangerously high.

Key Points to Discuss with the Patient

  • The patient's A1C level is significantly higher than the recommended target of <7% by the American Diabetes Association, as mentioned in the study by 2.
  • The risks associated with uncontrolled diabetes, such as heart attack, stroke, kidney failure, blindness, nerve damage, and foot ulcers that could lead to amputation.
  • The importance of immediate treatment with both lifestyle changes and medication to reduce the risk of complications.
  • The recommended treatment plan, including insulin therapy, typically starting with basal insulin like glargine (Lantus) or detemir (Levemir) at 10 units daily, along with metformin 500mg twice daily if not contraindicated, as suggested in the studies by 1.
  • The need for the patient to monitor blood glucose levels at least twice daily and follow a diabetic diet limiting carbohydrates to 45-60g per meal.
  • The explanation that the body's cells are essentially "starving" despite high blood sugar because insulin resistance prevents glucose from entering cells, and that sustained high blood sugar damages blood vessels and nerves throughout the body.

Treatment Plan

  • Insulin therapy: basal insulin like glargine (Lantus) or detemir (Levemir) at 10 units daily, along with metformin 500mg twice daily if not contraindicated.
  • Lifestyle changes: diabetic diet limiting carbohydrates to 45-60g per meal, and regular physical activity.
  • Monitoring: blood glucose levels at least twice daily. With proper treatment, the patient could see significant improvement within 3 months, potentially avoiding serious complications, as supported by the studies by 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Understanding the Severity and Risk of Diabetes

To relay the severity and risk of diabetes to a patient with an A1C of 10.6%, it's essential to consider the following points:

  • The patient's A1C level is significantly higher than the recommended target of 6.5% or less, as stated in the algorithm for glycemic control 3.
  • This elevated A1C level indicates a high risk of diabetes-related complications, emphasizing the need for timely adjustment to the treatment regimen 4.
  • The patient's current A1C level is comparable to the mean A1C at baseline (10.5%) in a study where patients received premixed insulin and a GLP-1 receptor agonist, resulting in improved glycemic control over 12 months 5.

Therapeutic Approaches

Considering the patient's high A1C level, the following therapeutic approaches may be relevant:

  • Combination therapy with premixed insulin, metformin, and a GLP-1 receptor agonist, as explored in a study where patients achieved improved glycemic control and reduced insulin doses 5.
  • Adding other antidiabetes medications to insulin therapy, which can improve glycemic control and potentially lower the required insulin dose, resulting in less weight gain and lower risk for hypoglycemia 6.
  • Using GLP-1 receptor agonists, DPP-4 inhibitors, and SGLT2 inhibitors, which have been shown to improve glycemic control when added to insulin and have a low propensity for hypoglycemia and weight gain 6, 7.

Key Considerations

When discussing the severity and risk of diabetes with the patient, consider the following:

  • The importance of achieving the recommended A1C target to minimize the risk of diabetes-related complications 3.
  • The need for individualization of therapy to minimize the risks of hypoglycemia and other adverse events 3.
  • The potential benefits of combination therapy and the use of newer classes of antidiabetes agents, such as GLP-1 receptor agonists and SGLT2 inhibitors, in improving glycemic control and reducing cardiovascular risk factors 5, 7.

References

2
Guideline

tests of glycemia in diabetes.

Diabetes Care, 2003

3
Research

Statement by an American Association of Clinical Endocrinologists/American College of Endocrinology consensus panel on type 2 diabetes mellitus: an algorithm for glycemic control.

Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists, 2009

4
Research

Addressing Therapeutic Inertia in 2020 and Beyond: A 3-Year Initiative of the American Diabetes Association.

Clinical diabetes : a publication of the American Diabetes Association, 2020

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.