Blood Sugar Goals for Type 2 Diabetes Mellitus
For most non-pregnant adults with type 2 diabetes, a target HbA1c of 7-8% is recommended, with individualization based on patient characteristics including age, comorbidities, and risk of hypoglycemia. 1, 2
General HbA1c Targets
The American College of Physicians (ACP) recommends:
- HbA1c target of 7-8% for most adults with type 2 diabetes 1
- Consider treatment intensification if HbA1c rises to ≥7.5% despite adherence to lifestyle modifications and medication 2
Other organizations provide slightly different recommendations:
- American Diabetes Association (ADA): <7% for many non-pregnant adults 1, 2
- National Institute for Health and Clinical Excellence (NICE): 6.5-7.5% depending on treatment regimen 1
- Institute for Clinical Systems Improvement (ICSI): <7% to <8% based on individual factors 1
Patient-Specific Target Recommendations
More Stringent Targets (HbA1c <6.5-7%)
Consider for patients with:
- Short duration of diabetes 1, 2
- Longer life expectancy (>10-15 years) 2
- Treatment with lifestyle modifications or metformin only 1, 2
- Absence of significant cardiovascular disease 1, 2
- Low risk of hypoglycemia 1, 2
Less Stringent Targets (HbA1c 7.5-8% or higher)
Appropriate for patients with:
- History of severe hypoglycemia 1, 2
- Limited life expectancy (<5-10 years) 1, 2
- Advanced microvascular or macrovascular complications 1, 2
- Extensive comorbid conditions 1, 2
- Long-standing diabetes with difficulty achieving lower targets 1, 2
- Cognitive impairment or frailty 2
- Elderly patients (≥80 years): target of 8% or higher 2
- Frail elderly or those with life expectancy <5 years: 8-8.5% 2
VA/DoD Guidelines Based on Life Expectancy and Complications
| Life Expectancy | Microvascular Complications | HbA1c Target |
|---|---|---|
| >10-15 years | Absent/mild | 6.0-7.0% |
| 5-10 years | Established | 7.0-8.5% |
| <5 years | Significant comorbidities | 8.0-9.0% |
Blood Glucose Monitoring Targets
- Fasting and pre-meal glucose: <7.2 mmol/L (<130 mg/dL) 1
- Postprandial glucose (1-2 hours after meals): <10 mmol/L (<180 mg/dL) 1
Important Clinical Considerations
Hypoglycemia Risk: Pursuing HbA1c targets <7% in older patients or those with comorbidities increases the risk of hypoglycemia, which can cause falls, cognitive decline, and cardiovascular events 2
Monitoring Frequency: Measure HbA1c at least twice yearly in patients meeting treatment targets with stable glycemic control, and quarterly in patients whose therapy has changed or who are not meeting targets 2
Treatment Progression: The UKPDS study showed that the proportion of patients maintaining target glycemic levels declines markedly over time, with only 24% of patients on sulfonylurea monotherapy achieving HbA1c <7% after 9 years 3
Patterns of Hyperglycemia: Patients with normal fasting glucose but elevated HbA1c often have postprandial hyperglycemia or elevated glucose throughout the day 4
Deintensification: Consider reducing therapy for patients who have an HbA1c level lower than 6.5% to avoid hypoglycemia 5
Common Pitfalls to Avoid
Over-reliance on fasting glucose: A sole measurement of fasting plasma glucose should not be used to assure optimal glycemic control, as patients may have normal fasting glucose but elevated HbA1c due to postprandial hyperglycemia 4
One-size-fits-all approach: Applying the same target to all patients can lead to overtreatment in elderly or comorbid patients and undertreatment in younger, healthier patients 1, 2
Ignoring patient preferences: Patient values and preferences should be considered when setting targets, as achieving glycemic control requires active participation and commitment 1
Failure to adjust targets over time: As diabetes progresses and patients age, glycemic targets may need to be adjusted to balance benefits and risks 2