Target HbA1c Levels for Individuals with Diabetes
For most nonpregnant adults with diabetes, the recommended HbA1c target is <7% (<53 mmol/mol), with personalized targets based on individual factors that may warrant more or less stringent goals. 1
General Target Recommendations
The most recent guidelines provide the following HbA1c targets:
- Standard target for most nonpregnant adults: <7% (<53 mmol/mol) 1, 2
- More stringent target (<6.5% or <48 mmol/mol): May be appropriate for selected individuals with short duration of diabetes, diet-treated type 2 diabetes, long life expectancy, and no significant cardiovascular disease, if achievable without significant hypoglycemia 1, 2
- Less stringent target (<8% or <64 mmol/mol): Recommended for individuals with history of severe hypoglycemia, limited life expectancy, advanced microvascular or macrovascular complications, extensive comorbid conditions, or long-standing diabetes 1, 2
Individualization Factors
The target HbA1c should be determined based on:
- Risk of hypoglycemia: Higher targets for those at increased risk
- Disease duration: More stringent targets for newly diagnosed patients
- Life expectancy: Less stringent targets for limited life expectancy (<10 years)
- Comorbid conditions: Higher targets with significant comorbidities
- Vascular complications: Less stringent targets with advanced complications
- Patient resources and support: Consider patient's ability to safely achieve targets
Target Recommendations by Patient Population
By Treatment Approach
- Patients managed by lifestyle and diet alone: Target HbA1c of 6.5% 1, 2
- Patients on medication with hypoglycemia risk: Target HbA1c of 7.0% 1, 2
- Patients on combination therapy: Consider target up to 7.5% 1
By Age Group
- Children and adolescents: Higher targets recommended 1
- Older adults:
Special Populations
- Patients on hemodialysis: Evidence suggests a target range of 7.0-7.9% may be optimal, as both lower (<7%) and higher (>8%) HbA1c levels are associated with increased mortality 3
Clinical Implications
- Each 10% reduction in HbA1c (e.g., 8% vs. 7.2%) was associated with a 44% lower risk for progression of diabetic retinopathy 1
- Above the thresholds of 7.0% for macrovascular events and death, and 6.5% for microvascular events, every 1% higher HbA1c is associated with approximately 38-40% higher risk of complications 4
- The American College of Physicians recommends deintensifying pharmacologic therapy in patients who achieve HbA1c levels less than 6.5% 2
HbA1c and Mean Plasma Glucose Correlation
| A1c (%) | Mean Plasma Glucose (mg/dL) |
|---|---|
| 6 | 126 |
| 7 | 154 |
| 8 | 183 |
| 9 | 212 |
| 10 | 240 |
Common Pitfalls to Avoid
- One-size-fits-all approach: Failing to individualize targets based on patient characteristics
- Ignoring hypoglycemia risk: Pursuing overly aggressive targets in vulnerable populations
- Delayed intensification: Not adjusting therapy when A1c goals are not met
- Racial differences: Be aware that Black and Hispanic populations may have relatively higher HbA1c values than White populations at the same level of glycemia 1
- Aging effects: Normal HbA1c levels increase slightly with age, which may need consideration when setting targets 1
Monitoring Recommendations
- Test HbA1c at least twice a year in patients meeting treatment goals
- Quarterly testing for patients whose therapy has changed or who are not meeting glycemic goals 1
- Serial (quarterly for 1 year) measurements of HbA1c are associated with significant reductions in HbA1c values in people with type 1 diabetes 1
Remember that these targets apply only when the assay method is certified by the NGSP as traceable to the DCCT reference.