From the Guidelines
For insulin-dependent diabetes, management should be intensified when HbA1c levels exceed 7.0% (53 mmol/mol). At this threshold, consider adjusting insulin regimens by increasing basal insulin doses (such as glargine, detemir, or degludec) by 10-15%, adding or increasing bolus insulin (like lispro, aspart, or glulisine) before meals, or implementing more frequent blood glucose monitoring. For patients already on multiple daily injections, consider adding a GLP-1 receptor agonist (such as semaglutide or dulaglutide) or transitioning to an insulin pump therapy. Intensification should be individualized based on hypoglycemia risk, with less stringent goals (7.5-8.0%) appropriate for elderly patients or those with comorbidities. The 7.0% target balances long-term complication prevention with hypoglycemia risk, as each 1% reduction in HbA1c significantly decreases microvascular complications 1.
Some key considerations for individualizing HbA1c targets include:
- Patient age and life expectancy
- Presence of comorbidities, such as cardiovascular disease or kidney disease
- Risk of hypoglycemia and hypoglycemia unawareness
- Patient preferences and ability to manage treatment regimens Regular follow-up every 2-3 months is essential until target HbA1c is achieved, and adjustments to treatment regimens should be made as needed to minimize the risk of complications and optimize quality of life 1.
It's also important to note that the American Diabetes Association recommends individualized HbA1c targets, taking into account the patient's risk factors, comorbidities, and preferences 1. The American College of Physicians also recommends a target HbA1c level of less than 7% for most patients, but notes that less stringent targets may be appropriate for patients with limited life expectancy or significant comorbidities 1.
Overall, the goal of diabetes management is to balance the benefits of tight glycemic control with the risks of hypoglycemia and other adverse events, and to optimize quality of life for patients with insulin-dependent diabetes.
From the Research
HbA1c Levels and Insulin Management
- The American Diabetes Association suggests the use of long-acting (basal) insulin to augment therapy with one or two oral agents or one oral agent plus a glucagon-like peptide 1 receptor agonist when the A1C level is 9% or more, especially if the patient has symptoms of hyperglycemia or catabolism 2.
- For people with type 2 diabetes (T2D) with HbA1c levels exceeding 9.0% and 10%, respectively, insulin administration be strongly considered 3.
- However, studies comparing basal insulin directly with glucagon-like peptide-1 (GLP-1) receptor agonists (RA) suggest that the latter agents may offer superior benefit 3.
Considerations for Insulin Management
- Insulin regimens should be adjusted every three or four days until targets of self-monitored blood glucose levels are reached 2.
- A fasting and premeal blood glucose goal of 80 to 130 mg per dL and a two-hour postprandial goal of less than 180 mg per dL are recommended 2.
- The goals of therapy should be individualized based on many factors, including age, life expectancy, comorbid conditions, duration of diabetes, risk of hypoglycemia, cost, patient motivation, and quality of life 2.
Relationship Between HbA1c and Diabetic Complications
- Long-term glycemic control reduces retinopathy risk, but transient worsening can occur with glucose control intensification 4.
- A significant linear trend was associated with HbA1c levels and coronary artery disease (CAD) events in the diet-only group 5.
- A linear association was observed regardless of treatment modality between achieved HbA1c levels and risk of severe diabetic eye disease 5.