What is the target glycaemic control for patients with type 2 diabetes in the UK?

Target Glycaemic Control for Type 2 Diabetes in the UK

The target HbA1c for most patients with type 2 diabetes in the UK is between 7% (53 mmol/mol) and 8% (64 mmol/mol), with individualization based on patient characteristics. 1

Recommended HbA1c Targets

General Target Range

• NICE guidelines for the UK recommend an HbA1c target of 7% (53 mmol/mol) for most adults with type 2 diabetes 1
• The American College of Physicians guidance statement, which influences UK practice, recommends an HbA1c target between 7-8% (53-64 mmol/mol) for most patients 1

Patient-Specific Considerations for Target Selection

Lower Target (6.5-7% or 48-53 mmol/mol)

• Appropriate for:
  • Newly diagnosed patients with short duration of diabetes 1
  • Patients treated with lifestyle modifications or metformin only 1
  • Longer life expectancy (>15 years) 1
  • Absence of significant cardiovascular disease 1
  • Low risk of hypoglycemia 1
  • Minimal comorbidities 1

Higher Target (7.5-8% or 58-64 mmol/mol)

• Appropriate for:
  • History of severe hypoglycemia 1
  • Limited life expectancy 1
  • Advanced microvascular or macrovascular complications 1
  • Extensive comorbid conditions 1
  • Long-standing diabetes where target is difficult to achieve despite appropriate therapy 1
  • Frailty or advanced age 1

Evidence Supporting These Targets

The target recommendations are based on several landmark trials:

• UKPDS: Showed that intensive glycemic control (HbA1c ~7%) in newly diagnosed patients reduced microvascular complications, with benefits persisting for many years after the intervention 1

• ACCORD: Demonstrated increased mortality with very intensive control (target HbA1c <6.5%), suggesting caution with overly aggressive targets 1

• ADVANCE: Showed modest reductions in nephropathy but no significant reduction in major macrovascular events with intensive control (HbA1c target ≤6.5%) 1

Monitoring and Treatment Adjustment

• For patients with HbA1c above target, the average time to next measurement in UK practice is approximately 6 months 2
• Only 26% of cases with above-target HbA1c receive appropriate medication adjustments 2
• Patients with higher glycemic variability have increased risk of major adverse cardiovascular events (HR 1.51) 3

Common Pitfalls in Glycemic Management

1. Therapeutic inertia: Failure to intensify therapy despite above-target HbA1c is common in UK practice 4, 2

2. Overtreatment risk: Targeting HbA1c below 6.5% (48 mmol/mol) can increase mortality and hypoglycemia risk without providing additional benefits 1

3. Ignoring early control importance: Achieving early glycemic control (within first year of diagnosis) is associated with reduced risk of cardiovascular events 3

4. Neglecting lifestyle interventions: High BMI is associated with insulin resistance and difficulty achieving targets despite high insulin doses 5

5. Focusing solely on HbA1c: Other targets like blood pressure and lipid control may be equally or more important for preventing macrovascular complications 1

Practical Approach to Setting Targets

1. Assess patient's overall health status, comorbidities, and life expectancy
2. Consider duration of diabetes and risk of hypoglycemia
3. Set initial target:
   • For most patients: 7-8% (53-64 mmol/mol)
   • For younger, healthier patients with recent diagnosis: closer to 7% (53 mmol/mol)
   • For older, frailer patients with comorbidities: closer to 8% (64 mmol/mol)
4. Monitor and adjust therapy accordingly
5. Consider deintensifying treatment if HbA1c falls below 6.5% (48 mmol/mol) 1

The evidence clearly shows that while tight glycemic control reduces microvascular complications, the risk-benefit ratio must be carefully considered for each patient, with mortality and quality of life as primary considerations.