ADA Glycemic Targets for Diabetes Treatment
For most nonpregnant adults with diabetes, target an A1C <7.0% (53 mmol/mol), preprandial glucose 80-130 mg/dL (4.4-7.2 mmol/L), and peak postprandial glucose <180 mg/dL (10.0 mmol/L). 1
Standard Glycemic Targets
The American Diabetes Association establishes these core targets for the majority of nonpregnant adults with diabetes 1:
- A1C: <7.0% (53 mmol/mol) 1
- Preprandial capillary plasma glucose: 80-130 mg/dL (4.4-7.2 mmol/L) 1
- Peak postprandial capillary plasma glucose: <180 mg/dL (10.0 mmol/L) 1
The preprandial target was revised in 2015 from 70-130 mg/dL to 80-130 mg/dL based on the ADAG study, which demonstrated that higher glycemic targets corresponded better to A1C goals and provided a safety margin to limit overtreatment and hypoglycemia risk in patients titrating insulin 1.
Postprandial glucose should be measured 1-2 hours after the beginning of a meal and targeted specifically when A1C goals are not met despite achieving preprandial glucose targets 1.
Individualization Algorithm: When to Intensify or Relax Targets
More stringent A1C targets (<6.5%) are appropriate for patients with 1:
- Short duration of diabetes (newly diagnosed) 1
- Long life expectancy 1
- No established cardiovascular disease 1
- Absent or few/mild comorbidities 1
- Low risk of hypoglycemia 1
- High motivation with excellent self-care capabilities 1
- Readily available resources and support 1
Less stringent A1C targets (<8.0%) are appropriate for patients with 1:
- Long-standing diabetes 1
- Short life expectancy 1
- Severe comorbidities 1
- Established vascular complications (advanced microvascular or macrovascular disease) 1
- History of severe hypoglycemia or hypoglycemia unawareness 1
- High risk of hypoglycemia and other drug adverse effects 1
- Preference for less burdensome therapy 1
- Limited resources and support 1
The American College of Physicians recommends an A1C target of 7-8% for most patients with type 2 diabetes, with deintensification for those achieving A1C <6.5% 1.
Critical Safety Considerations
Hypoglycemia prevention takes absolute precedence over achieving A1C targets. 1 The following situations mandate raising glycemic targets 1:
- Hypoglycemia unawareness 1
- One or more episodes of level 3 hypoglycemia (severe event requiring assistance) 1
- Pattern of unexplained level 2 hypoglycemia (glucose <54 mg/dL) 1
- History of severe hypoglycemia 1
Patients with these characteristics should have their glycemic targets raised to strictly avoid further hypoglycemia 1. Severe or frequent hypoglycemia is an absolute indication for treatment regimen modification, including setting higher glycemic goals 1.
Evidence from Major Trials
The DCCT/EDIC trials demonstrated that intensive glycemic control (A1C <7%) reduces microvascular complications in type 1 diabetes, with benefits persisting for decades even after control was relaxed—a phenomenon called "metabolic memory" or "legacy effect" 1. However, the ACCORD, ADVANCE, and VADT trials in type 2 diabetes showed that intensive glycemic control in patients with long-standing disease, established cardiovascular disease, or advanced age increased the risk of severe hypoglycemia and, in ACCORD, increased mortality 1.
These findings underscore that patients with long duration of diabetes, known history of hypoglycemia, advanced atherosclerosis, or advanced age/frailty may benefit from less aggressive targets 1.
Monitoring Frequency
- A1C should be tested at least twice yearly in patients meeting treatment goals with stable glycemic control 1
- A1C should be tested quarterly in patients whose therapy has changed or who are not meeting glycemic goals 1, 2
Common Pitfalls to Avoid
Do not aggressively pursue near-normal A1C levels in patients with advanced disease, limited life expectancy, or high hypoglycemia risk. 1 The potential risks of intensive glycemic control may outweigh benefits in higher-risk individuals 1.
Avoid overtreatment in patients already achieving A1C <6.5%, as this increases hypoglycemia risk without additional benefit 1, 3. The American College of Physicians specifically recommends deintensification of therapy for patients with A1C <6.5% 1.
Reassess glycemic targets over time as patient characteristics change—comorbidities emerge, life expectancy decreases, or diabetes becomes more difficult to control 1. A goal appropriate early in disease may need adjustment as the disease progresses 1.
African American individuals are at substantially increased risk of severe hypoglycemia, requiring particular vigilance in this population 1.