Should Lantus Be Continued at HbA1c 6.5%?
You should consider deintensifying or discontinuing the Lantus, as no trials demonstrate clinical benefit from targeting HbA1c levels below 6.5%, and maintaining pharmacologic therapy at this level increases the risk of hypoglycemia, treatment burden, and costs without proven mortality or morbidity benefit. 1
Evidence-Based Rationale for Deintensification
The American College of Physicians 2018 guidance explicitly recommends deintensifying pharmacologic therapy when HbA1c falls below 6.5% 1. This recommendation stems from:
- The ACCORD trial, which targeted HbA1c <6.5% (achieving 6.4%), was stopped early due to increased overall mortality and cardiovascular-related deaths compared to less intensive control 1
- The ADVANCE study showed no statistically significant clinical benefit at an achieved median HbA1c of 6.4% versus 7.0%, with more adverse effects in the intensive group 1
- No randomized trials have demonstrated improved clinical outcomes (mortality, cardiovascular events, or quality of life) when targeting HbA1c below 6.5% 1
Practical Deintensification Strategy
When HbA1c is <6.5%, you should 1:
- Reduce the Lantus dosage as a first step, rather than abrupt discontinuation
- Monitor HbA1c every 3 months after dose reduction to ensure levels remain in the target range of 7-8% 1
- Consider complete discontinuation if the patient is on lifestyle modifications that can maintain glycemic control, particularly if they achieved this level through diet and exercise improvements 1, 2
Target HbA1c Range
The appropriate target for most nonpregnant adults with type 2 diabetes is 7-8% 1. An HbA1c of 6.5% places this patient below the evidence-based target range where benefits outweigh harms 1.
Important Caveats
Hypoglycemia risk: Continuing insulin at an HbA1c of 6.5% substantially increases the risk of severe hypoglycemia without offsetting clinical benefit 1
Treatment burden: Maintaining insulin therapy adds unnecessary complexity, cost, and patient burden when the HbA1c is already below target 1
Long-term considerations: While early intensive control may provide legacy benefits in newly diagnosed patients with long life expectancy (>15 years), this applies to achieving targets around 7%, not pushing below 6.5% 1
Monitoring After Deintensification
- Check HbA1c in 3 months after any dose reduction 2
- Reinforce lifestyle modifications including diet, exercise, and weight management to maintain glycemic control without pharmacotherapy 1
- Target time in range >70% (70-180 mg/dL) if using continuous glucose monitoring 2
The current HbA1c of 6.5% represents excellent glycemic control that likely reflects both the insulin therapy and lifestyle factors 2. Reducing or stopping Lantus while maintaining lifestyle interventions is the evidence-based approach that prioritizes patient safety and quality of life over an arbitrary lower number.