Optimal A1C Goals for Type 2 Diabetes Mellitus
For most patients with type 2 diabetes mellitus, the recommended target hemoglobin A1C is less than 7%, but this should be individualized based on specific patient factors including age, comorbidities, hypoglycemia risk, and life expectancy. 1
General A1C Targets
The American Diabetes Association recommends:
- <7% for most nonpregnant adults with diabetes 1
- This target has been shown to reduce microvascular complications and is associated with long-term reduction in macrovascular disease when implemented soon after diagnosis
Individualized A1C Targets Based on Patient Characteristics
More Stringent A1C Goals (<6.5%)
Consider for patients with:
- Short duration of diabetes
- Type 2 diabetes treated with lifestyle or metformin only
- Long life expectancy
- No significant cardiovascular disease
- Low risk of hypoglycemia 1, 2
Less Stringent A1C Goals (7-8% or <8%)
Appropriate for patients with:
- History of severe hypoglycemia
- Limited life expectancy
- Advanced macrovascular and microvascular complications
- Extensive comorbidities
- Long-standing diabetes where goal is difficult to attain despite multiple medications including insulin 1, 2
Elderly Patients
- Target A1C of <8.5% for elderly patients with limited life expectancy or multiple severe comorbidities 1
- The American College of Physicians recommends against performance measures with targets below 8% for adults ≥80 years 1
Clinical Decision-Making Algorithm
Assess patient's individual risk profile:
- Age and life expectancy
- Duration of diabetes
- Presence of cardiovascular disease
- Risk of hypoglycemia
- Comorbidities
Select appropriate A1C target:
- <7%: Standard target for most patients
- <6.5%: Consider for younger patients with recent diagnosis and low complication risk
- 7-8%: For patients with established cardiovascular disease
- <8% or <8.5%: For elderly patients with limited life expectancy or significant comorbidities
Monitor and adjust therapy:
- Test A1C quarterly if therapy has changed or goals not met
- Test A1C at least twice yearly if meeting treatment goals with stable control 1
Important Considerations
- The American College of Physicians (ACP) recommends a general target A1C between 7-8% for most patients 3, 1
- Intensive glycemic control requires years before reduction in complications like kidney failure or blindness becomes evident 1
- Hypoglycemia risk increases with age and is associated with higher mortality, particularly in elderly patients 1
- Consider simplifying regimens and de-intensification of therapy in patients with A1C <6.5% to reduce medication burden and hypoglycemia risk 1
Correlation Between A1C and Mean Plasma Glucose
| A1C (%) | Mean Plasma Glucose (mg/dL) |
|---|---|
| 6 | 126 |
| 7 | 154 |
| 8 | 183 |
| 9 | 212 |
| 10 | 240 |
| 11 | 269 |
| 12 | 298 |
This correlation helps patients and providers understand the relationship between A1C values and daily glucose readings 1
Common Pitfalls to Avoid
- Applying a one-size-fits-all approach to all patients with diabetes
- Failing to consider hypoglycemia risk when setting aggressive targets
- Not adjusting targets as patients age or develop complications
- Delaying intensification of therapy when A1C goals are not met (clinical inertia) 4
- Focusing solely on A1C without addressing other cardiovascular risk factors