How to manage a patient with elevated Hemoglobin A1c (HbA1c) levels indicating poor glycemic control?

From the Guidelines

For a patient with elevated Hemoglobin A1c (HbA1c) levels, the primary goal is to achieve an HbA1c level between 7% and 8% through personalized treatment, considering the benefits and harms of pharmacotherapy, patient preferences, and individual health and life expectancy 1.

To manage a patient with elevated HbA1c levels, the following steps can be taken:

• Start with lifestyle modifications, including a low-carbohydrate diet, regular exercise, and weight loss if appropriate.
• Medication therapy should begin with metformin, typically starting at 500 mg once or twice daily with meals, gradually increasing to 1000 mg twice daily as tolerated to minimize gastrointestinal side effects.
• Due to the high HbA1c, combination therapy may be warranted, adding a second agent such as a GLP-1 receptor agonist (like semaglutide 0.25 mg weekly, titrating up to 1 mg weekly) or an SGLT-2 inhibitor (such as empagliflozin 10 mg daily) 2.
• If the patient has symptoms of hyperglycemia or evidence of metabolic decompensation, insulin therapy should be initiated, typically with a basal insulin like glargine 10 units at bedtime, adjusted by 2-4 units every 3-7 days based on fasting glucose readings.
• Monitor blood glucose regularly, aiming for fasting levels below 130 mg/dL and postprandial levels below 180 mg/dL.
• Schedule follow-up within 2-4 weeks to assess response and adjust therapy as needed.

It is essential to consider the patient's individual characteristics, such as life expectancy, comorbid conditions, and risk for hypoglycemia, when determining the optimal HbA1c target and treatment plan 1. Additionally, the treatment plan should be tailored to minimize symptoms related to hyperglycemia and avoid targeting an HbA1c level in patients with a life expectancy less than 10 years due to advanced age or chronic conditions 1.

Some key points to consider when managing a patient with elevated HbA1c levels include:

• The importance of personalized treatment and consideration of individual patient characteristics.
• The need to balance the benefits and harms of pharmacotherapy and lifestyle modifications.
• The importance of regular monitoring and follow-up to adjust the treatment plan as needed.
• The consideration of patient preferences and values in the treatment decision-making process.

Overall, the goal of managing a patient with elevated HbA1c levels is to achieve optimal glycemic control while minimizing the risk of adverse events and improving quality of life.

From the FDA Drug Label

The management of antidiabetic therapy should be individualized. Ideally, the response to therapy should be evaluated using HbA1c which is a better indicator of long-term glycemic control than FPG alone. In clinical use, it is recommended that patients be treated with ACTOS for a period of time adequate to evaluate change in HbA1c (three months) unless glycemic control deteriorates.

To manage a patient with elevated Hemoglobin A1c (HbA1c) levels indicating poor glycemic control, the following steps can be taken:

• Individualize the management of antidiabetic therapy.
• Use HbA1c as a better indicator of long-term glycemic control.
• Treat the patient with pioglitazone (ACTOS) for a period of time adequate to evaluate change in HbA1c, typically three months, unless glycemic control deteriorates.
• Consider monotherapy or combination therapy with other antidiabetic medications such as sulfonylureas, metformin, or insulin.
• Monitor patients carefully for adverse events related to fluid retention.
• Adjust the dose of pioglitazone (ACTOS) as needed, up to a maximum of 45 mg once daily. 3

From the Research

Management of Elevated HbA1c Levels

To manage a patient with elevated Hemoglobin A1c (HbA1c) levels indicating poor glycemic control, several strategies can be employed:

• Insulin initiation is a major step in medical management and life of patients with type 2 diabetes, especially if HbA1c levels are superior to 1% from target or weight loss 4
• Insulin can be initiated with 10 units or 0.2 units/kg, then increased by 2 units every 3 days until fasting levels are consistently in the target range 4
• Basal insulin should be titrated regularly on a prophylactic basis, with adjustments made based on fasting glucose levels 5
• Self-monitoring of blood glucose (SMBG) is an effective way to manage diabetes, with studies showing that SMBG-based educational and pharmacological intervention can lead to better outcomes than conventional HbA1c algorithms 6

Insulin Therapy

Insulin therapy is often indicated for patients with suboptimally controlled type 2 diabetes mellitus, despite lifestyle modification and oral antidiabetic agents:

• Insulin initiation options include bedtime basal insulin (NPH, glargine) or twice daily premixed insulin, with dosages adjusted based on fasting glucose levels 5
• The American Association of Clinical Endocrinologists and the American Diabetes Association recommend considering insulin administration for people with type 2 diabetes with HbA1c levels exceeding 9.0% and 10%, respectively 7
• Short-term intensive insulin therapy (STII) may be a preferred option for new-onset type 2 diabetes mellitus patients with HbA1c >9, with studies showing that STII can quickly normalize glycemic control and improve β-cell function 8

Alternative Therapies

Alternative therapies to insulin may be considered, including:

• Glucagon-like peptide-1 (GLP-1) receptor agonists, which have been shown to offer superior benefit to insulin in some studies 7
• Metformin-based dual-agent oral treatment approaches, which can lead to significant reductions in HbA1c levels 7
• Sodium-glucose cotransporter 2 (SGLT2) inhibitors, which have been shown to be effective in reducing HbA1c levels 7