What is the recommended Hemoglobin A1c (HbA1c) target for adults with diabetes?

HbA1c Target Recommendations for Adults with Diabetes

The recommended HbA1c target range for most adults with diabetes is between 7% and 8%, which balances benefits of glycemic control with risks of hypoglycemia and other adverse effects. 1

General Target Recommendations

• The American College of Physicians (ACP) recommends an HbA1c target between 7% and 8% for most adults with type 2 diabetes to balance benefits and risks 1, 2
• The Institute for Clinical Systems Improvement (ICSI) recommends personalizing goals with patients to achieve glycemic control with an HbA1c between <7% to <8% depending on individual patient factors 1
• The Veterans Affairs/Department of Defense (VA/DoD) guidelines recommend a range of HbA1c 7.0-8.5% for most individuals with established microvascular or macrovascular disease, comorbid conditions, or 5-10 years life expectancy 1

Factors Influencing Target Selection

More Stringent Targets (<7%)

• A target HbA1c of <7% may be appropriate for:

  • Patients with short duration of diabetes 2
  • Those treated with lifestyle modifications or metformin only 1
  • Patients with long life expectancy (>10-15 years) 1
  • Those without significant cardiovascular disease 2
  • Patients with no history of severe hypoglycemia 1, 2

• The VA/DoD suggests a target HbA1c range of 6.0-7.0% for patients with life expectancy greater than 10-15 years and absent or mild microvascular complications, if it can be safely achieved 1

Less Stringent Targets (7-8% or higher)

• A less stringent HbA1c target (7-8% or higher) is more appropriate for:
  • Patients with history of severe hypoglycemia 1, 2
  • Those with advanced microvascular or macrovascular complications 1, 2
  • Patients with extensive comorbid conditions 1
  • Those with long-standing diabetes that is difficult to control 1
  • Patients with limited life expectancy (<10 years) 1
  • Older adults, particularly those who are frail 2

Clinical Considerations and Pitfalls

• Targeting HbA1c levels below 7% may increase risk for death, weight gain, hypoglycemia, and other adverse effects in many patients 1
• A study found that 100% of institutionalized elderly patients with HbA1c <7% experienced hypoglycemic events, compared to 79% of those with HbA1c ≥8% 3
• Continuous glucose monitoring revealed a very high prevalence of hypoglycemia in older institutionalized patients with diabetes, even in those with HbA1c ≥8% 3
• The NICE guideline recommends involving adults with type 2 diabetes in decisions about their individual HbA1c target, considering quality of life impacts 1

Treatment Approach Based on Current HbA1c

• For patients with severely elevated HbA1c (>9%), combination therapy options including metformin plus a second agent or insulin should be considered 4
• For patients with HbA1c between 7-8%, maintain current therapy if they are at appropriate individualized target 2
• For patients with HbA1c <6.5%, consider deintensification of therapy to reduce hypoglycemia risk 5

Monitoring Recommendations

• Perform HbA1c testing at least twice yearly in patients meeting treatment goals with stable glycemic control 2
• Test quarterly in patients whose therapy has changed or who are not meeting glycemic goals 2