Recommended A1C Goals for Adults with Diabetes
For most non-pregnant adults with diabetes, a target A1C of <7% is appropriate to reduce microvascular complications and, when implemented soon after diagnosis, is associated with long-term reduction in macrovascular disease. 1
General A1C Target Recommendations
- A target A1C of <7% is recommended by the American Diabetes Association (ADA) for most non-pregnant adults with diabetes as this level has been shown to reduce microvascular complications 2, 1
- The American College of Physicians (ACP) recommends an A1C target between 7% and 8% for most adults to balance benefits and risks 3
- The Veterans Affairs/Department of Defense guidelines recommend a range of A1C 7.0-8.5% for most individuals with established microvascular or macrovascular disease, comorbid conditions, or 5-10 years life expectancy 3
Individualized A1C Goals Based on Patient Characteristics
More Stringent Goals (<6.5%)
- Consider a more stringent A1C goal of <6.5% for patients with: 1, 3
- Short duration of diabetes
- Treatment with lifestyle modifications or metformin only
- Long life expectancy
- Absence of significant cardiovascular disease
- No history of severe hypoglycemia
Less Stringent Goals (7-8% or higher)
- Consider a less stringent A1C goal of <8% for patients with: 1, 3, 4
- History of severe hypoglycemia
- Advanced microvascular or macrovascular complications
- Extensive comorbid conditions
- Long-standing diabetes that is difficult to control
- Limited life expectancy (<10 years)
- Older adults, particularly those who are frail
A1C Goals for Older Adults
- For older adults with good functional status, few comorbidities, and longer life expectancy (>10 years), a target A1C of approximately 7% is reasonable 4
- For frail older patients, those with limited life expectancy (<5 years), or with advanced complications, a target A1C of approximately 8% is appropriate 4
- Focus should be on avoiding symptoms of hyperglycemia rather than achieving specific targets in frail older adults 4
Important Clinical Considerations
- Targeting A1C levels below 7% may increase risk for death, weight gain, hypoglycemia, and other adverse effects in many patients 3, 5
- A reasonable individualized glycemic goal is the lowest A1C that does not cause severe hypoglycemia and preserves awareness of hypoglycemia 5
- Hypoglycemia risk is particularly concerning in patients with history of severe hypoglycemia, impaired renal function, or cognitive impairment 4
- Consider de-escalation of therapy if A1C falls below 6.5% to reduce risk of adverse events, especially in older adults 4
Monitoring Recommendations
- Perform A1C testing at least twice yearly in patients meeting treatment goals with stable glycemic control 2, 6
- Test quarterly in patients whose therapy has changed or who are not meeting glycemic goals 2, 6
- Point-of-care testing for A1C provides opportunity for more timely treatment adjustments 1
Treatment Approach
- The ADA recommends initiating metformin therapy along with lifestyle interventions at the time of type 2 diabetes diagnosis, unless metformin is contraindicated 1
- For patients not meeting goals, consider therapy intensification with additional agents 1
- For patients with severely elevated A1C (>9%), combination therapy options including metformin plus a second agent or insulin should be considered 3