What is the management plan for an individual with hyperglycemia (elevated A1c)?

Management of Elevated A1c

For individuals with elevated A1c, the management plan should include a combination of lifestyle modifications, pharmacotherapy, and regular monitoring, with treatment intensification as needed to achieve target glycemic goals and reduce the risk of diabetes complications.

Assessment and Target Setting

• A1c should be tested quarterly in patients whose therapy has changed or who are not meeting glycemic goals 1
• For most nonpregnant adults, a reasonable A1c goal is <7%, which has been shown to reduce microvascular complications of diabetes 1
• More stringent A1c goals (such as <6.5%) may be appropriate for selected patients with short duration of diabetes, long life expectancy, and no significant cardiovascular disease 1
• Less stringent A1c goals (such as <8%) may be appropriate for patients with history of severe hypoglycemia, limited life expectancy, advanced complications, or extensive comorbidities 1

Initial Pharmacotherapy

• At the time of type 2 diabetes diagnosis, initiate metformin therapy along with lifestyle interventions, unless metformin is contraindicated 1
• In newly diagnosed patients with markedly symptomatic hyperglycemia or very elevated A1c (>10%), consider insulin therapy with or without additional agents from the outset 1, 2
• For patients with A1c >8.5% (69 mmol/mol) who are symptomatic with polyuria, polydipsia, nocturia, and/or weight loss, basal insulin should be initiated while metformin is started and titrated 1
• In patients with ketosis/ketoacidosis, treatment with subcutaneous or intravenous insulin should be initiated to rapidly correct hyperglycemia and metabolic derangement 1

Treatment Intensification

• If noninsulin monotherapy at maximal tolerated dose does not achieve or maintain the A1c target over 3-6 months, add a second oral agent, a GLP-1 receptor agonist, or insulin 1
• Consider initial combination therapy with glucose-lowering agents in those with high A1c at diagnosis (>8.5%), in younger people with type 2 diabetes, and when a stepwise approach would delay access to agents that provide cardiorenal protection 1
• Avoid therapeutic inertia - re-evaluate health behaviors, medication adherence, and side effects at every clinic visit 1
• When additional glycemic control is needed, incorporate rather than substitute glucose-lowering therapies with complementary mechanisms of action 1

Insulin Therapy

• For patients treated with basal insulin up to 1.5 units/kg/day who do not meet A1c target, consider multiple daily injections with basal and premeal bolus insulins 1
• In patients initially treated with insulin and metformin who are meeting glucose targets, insulin can be tapered over 2-6 weeks by decreasing the insulin dose 10-30% every few days 1
• Technologies allowing continuous monitoring of glucose levels have clear advantages for patients on insulin 1

Lifestyle Management

• All individuals with diabetes should receive individualized medical nutrition therapy (MNT), preferably provided by a registered dietitian 1
• Weight loss is recommended for all overweight or obese individuals who have or are at risk for diabetes 1
• For weight loss, either low-carbohydrate, low-fat calorie-restricted, or Mediterranean diets may be effective in the short term (up to 2 years) 1
• People with diabetes should perform at least 150 min/week of moderate-intensity aerobic physical activity, spread over at least 3 days per week 1

Diabetes Self-Management Education (DSME)

• People with diabetes should receive DSME according to national standards at the time of diagnosis and as needed thereafter 1
• DSME should address psychosocial issues, since emotional wellbeing is associated with positive diabetes outcomes 1
• Effective self-management and quality of life are key outcomes of DSME and should be measured and monitored as part of care 1

Monitoring and Follow-up

• A1c should be measured every 3 months to assess effectiveness of the treatment regimen 1, 3
• Use of point-of-care testing for A1c provides the opportunity for more timely treatment changes 1
• Response to all therapies should be reviewed at regular intervals, including impact on efficacy (A1c, weight), safety, and organ protection 1
• Consider de-intensification of therapy in frail older adults and in those using hypoglycemia-causing medications when glycemic metrics are substantially better than target 1

Common Pitfalls to Avoid

• Failure to intensify therapy leads to suboptimal control, even with adequate visits and monitoring 4
• Poor medication adherence can increase clinical inertia, as clinicians may be less likely to intensify treatment in patients with poor adherence 5
• Overly aggressive correction of severe hyperglycemia can lead to rapid fluid shifts and electrolyte abnormalities 2
• A1c level does not necessarily predict the presence or duration of hypoglycemia, so careful monitoring is needed regardless of A1c 6