What is the recommended HbA1c (hemoglobin A1c) level for individuals with diabetes?

Recommended HbA1c Targets for Individuals with Diabetes

For most nonpregnant adults with diabetes, the recommended HbA1c target is <7% (53 mmol/mol), but this should be personalized based on patient characteristics, comorbidities, and risk of hypoglycemia. 1

General Target Recommendations

• A target HbA1c of <7% (53 mmol/mol) is appropriate for many nonpregnant adults with diabetes and is supported by strong evidence from major clinical trials 1
• This target applies only when using assay methods certified as traceable to the DCCT reference 1
• Each 10% reduction in HbA1c (e.g., 8% vs. 7.2%) is associated with a 44% lower risk for progression of diabetic retinopathy 1

Patient-Specific Target Recommendations

More Stringent Targets (HbA1c <6.5%)

• Consider for selected individuals if achievable without significant hypoglycemia or other adverse effects 1
• Appropriate candidates include:
  • Patients with short duration of diabetes 1
  • Type 2 diabetes treated with lifestyle or metformin only 1
  • Long life expectancy (>10-15 years) 1
  • No significant cardiovascular disease 1
  • Patients managed by diet and lifestyle or single drug not associated with hypoglycemia (target 6.5%) 1

Standard Targets (HbA1c 7-8%)

• Appropriate for most adults with established diabetes 1, 2
• The American College of Physicians recommends a target range of 7-8% for most nonpregnant adults with type 2 diabetes 1, 2
• Patients on medications associated with hypoglycemia should aim for 7% 1

Less Stringent Targets (HbA1c 7.5-8.5%)

• Appropriate for patients with: 1
  • History of severe hypoglycemia requiring assistance
  • Limited life expectancy (<5-10 years)
  • Advanced microvascular or macrovascular complications
  • Extensive comorbid conditions
  • Long-standing diabetes with difficulty achieving lower targets
  • Frailty or older age with multiple chronic conditions
  • Cognitive impairment
  • Risk of falls or impaired hypoglycemia awareness

Special Considerations

Hypoglycemia Risk

• Intensive glycemic control (HbA1c <7%) significantly increases risk of hypoglycemia, especially in those with advanced kidney disease (CKD stages 4-5) 1
• Avoid targeting HbA1c <7% in patients at high risk for hypoglycemia, including those on insulin or sulfonylureas 1, 2
• Hypoglycemia risk is a critical factor in determining appropriate targets, as it can lead to falls, cognitive impairment, and potentially increased mortality 2, 3

Kidney Disease Considerations

• For patients with chronic kidney disease, particularly advanced stages, targets should be less stringent (7-8%) due to increased hypoglycemia risk 1
• We recommend not treating to an HbA1c target of <7.0% in patients with CKD who are at risk of hypoglycemia 1

Cardiovascular Risk

• Meta-analyses suggest that targeting HbA1c <7% may not maximize cardiovascular benefits compared to more moderate targets 3, 4
• A target range of 7.0-7.9% may provide better balance between microvascular benefits and hypoglycemia risk 4

Long-term Complications

• Long-term weighted mean HbA1c below 7.6% (60 mmol/mol) has been associated with prevention of proliferative retinopathy and persistent macroalbuminuria for up to 20 years in type 1 diabetes 5
• The risk of microvascular complications increases sharply with HbA1c levels above 8% 1

Implementation Approach

• Assess individual patient characteristics including age, duration of diabetes, comorbidities, and hypoglycemia risk 1, 2
• Consider race and ethnicity when interpreting HbA1c results, as values may be relatively higher in Black and Hispanic populations at the same level of glycemia 1
• Monitor HbA1c at least twice yearly in patients meeting treatment goals with stable glycemic control, and quarterly in those with therapy changes or not meeting goals 1
• Serial quarterly measurements have been associated with significant reductions in HbA1c values 1
• Balance the benefits of tight control against potential risks, particularly in older adults or those with multiple comorbidities 2

Common Pitfalls to Avoid

• Setting overly aggressive targets (HbA1c <6.5%) for patients with multiple comorbidities or at high risk for hypoglycemia 1, 2
• Failing to adjust targets as patient circumstances change (e.g., development of comorbidities, aging) 2
• Overlooking the increased risk of hypoglycemia with intensive control, especially in patients with renal impairment 1
• Focusing solely on HbA1c numbers without considering quality of life and treatment burden 2
• Maintaining intensive therapy in patients with limited life expectancy where benefits may not be realized 1