Should a type 2 diabetic patient with a Hemoglobin A1c (HbA1c) level less than 6 continue with the current diabetic standard of care?

Management of Type 2 Diabetes with HbA1c Less Than 6%

For type 2 diabetic patients with HbA1c less than 6%, pharmacologic therapy should be deintensified as the harms outweigh the benefits. 1

Rationale for Deintensification

The American College of Physicians (ACP) provides clear guidance on this issue:

1. No proven benefit of very low targets: No clinical trials demonstrate that targeting HbA1c levels below 6.5% improves outcomes 1

2. Documented harms: Pharmacologic treatment to achieve very low HbA1c targets has substantial harms:

   • The ACCORD trial (targeting HbA1c <6.5%) was discontinued early due to increased overall mortality, cardiovascular-related death, and severe hypoglycemic events 1
   • The ADVANCE study with achieved median HbA1c of 6.4% failed to show statistically significant clinical benefits while demonstrating more adverse effects 1

3. Increased costs and burden: More intensive treatment to achieve lower targets increases costs and patient burden 1

How to Deintensify Treatment

When a patient achieves an HbA1c less than 6%, clinicians should implement one of the following approaches:

1. Reduce medication dosage of current therapy
2. Remove a medication if the patient is on multiple agents
3. Discontinue pharmacologic treatment entirely 1

Special Considerations for Metformin

While metformin has a better safety profile than many diabetes medications:

• It is not associated with hypoglycemia
• It is generally well-tolerated and low cost
• However, it still has known adverse effects
• Using metformin to maintain HbA1c below 7% provides little to no benefit while exposing patients to potential side effects 1

Exceptions to Consider

There are limited situations where maintaining a lower HbA1c might be appropriate:

1. Diet and lifestyle management: If the low HbA1c is achievable with diet and lifestyle modifications alone (without medications), a lower target is appropriate 1

2. Patient-specific factors: For patients with short duration of diabetes, long life expectancy (>15 years), and no significant cardiovascular disease, more stringent targets may be considered if achievable without significant hypoglycemia or adverse effects 1

Monitoring After Deintensification

After deintensifying therapy:

1. Continue regular monitoring: Perform HbA1c testing at least twice yearly for stable patients 1
2. Watch for glycemic changes: If HbA1c rises above 7%, consider reintroducing appropriate therapy 1
3. Maintain lifestyle interventions: Continue to emphasize diet, exercise, and weight management 2

Avoiding Common Pitfalls

1. Clinical inertia: Many clinicians are reluctant to reduce or stop medications even when HbA1c is very low
2. Fear of worsening control: Remember that medication can be restarted if glycemic control deteriorates
3. Overlooking risks: Very low HbA1c levels increase hypoglycemia risk, which can lead to falls, cognitive impairment, and cardiovascular events, especially in older adults
4. Ignoring patient burden: Multiple medications increase cost, complexity, and potential for drug interactions

Bottom Line

The evidence clearly shows that for type 2 diabetic patients with HbA1c less than 6%, the standard diabetic care should be modified by deintensifying pharmacologic therapy. The focus should shift to maintaining good control through lifestyle measures while reducing medication burden and potential harms.