What are the current recommendations for HbA1c (Hemoglobin A1c) targets and management strategies in the standard of diabetes care, including recent updates?

HbA1c in Standard of Diabetes Care 2025

Current HbA1c Target Recommendations

For most nonpregnant adults with diabetes, the target HbA1c should be <7% (53 mmol/mol), with more stringent targets of <6.5% (48 mmol/mol) appropriate for selected individuals if achievable without significant hypoglycemia. 1

Standard Target: <7% (53 mmol/mol)

• The general HbA1c target of <7% applies to most nonpregnant adults with diabetes and is supported by landmark trials (DCCT for type 1 diabetes, UKPDS for type 2 diabetes) demonstrating that each 10% reduction in HbA1c reduces diabetic retinopathy progression risk by 44%. 1
• This target is based on NGSP-certified assay methods traceable to the DCCT reference, with a non-diabetic reference interval of approximately 4-6% HbA1c (20-42 mmol/mol). 1

More Stringent Target: <6.5% (48 mmol/mol)

More stringent HbA1c goals of <6.5% are appropriate for patients with:

• Short duration of diabetes 1
• Type 2 diabetes treated with lifestyle modifications or metformin alone 1
• Long life expectancy 1
• No significant cardiovascular disease 1
• Young patients without comorbidities who can safely achieve this target with low-risk medications (metformin, DPP4 inhibitors, SGLT2 inhibitors) 1

Less Stringent Target: <8% (64 mmol/mol)

Higher HbA1c targets of <8% are appropriate for patients with:

• History of severe hypoglycemia 1
• Limited life expectancy (<10 years) 1
• Advanced microvascular or macrovascular complications 1
• Extensive comorbid conditions 1
• Long-standing diabetes where the <7% goal is difficult to achieve despite intensive management 1
• Cognitive impairment or difficulties with self-management 1

Testing Frequency Recommendations

Stable Patients

• HbA1c should be tested at least twice per year in patients meeting treatment goals with stable glycemic control. 1

Unstable Patients or Treatment Changes

• HbA1c should be tested quarterly (every 3 months) in patients whose therapy has changed or who are not meeting glycemic goals. 1

Hospitalized Patients

• HbA1c should be measured in hospitalized patients with diabetes if results from the previous 3 months are not available. 1

Diagnostic Considerations

Assay Requirements

• Only NGSP-certified HbA1c methods should be used for diagnosis or screening of diabetes. 1
• Point-of-care testing (POCT) devices should not be used for diagnosis, despite some being NGSP certified, as they are CLIA-waived and proficiency testing is not required. 1

Diagnostic Threshold

• HbA1c ≥6.5% (48 mmol/mol) on two separate occasions confirms diabetes diagnosis. 2, 3
• HbA1c 5.7-6.4% defines prediabetes and does not warrant diabetes medication. 2

Special Population Considerations

Pregnancy

• HbA1c target <6% (42 mmol/mol) is recommended during pregnancy in women with pre-existing diabetes to decrease congenital malformations, large-for-date infants, and pregnancy/delivery complications. 1
• Women of childbearing age should maintain HbA1c as close to normal as possible, as HbA1c >6.5% is associated with increased miscarriage and birth defect rates. 1

Children and Adolescents

• Higher target ranges are recommended for children and adolescents compared to adults. 1

Racial and Ethnic Considerations

• Black individuals may have mean HbA1c values approximately 0.4% higher than White individuals at the same glycemia level, though race does not modify the association between HbA1c and adverse cardiovascular outcomes or death. 1
• Patient characteristics including race, ethnicity, and chronic kidney disease should be assessed when interpreting HbA1c results. 1

Limitations and Alternative Monitoring

Conditions Affecting HbA1c Accuracy

• HbA1c may not accurately reflect average glycemia in patients with increased red blood cell turnover, including those with anemia, hemolysis, hemoglobinopathies, pregnancy, or renal insufficiency. 1, 4
• Alternative glycemic markers (fructosamine, glycated albumin) or continuous glucose monitoring should be considered when HbA1c does not correlate with glucose monitoring results. 1, 3

Complementary Monitoring

• HbA1c reflects average glycemia over 2-3 months but does not measure glycemic variability or hypoglycemia. 1, 5
• Continuous glucose monitoring (CGM) provides real-time glycemic data and is increasingly important for comprehensive diabetes management, particularly in type 1 diabetes. 1, 5

Critical Pitfalls to Avoid

Overtreatment Risk

• The American College of Physicians recommends deintensifying or discontinuing pharmacologic therapy when HbA1c falls below 6.5%, as more stringent targets are associated with increased risks of hypoglycemia, cardiovascular events, and mortality without demonstrated improved clinical outcomes. 1, 2
• Treatment to HbA1c <6.5% versus 7-8% showed higher risks in trials like ACCORD and VADT, particularly in older patients with multiple comorbidities and significant diabetes duration. 1

Hypoglycemia Prevention

• Avoiding hypoglycemia should always take precedence over achieving HbA1c targets. 1
• Decreased HbA1c in DCCT and UKPDS was associated with increased risk for severe hypoglycemia. 1

Individualization Remains Essential

• While general targets are established, HbA1c goals must balance potential benefits for long-term complications against increased hypoglycemia risk, treatment burden, and cost. 1
• Shared decision-making with patients about their individual HbA1c target is emphasized across all major guidelines. 1