From the Guidelines
Clinicians should aim to achieve an HbA1c level between 7% and 8% in most patients with type 2 diabetes. This recommendation is based on the American College of Physicians' guidance statement update from 2018 1, which suggests that targeting an HbA1c level between 7% and 8% is appropriate for most patients with type 2 diabetes. The statement is adapted from and most consistent with the Institute for Clinical Systems Improvement (ICSI) guideline, which recommends an HbA1c target range between less than 7% and less than 8% 1.
Key Considerations
- The benefits and harms of more versus less intensive glycemic control may be finely balanced for many persons and vary according to expected duration of treatment, comorbid conditions, risk factors for hypoglycemia, and choice of medication 1.
- Any benefit of more intensive glycemic control likely requires a long time to manifest, and more stringent targets may be appropriate for patients who have a long life expectancy (>15 years) and are interested in more intensive glycemic control with pharmacologic therapy despite the risk for harms 1.
- For patients with multiple comorbid conditions, limited life expectancy, or increased risk for hypoglycemia, the harms of more intensive HbA1c targets outweigh the benefits, and clinicians should instead focus on treating to reduce symptoms from both disease and treatment 1.
Individualized Approach
- Clinicians should personalize goals for glycemic control in patients with type 2 diabetes on the basis of a discussion of benefits and harms of pharmacotherapy, patients' preferences, patients' general health and life expectancy, treatment burden, and costs of care 1.
- Consideration of how this evidence base applies in older populations is important, and for patients with multiple chronic comorbid conditions, including renal failure, liver failure, end-stage disease complications, cognitive impairment, advanced microvascular or macrovascular complications, or any other conditions that limit life expectancy, the harms of more intensive HbA1c targets outweigh the benefits 1.
Deintensification of Therapy
- Clinicians should consider deintensifying pharmacologic therapy in patients with type 2 diabetes who achieve HbA1c levels less than 6.5%, as no trials show that targeting HbA1c levels below 6.5% in diabetic patients improves clinical outcomes, and pharmacologic treatment to below this target has substantial harms 1.
From the Research
Hemoglobin A1c (HbA1c) Goals
The HbA1c goals vary depending on individual factors, such as age, health status, and risk of hypoglycemia.
- For most nonpregnant adults, a goal of less than 7% is recommended 2.
- However, for some individuals, such as those at risk for hypoglycemia, a somewhat higher A1C level may be appropriate 3.
- The American Diabetes Association (ADA) guidelines recommend different A1C targets in older adults based on comorbid health status, with a goal of less than 7% for healthy older adults and less stringent goals for those with complex or poor health status 4.
- Individualized glycemic targets may be necessary, taking into account factors such as duration of diabetes, age, and presence of complications or comorbidities 5, 6.
Factors Influencing HbA1c Goals
Several factors can influence the HbA1c goals, including:
- Risk of hypoglycemia: individuals at risk for hypoglycemia may require a higher A1C target 3.
- Duration of diabetes: individuals with a longer duration of diabetes may require a higher A1C target 3.
- Age: older adults may require a higher A1C target due to increased risk of hypoglycemia and other complications 4.
- Presence of complications or comorbidities: individuals with certain complications or comorbidities, such as cardiovascular disease or kidney disease, may require a higher A1C target 6.
Implications of HbA1c Goals
Achieving individualized HbA1c goals can have significant implications for health outcomes, including: